Other·January 25, 2024

California Health and Safety Code, 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately or within twenty-four hours. (b) Failure to comply with the requirements of the section shall be a Class B Citation. On 11/21/23, an unannounced visit was conducted at the facility to investigate an allegation of abuse. Resident 1's Facesheet, dated 11/3/23, indicated she was admitted to the facility for aftercare following a knee surgery. On 11/17/23 Resident 1 informed Occupational Therapist (OT) 1 (A health care worker who helps individuals resume daily tasks such as dressing) that a male occupational therapist (OT) inappropriately touched Resident 1 on her left breast The facility failed to Implement policies and procedures, and state law related to alleged patient abuse and abuse reporting when the facility failed to report an allegation of abuse to the Department within 24 hours. During a review of Resident 1's Facesheet (demographic and medical information sheet), dated 11/3/23, the Facesheet indicated Resident 1 was admitted for aftercare following a knee surgery. A MDS (Minimum Data Set, an assessment tool) dated 11/7/23, described Resident 1 as cognitively intact (able to follow instructions and make decisions). During an interview on 11/21/23 at 10:25 a.m. with Resident 1 in Resident's 1 room, Resident 1 was teary eyed and indicated that while unbuckling her gait belt (safety device to assist moving from bed to chair) the OT reached over her right shoulder and touched/rubbed her left breast. Resident 1 indicated she did not recall the exact date of the event but did tell a physical therapist (PT) the next day or after. During an interview with OT 1 on 11/21/23 at 11:50 a.m., OT 1 indicated that on 11/17/23, at around 3 p.m., Resident 1 stated that she was inappropriately touched by OT and would not work with him. OT 1 indicated that she did not know when the event occurred, but Resident 1 said it was the last time she worked with OT. OT 1 indicated she notified her director the same day. During an interview with the Rehabilitation Director (RD), on 11/21/23 at 11:08 a.m., the RD indicated OT 1 notified her in the afternoon on 11/17/23 (via text) that Resident 1 said the incident with OT happened a few weeks ago. Resident 1 said it was the last time OT and Resident 1 worked on dressing, and when trying to remove the gait belt, OT rubbed and touched her breast. RD indicated she notified her Regional Director but not the Facility Administrator (FA). During an interview with the FA, on 11/21/23 at 10:04 a.m., the FA indicated he was notified of the allegation against OT on the morning of 11/20/23. The FA indicated that the facility Abuse Policies and Procedures were not followed. Review of the facility policy titled "Abuse Prevention Program", dated 12/1/22, indicated "... The facility shall report any and all allegations of abuse to the District CDPH, Local Ombudsman and/or Local Law Enforcement, either by phone, email or facsimile, within 2-hour timeframe." In violation of the above cited standards, the facility failed to report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately or within twenty-four hours, including but not limited to the facility failed to Implement policies and procedures, and state law related to alleged patient abuse and abuse reporting when the facility failed to report an allegation of abuse to the Department within 24 hours. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.