Health inspection·May 17, 2024

F609 Reporting of Alleged Violations Section 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Section 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. Section 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. The following citation was written as a result of an unannounced visit to the facility on 4/26/24 for the investigation of the facility reported incident #CA00896900. As a result of the investigation, the Department determined the facility failed to report an allegation of abuse for Resident 1 as required by the regulations. This failure resulted in 4 (four) days delay in investigations and caused Resident 1 to be fearful of living in the facility. Resident 1 was admitted by the facility in April 2024, with diagnoses which included depression and difficulty walking. A Minimum Data Set (MDS, an assessment tool), dated 4/23/24, contained a Brief Interview for Mental Status (BIMS, tests memory and recall) with a score of 13 out of 15 which indicated Resident 1 was cognitively intact. On 4/24/24, the Department received a report from the facility for an alleged abuse event which occurred on 4/20/24. No report of this event was received by the Department prior to 4/24/24. The report indicated that on 4/24/24, Resident 1 alleged Resident 2 "...touched me, he kept getting closer and then grabbed my shirt and pulled up. I am afraid to be here after that has happened that is why I haven't been leaving my room. I am scared he will do it again ..." Resident 1 enquired from LN 1 if anything had been done about the incident. LN 1 stated to Resident 1 that the incident had not been reported but she would do that right away. LN 1 called Resident 1's daughter who confirmed that the incident occurred on 4/20/24 and Resident 1 had mentioned to LN 2 about it in her presence and; LN 2 had indicated to Resident 1 and her daughter on 4/20/24 that "that is not okay, and I will report this." A review of an email statement, dated 4/26/24, written at 12:10 p.m. and titled, 'LN2's statement' indicated LN 2 was giving medications to Resident 1 and the resident's daughter was at the bedside. Resident 1 told LN 2 and her daughter that she was out in the common area in her wheelchair with the rest of the residents when Resident 2 started tugging her pants and behaving inappropriately towards her. LN 2 in her statement stated that she spoke to Resident 2 about the incident and stated that it was not okay, and he [Resident 2] should not touch other residents. In an interview on 4/26/24 at 1:03 p.m. with the Director of Nursing (DON), the DON stated that the Assistant Director of Nursing (ADON) who conducted the investigation identified the nurse who worked with Resident 1 when the incident occurred on 4/20/24. The DON stated LN 2 did not call her, or the administrator and she did not see any documentation related to the incident. The DON stated her expectation from the staff was that these incidents should be reported within two hours. In an interview on 4/26/24 at 1:35 p.m. with the Director of Staff Development (DSD), DSD stated " ...when incidents like this happens, all the staff are responsible, they are mandated reporters and should file an SOC 341 [a form used to report allegations of abuse to the authorities], they all should know that it has to be reported as soon as possible and no later than 2 hours ...it is terrible that it was not reported ... " In an interview on 4/26/24 at 5:31 p.m. with the ADON, the ADON stated that she had conducted the investigation and spoken to LN 2. The ADON further stated that when talking to LN 2, LN 2 verbalized that it was on 4/20/24 that Resident 2 touched Resident 1 inappropriately. ADON confirmed LN 2 did not report the incident, did not document it and no progress notes were completed. A review of the facility's policy and procedure titled, "Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating", revised on September 2022 indicated that, "... if resident abuse ...is suspected, the suspicion must be reported immediately to the administrator and to the other officials according to state law ... ' Immediately' is defined as within two hours of an allegation involving abuse ..." This failure resulted in a delay in the abuse investigation process and decreased the facility's potential to protect residents from physical and psychosocial harm. Therefore, the Department determined the facility failed to report an allegation of abuse for Resident 1 as required by the regulations. This violation had a direct or immediate relationship to the health, safety, or security of long-term care residents.