Health inspection·January 2, 2025

Health & 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. On 11/12/24 at 8 a.m. an unannounced visit was conducted at the facility to perform the facility's recertification survey. A record review of Patient 21's "Behavior Note" created 8/2/24 at 3:42 a.m. written by LN 4, indicated, " ... [LN 4] went to [Patient 21's] room with 1 CNA for witness ... [Patient 21] started to claim and shown a bruise purplish on his R posterior hand radial side. Approximately 3x3 cm. No noted open skin noted. [Patient 21] claimed that it was inflicted last night (8/1/2024 noc [night]) when he was being changed by 2 CNAs, he described the event as follows. When the CNAs are changing me (the female CNA), she was playing with my [anus] ...and the male CNA held my arm down. This is why I have this (pointing to the bruise) ..." The facility failed to report this allegation of abuse to the department within 24 hours. A review of Patient 21's admission record indicated Patient 21 was admitted to the facility in March 2024 with diagnoses including intracerebral hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain) and hemiplegia (complete paralysis) and hemiparesis (partial paralysis) to the left dominant side. During an interview on 11/13/24 at 10:38 a.m. in Patient 21's room, when asked if patient 21 had concerns with the way the facility addresses his mood, behaviors, and care planning, Patient 21 stated, "I keep telling them [I need help], I'm scared I'm going to die here ...the staff don't care about me, they're going to let me die here ...the [Social Services Director (SSD)] is supposed to help me, but she doesn't. I want to get out of here ...they don't listen to me." During an interview on 11/15/24 at 1:43 p.m., CNA 4 stated if a patient notified her of an incident of abuse, "I would tell the nurse what happened ...verbally tell the nurse or any supervisor ...ask the person about the situation and then alert the nurse." CNA 4 indicated she would fill out paperwork if requested by the nurse and ask what else needs to be done. CNA 4 was unsure if an "abuse binder" is available. During an interview on 11/15/24 at 2:03 p.m., LN 2 stated, "If I received an allegation of abuse from a [patient], I would interview the [patient], get details and names, if the [patient] was willing to tell me ...I would notify the Director of Nursing (DON) and Administrator (ADM) ...check the policy and procedure (P&P) for abuse reporting ...complete a change of condition form, perform frequent checks on the [patient] ...and initiate behavioral monitoring." LN 2 added, "I'd let the state [California Department of Public Health (CDPH)] know of the allegation as soon as possible .... I know there's an abuse binder around here somewhere." During a concurrent interview and record review on 11/15/24 at 2:14 p.m. Patient 21's "Behavior Note" dated 8/2/24 was reviewed with the DON and ADM. The DON and ADM stated they were unaware of the abuse allegation. The DON stated when allegations of abuse, "I expected staff to start the 'abuse protocol'... which included notifying the facility's Abuse Coordinator (ADM), complete an SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) and to fax it to the number on form ...as well as notify myself and to monitor the [patient] ...notify the Medical Director (MD) and assess for physical injury." The DON added she does not have access to the SOC 341 reports; the ADM does. The ADM stated, "I would expect the incident to be reported to me immediately since I'm the abuse coordinator and to the proper authorities ...I would complete an investigation with the CNAs named in the allegation, make sure a physical assessment is completed on the [patient] and file the SOC 341." During a phone interview on 11/15/24 at 3:35 p.m. with LN 4, LN 4 stated she was familiar with Patient 21 and remembered the incident in question. LN 4 added, "[Patient 21] reported to me that two CNAs were changing him and the female one was playing with his [buttocks] ...I didn't see her doing that ..." and, "I'm definitely a mandated reporter [person legally required to report suspicion of abuse or neglect to the relevant authorities] for the [patients] ...for the bruise, I didn't know where he got it so I did a change of condition form ...no, I did not do anything for the sexual abuse allegation, it was a non-emergency situation, he wasn't in respiratory distress or anything." When questioned further about the details of the incident LN 4 stated, "I don't know when the allegation occurred ...I just documented everything [Patient 21] said ...I should have notified [DON] about the incident and allegations ..." A review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," revised September 2022 indicated, "All reports of [patient] abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of [patient] property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported ...If [patient] abuse, neglect, exploitation, misappropriation of [patient] property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law ...Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of [patient] property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of [patients] ...All allegations are thoroughly investigated. The administrator initiates investigations ...The administrator is responsible for keeping the [patient] and his/her representative (sponsor) informed of the progress of the investigation ... The investigator notifies the ombudsman that an abuse investigation is being conducted ...Within five (5) business days of the incident, the administrator will provide a follow-up investigation report." 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 24 hours, including but not limited to failure to report an allegation of abuse within prescribed timeframes. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.