Health inspection·September 9, 2024

CLASS B CITATION -- ABUSE/FACILITY NOT SELF REPORTED The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00908484 State Citation B was written. C.F.R. §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. C.F.R. §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law , including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. WIC § 15630 (A) If the suspected or alleged abuse is physical abuse, as defined in Section 15610.63, and the abuse occurred in a long-term care facility, except a state mental health hospital or a state developmental center, the following shall occur: (ii) If the suspected abuse does not result in serious bodily injury, a telephone report shall be made to the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse. (D) With regard to abuse reported pursuant to subparagraph (C), the local ombudsman and the local law enforcement agency shall, as soon as practicable, except in the case of an emergency or pursuant to a report required to be made pursuant to clause (v), in which case these actions shall be taken immediately, do all of the following: (i) Report to the State Department of Public Health any case of known or suspected abuse occurring in a long-term health care facility, as defined in subdivision (a) of Section 1418 of the Health and Safety Code. Based on interview and record review the facility failed to implement its abuse reporting policy when it had knowledge of an allegation of exposure by Resident 3 to Resident 4 and did not report it to the State Agency (SA). Resident 3 was admitted to the facility on 1/31/23, with diagnoses that included schizoaffective disorder bipolar type (a mental illness that can affect your thoughts, mood, and behavior) and schizophrenia (a mental disorder characterized by disruptions in thought processes). Resident 4 was admitted to the facility on 3/20/23, with diagnoses that included paranoid schizophrenia (a pattern of behavior where a person feels distrustful of others and behaves accordingly) and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). A review of the facility policy entitled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised September 2022 indicated, "All reports of resident abuse... are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported." A review of the facility policy entitled Abuse, Neglect, Exploitation and Misappropriation Prevent Program revised April 2021 indicated, "Protect residents from any further harm during investigation." On 7/16/24 at 12:20 P.M. an interview was conducted with Resident 4 who stated, "(Resident 3) exposed his genitals to me and the staff aren't doing anything about it." On 7/19/24 a review of Resident 3's Communication note dated 7/8/24 at 8:13 A.M. indicated, "Female resident (Resident 4) pointed to male resident (Resident 3) claiming he exposed himself to her in the lunchroom near lunch hour." On 7/19/24 a review of Resident 4's Communication Note dated 7/11/24 at 8:36 A.M. indicated, "Writer check in with both the resident and fellow female resident (Resident 4) on claim made by (resident 4) on 7/8/24 about the resident exposing himself to her." On 7/19/24 at 2:14 P.M. a follow up telephone interview was conducted with the Social Worker (SW) who stated, "I didn't report what (Resident 4) said because I wasn't here when it happened." On 7/16/24 at 12:39 P.M. an interview was conducted with the DON who stated, "It was not reported to the SA." The facility failed to follow their abuse reporting policy when an allegation of potential abuse was reported to them by a resident. This failure put residents at risk for continued abuse. This violation(s) caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient.