Other·June 25, 2024

897935 BPSV B citation draft The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00897935. Representing the Department, HFEN #46980. 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. On 5/2/24 at 2:42 P.M., an unannounced visit was conducted at the facility to investigate a complaint regarding alleged abuse by staff members against a resident. It was determined that the facility failed to ensure: 1. Repeated allegations of abuse by staff against a resident were reported to the California Department of Public Health (CDPH) after the Administrator, Director of Nursing and Social Worker were notified of allegations by the resident via email multiple times. As a result of these failures, the investigation was delayed and placed Resident 1 at further risk of harm. Based on interview and record review, the Facility failed to report allegations of abuse by staff members against one resident, Resident 1. Resident 1 reported feeling violated while in the Facility. Resident 1 was admitted to the Facility on 10/18/23, with diagnoses that included acute osteomyelitis left ankle and foot (inflammation of bone), anxiety (a condition which creates excessive worry or nervousness about real or perceived threats), alcohol abuse and withdrawal (unhealthy consumption of alcohol accompanied by physical and psychological symptoms when alcohol consumption stops), and unspecified psychosis not due to a substance or known physiological condition (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality) . On 5/2/24 at 12:36 P.M., a telephone interview was conducted with Resident 1 who was no longer residing in the Facility. Resident 1 stated, "In the past week one of the nurses drug her finger up my inner thigh to wake me up during the night shift ... I reported to the old and new Social Worker (SW) and to the Director of Nursing (DON) and Administrator (ADM). I talked to the Ombudsman with the ADM and SW. The DON herself sexually made advances on me. I am so hurt and violated. I thought the ADM was going to handle all of this." On 5/2/24 at 2:42 P.M., an unannounced visit was made to the facility. A review of an email dated 10/26/23 at 3:58 P.M., provided on 5/2/24 by Resident 1 was reviewed. The email was sent to the SW, DON and ADM. The email indicated, "To all: I (Resident 1) have put up with assaults, harassment, women entering my secured and safe 10 by 10 (WITH curtain DRAWN) and have asked to have an INCIDENT REPORT DONE. I ASKED (name of ADM) AND SOCIAL SERVICES FOR THE INCIDENT REPORTS." A review of an email dated 4/23/24 at 6:52 A.M., provided on 5/2/24 by Resident 1 was reviewed. The email was sent to the SW, DON, and ADM. The email indicated, "This morning at 5:50 a.m. [sic] (name) doesn't knock comes in runs her fingers up from my ankle to my knees. ...I've texted the DON, (name of social worker) told (name) another med nurse and now I want to file a report as soon as anyone of authority comes to work. Once again ive [sic] got to deal with 100% PERVERT and illegal. Why is she touching me. No knock, nothing! Just touching and fondling." A review of an email dated 4/23/24 at 9:13 A.M., provided on 5/2/24 by Resident 1 was reviewed. The email was sent to the Facility SW, DON, and ADM. The email indicated, "Just straight to rubbing FINGERS from my ANKLE past my KNEE by your employee (Licensed Nurse 1) MED NURSE at 5:50 a.m. [sic] I asked her 3 times to leave AFTER being CAUGHT TOUCHING ME. She THEN threatened me, telling me she'd hold my medications in the future." An interview and concurrent record review were conducted with the ADM on 5/2/24 at 3:35 P.M. The ADM stated, "I did an investigation regarding (LN 1) about one week ago, I knew the allegation was false, so I didn't report it." The ADM stated no other investigations were done. The facility policy entitled "Abuse - Reporting and Investigations" revised 12/21/23 indicated, "The Administrator or designated representative will notify law enforcement by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of initial report. The Administrator or designated representative will send a written SOC341 (a report of suspected or known abuse) report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within twenty-four (24) hours." The facility policy entitled "Abuse - Prevention, Screening, & Training Program" revised July 2018 indicated, "The Facility provides and staff sign an acknowledgement of their responsibility to report alleged or suspected abuse, neglect, exploitation, misappropriation of resident property and/ or mistreatment." In violation of the above cited standards, the facility failed to ensure: 1. Allegations of abuse were reported to the California Department of Public Health after a resident alleged abuse by staff. As a result of these failures, the investigation was delayed and placed Resident 1 at further risk of harm. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.