Health inspection·March 12, 2024

The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported incident (FRI) CA00879730. Representing the Department, HFEN 39111. State Citation B was written. 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. 42 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. (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. On 1/24/24 at 8:30 A.M., an unannounced onsite visit was conducted related to an allegation of resident-to-resident physical abuse. It was determined the facility failed to implement its abuse policies when certified nursing assistant (CNA) 4 did not report Resident 1's allegation of physical abuse. In addition, the facility did not report the allegation of abuse within 24 hours to the California Department of Public Health (CDPH, state survey agency that regulates nursing homes) and law enforcement entity as was mandated by law. As a result, investigation into the allegation of abuse was delayed and placed residents at risk for further abuse. Findings: A review of the facility's document titled Report of Suspected Dependent Adult/Elder Abuse dated 1/16/24 and with fax transmittal date 1/16/24 at 4:44 A.M. to CDPH, indicated Resident 1 alleged Resident 3 had threatened to break her glasses and had hit her several times with a remote control on 1/13/24. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on 3/20/20, with diagnoses to include paralysis and weakness affecting the right side of the body following a stroke. A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment) dated 12/15/23, indicated the resident scored 15 on the brief interview of mental status (a score of 13-15 meant the resident was cognitively intact). A review of Resident 1's interdisciplinary (IDT) note dated 1/17/24, indicated on 1/15/24, "...[Resident 1] stated that approximately two days ago [1/13/24], another resident [Resident 3] came into her room and verbally threatened her and then grabbed a remote control and struck her on her left forearm, leaving a purple discoloration...Victim stated she spoke with [CNA 4] and said 'call the police'...." On 1/24/24 at 8:45 A.M., an interview was conducted with Resident 1 while inside the resident's room. Resident 1 stated on 1/13/24, Resident 3 went into her room and came to her bed and threatened to pull off her glasses. Resident 1 stated Resident 3 took the remote control off her bed and started hitting her on the arms with it. Resident 1 stated she then grabbed a hold on Resident 3's wrists to stop her from continuing to hit her. Resident 1 stated she yelled for help and CNA 4 came in and removed Resident 3 from her room. Resident 1 stated she told CNA 4 what had happened and that she wanted the police to be called. On 1/25/24 at 10:41 A.M., a telephone interview was conducted with CNA 4. CNA 4 stated she had been working on the evening of 1/13/24 and had heard Resident 1 yelling "Help!" and "Get out!" CNA 4 stated she responded to Resident 1's room and found Resident 3 in there standing over Resident 1 and taking the resident's stuffed toy. CNA 4 stated she gave Resident 1 her stuffed toy back and removed Resident 3 from the room. CNA 4 stated Resident 1 had told her, "[Resident 3] hit me," and had asked her to call the police. CNA 4 stated she did not report that Resident 1 told her Resident 3 had hit her because she did not witness it herself. CNA 4 stated hitting was considered abuse. CNA 4 then stated, "It's my fault. I should have reported what [Resident 1] said." On 1/25/24 at 11 A.M., an interview was conducted with CNA 9. CNA 9 stated all allegations of abuse had to be reported. CNA 9 stated abuse did not have to be witnessed to be reported. CNA 9 stated allegations of abuse had to be reported immediately to the charge nurse, director of nursing (DON), and administrator (ADM). On 1/25/24 at 11:05 A.M., an interview was conducted with CNA 10. CNA 10 stated, "You have to listen to your patient. If they tell you, they were abused you have to report it immediately. Don't wait." CNA 10 further stated, "You don't have to witness it to report it. Just report it. It's not your job to investigate or believe it." On 1/25/24 at 11:10 A.M., an interview was conducted with the DON. The DON stated CNA 4 should have immediately reported Resident 1's allegation that Resident 3 had hit her. The DON stated the incident and allegation between Resident 1 and Resident 3 occurred on 1/13/24, and it should have been reported the day it happened. The DON acknowledged Resident 1 had to again report the incident to staff on 1/15/24. The DON stated the facility's reporting of Resident 1's allegation of abuse was not timely. On 2/2/24 at 7:05 A.M., a telephone interview was conducted with licensed nurse (LN) 8. LN 8 stated he had gone in to assess Resident 1 on 1/15/24 around 11 P.M., and saw the resident had a small bruise on her arm. LN 8 stated he asked Resident 1 what had happened, and the resident told him two days ago Resident 3 came into her room. LN 8 stated Resident 1 told him she told Resident 3 to get out and then Resident 3 had grabbed her remote and started hitting her arms and that they "tussled over it." LN 8 stated he reported Resident 1's allegation on 1/15/24 when the resident told him about it because it was an allegation of abuse. LN 8 stated he asked CNA 4 what had happened on 1/13/24. LN 8 stated CNA 4 did not tell him that Resident 1 had alleged she was hit. LN 8 stated CNA 4 should have reported Resident 1's allegation of abuse on 1/13/24 when she first had knowledge of it. LN 8 stated, "You don't have to see it to report the resident's allegation." On 2/8/24 at 8:50 A.M., an interview was conducted with the ADM. The ADM stated staff had to report all allegations of abuse immediately to their supervisor or the ADM. The ADM stated staff did not have to witness the abuse to report it. The ADM stated Resident 1's allegation of abuse had not been reported timely and this was not done according to her expectations. On 2/8/24 at 10:10 A.M., a joint interview and record review was conducted with the ADM. CNA 4's employee training titled Abuse, Neglect, and Exploitation in the Elder Care Setting completed on 10/12/23, was reviewed. The ADM stated this training included reporting of abuse allegations and was assessed with a post test. On 2/8/24 at 12:55 P.M., a telephone interview was conducted with LN 11. LN 11 stated she was working on 1/13/24, and had been assigned to provide care to Resident 1 and Resident 3. LN 11 stated CNA 4 had not informed her of any altercation between the residents, nor of any allegation of abuse. LN 11 stated CNA 4 should have told her of Resident 1's allegation of abuse so she could have reported it on 1/13/24 when it happened. On 2/8/24 at 1:47 P.M., a joint interview was conducted with the facility's ADM, DON, and corporate clinical consultant (CCC). The ADM and CCC both stated the facility's abuse policies had not been implemented related to abuse reporting. The CCC stated Resident 1's allegation of abuse had not been reported to CDPH timely. A review of the facility's policy titled Abuse, Resident-to-Resident revised 5/2007, indicated, "...5. Immediately notify the administrator and the director of nursing... 7. Notify the family/guardian, physician, and state agency(ies) as required...." A review of the facility's policy titled Abuse: Prevention of and Prohibition Against revised 1/2021, indicated, "...H. Reporting/Response 1. All allegations of abuse...should be reported immediately to the administrator. 2. Allegations of abuse... will be reported outside the facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations...." In violation of the above cited standards, the facility failed to ensure its abuse policies were implemented when certified nursing assistant (CNA) 4 did not report Resident 1's allegation of physical abuse. In addition, the facility did not report the allegation of abuse within 24 hours to the California Department of Public Health (CDPH, state survey agency that regulates nursing homes) and law enforcement entity as was mandated by law. As a result, investigation into the allegation of abuse was delayed and placed residents at risk for further abuse. This violation threatened the patients' safety, health, and psychological well-being.