Health inspection·April 6, 2023

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. The following citation is written as a result of complaints #CA00827559 & CA00827571. An unannounced visit was made to the facility on 2/21/23, at 12:55 p.m., to investigate an allegation of abuse. The Department determined the facility failed to: Implement State law related to alleged and suspected patient abuse and abuse reporting when the facility administrator failed to report an allegation of abuse to the Department. Patient 1 was admitted to the facility in the winter of 2023 with endocarditis (infection of heart lining), stroke, heart failure, as well as multiple other diagnoses. During a review of Patient 1's Minimum Data Set (MDS, an assessment tool), dated 2/17/23, the MDS indicated Patient 1 had a BIMS (Brief Interview for Mental Status, an assessment tool) score of 14, indicating Patient 1 was cognitively (knowledge and memory) intact (healthy), but needed assistance in most Activities of Daily Living (ADLs). During a review of Patient 1's Progress Notes titled, "[Facility Name] Progress Notes," on 2/17/23, at 11:23 a.m., Patient 1 complained of chest pain and was transported to (name of acute [urgent] hospital emergency department.) During Patient 1's stay in the emergency department she reported to the nursing staff and the Licensed Clinical Social Worker (LCSW), that she had been hit on the right side of her face by a caregiver at [Facility Name]. Patient 1 described the caregiver as Asian and about 5'8" with brown hair and brown eyes. Patient 1 denied knowing the caregiver's name. During an interview with Patient 1 on 2/22/23, at 1:15 p.m., Patient 1 indicated that the caregiver was changing Patient 1's soiled brief when the caregiver accidently hit her (Patient 1) on the right side of her face with a closed hand. Patient 1 denied injury and stated that she believed it was an accident. Patient 1 described the caregiver as being from Indian descent, with an unknown name but stated, "the one who is always rough." Patient 1 had no further description of the caregiver. Patient 1 further stated she was receiving good care and had no complaints or concerns. During an interview on 2/21/23, at 1:50 p.m., with the Administrator, the Administrator indicated that at 11:00 p.m. on Saturday evening (2/18/23) he received a call from "a staff member" at the acute care facility regarding an allegation by Patient 1 that she had been hit on the right side of her face and handled roughly by one of the caregivers at this facility. The Administrator indicated he agreed to "take the resident back" into this facility. The Administrator said he had spoken to Patient 1 one time since her return from the hospital and that she was "doing fine." The Administrator indicated he had not reported the abuse allegation to the state as he "did not have to report or investigate because the resident had not reported it to him or his staff." The Administrator indicated that he had been given the direction that anytime care was provided for Patient 1, two staff members should always be present to prevent any further allegations of abuse or rough handling. The Administrator further indicated it was up to the acute hospital to report the abuse as Patient 1 had reported it to hospital staff, not him. The Administrator indicated he had not done an investigation into the allegation, as Patient 1 had not reported the incident to him or his staff. The Administrator further indicated that he believed it was the obligation of the staff at the acute care facility to report the abuse allegation. During a review of the facility policy titled "Abuse Reporting and Investigating," revised July 2017, the policy indicated, "All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property, will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: The State licensing/certification agency responsible for surveying/licensing the facility...report allegations involving abuse (physical, verbal, sexual, mental) not later than two (2) hours after the allegation is made." In violation of the above cited standards, the Department determined the facility failed to: Implement State law related to alleged and suspected patient abuse and abuse reporting when the facility administrator failed to report an allegation of abuse to the Department. This violation had a direct or immediate relationship to the health, safety or security of patients or residents.