Health inspection·August 5, 2024

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 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. This citation is written as a result of complaints # CA00906717 and #CA00907828. On 6/26/24 and 7/3/24 an unannounced visit was conducted at the facility to investigate allegations of abuse and neglect reported to the Department. As a result of the investigation, the Department determined the facility failed to report an allegation of abuse immediately or within twenty-four hours after the facility staff was made aware of the allegation. During a review of Resident 1's face sheet (a document containing patient information), Resident 1 was admitted to the facility November 2018 with multiple diagnoses which included fibromyalgia (chronic widespread pain), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), chronic pain, absence of left upper limb below elbow, and absence of right leg above knee. A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 4/19/24, indicated, Resident 1 had no memory problems. Resident 2 was admitted to the facility October 2023 with multiple diagnoses which included dementia (general term for loss of memory, language, and other thinking abilities) and brief psychotic disorder (mental disorder that causes abnormal thinking and perception). A review of Resident 2's MDS dated 5/2/24, indicated, Resident 2 had short term and long term memory problems and had severely impaired cognitive skills for daily decision making. During an interview on 6/26/24, at 1:34 p.m., with Resident 1, Resident 1 stated that on 4/9/2024 she was slapped on her arm by Resident 2 while walking in the hallway near the Nurse's Station. Resident 1 confirmed staff were present and aware of the incident. Resident 1 further stated nothing was done by facility staff and she was fearful of Resident 2 and what he may do. During an interview on 6/26/24, at 4:35 p.m., with the Administrator (Admin), the Admin stated he was not aware of any allegations of Resident 1 being slapped in April 2024 and had not investigated or reported the incident to state agencies. During a review of Resident 1's care plan initiated on 4/9/24, indicated, "Claiming slapped her Left Arm by other res. [resident] unwitnessed & skin assessed..." During a review of Resident 1's "Progress Note" (PN), dated 4/9/24, the PN indicated, "...claiming that [Resident 2] slappedher [sic] arm & its unwitnessed incident, resident separated." During a review of Resident 1's "SBAR Communication Form" (SBAR), dated 4/9/24, the SBAR indicated, "Resident alert and oriented...Resident claiming that [Resident 2] slapped her Left arm & its unwitnessed incident, resident separated." During a review of Resident 2's progress notes, dated 7/2/24, indicated, "...allegation of psychological abuse on resident 203B [Resident 1]. Resident states "he masturbated and went to the bathroom on my floor..." During an interview on 7/3/24 at 11:14 a.m. with the ADON, the ADON stated Resident 1 notified her on 7/2/24 at 3:30 p.m. that Resident 2 went inside her room unsupervised, masturbated, and pooped of the floor. The ADON also stated Resident 1 showed her the videos she took when Resident 2 went inside her room. The ADON further stated she reported the alleged incident to the state agency on 7/2/24 at around 4:30 p.m. The fax receipt of the sent report was requested, the ADON then explained that the fax receipt was in the Administrator's office, and she will provide it once her administrator is back on Monday the following week. During an interview on 7/3/24 at 11:45 a.m. with Resident 1, in Resident 1's room, Resident 1 stated, "...I saw him [resident 2] come inside the room and stood next to the curtain, I yelled at him to get out...he [Resident 2] started masturbating first and then he pooped on the floor." Resident 1 showed a video of Resident 2 standing inside her room next to a clump of brownish material, beside the door area, with Resident 2's pants down and was touching his own genitals. The video recording had a date and time stamp of 7/2/24 at 2:47 p.m. Resident 1 further stated, "I was so scared that time...I was shaking, and I got dizzy this morning, I got so stressed..." The fax receipt of the abuse allegation report sent to the state agency on 7/2/24 was again requested on 7/8/24 at 10:20 a.m. via e-mail to the Medical Record Assistant (MRA). No fax receipt was provided. The fax receipt of the abuse allegation report sent to the state agency on 7/2/24 was requested for the third time on 7/15/24 at 3:25 p.m. via e-mail to the MRA. No fax receipt was provided. A review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating", revised 9/22, indicated, "All reports of resident abuse...are reported to local, state and federal agencies (as required by current regulations) ...The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; ...e. Law enforcement officials; ...within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury." Therefore, the Department determined the facility failed to report an allegation of abuse immediately or within twenty-four hours after the facility's staff was aware and documented an allegation of abuse. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.