Other·March 13, 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. This citation is written as a result of complaint # CA00878419. On 1/9/24 an unannounced visit was conducted at the facility to investigate an allegation of abuse and theft/misappropriation of resident property 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's Social Services Director received an email and 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 October 2021 with multiple diagnoses which included pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region (near base of the spine) and type 2 diabetes mellitus (a disease where blood sugar is too high). Resident 1 was her own responsible party. During an interview and concurrent document review on 1/9/24, at 12:35 p.m., with the SSD, the SSD confirmed she received an email on 1/5/24 at 4:41 p.m. with a complaint that Resident 1 ' s roommate had eaten Resident's snacks while she slept. The email indicated Resident 1 is, " ...frightened by this invasion ...continues to feel unsafe." The SSD acknowledged she did not report the allegation to state agencies or had spoken to Resident 1 regarding the incident. The SSD stated, "Have not had a chance to follow up." During an interview on 1/9/24, at 12:50 p.m., with Resident 1, Resident 1 stated a few days ago, while she slept, her roommate had eaten her cookies and chips. Resident 1 stated she had texted her friend immediately that night and told her what had happened. Resident 1 stated, "Have not been able to sleep ...feels emotionally unsafe ...no one in management has came (sic) in." Resident 1 confirmed that no one in management had spoken to her about the incident since it had been reported. During an interview on 1/10/24, at 10 a.m., with Resident 1, Resident 1 confirmed she had not spoken to the Administrator or Director of Nursing (DON). Resident 1 stated, "Was hoping they would ...starting to give up hope that anything would be done." During an interview on 1/10/24, at 11:30 a.m., with the DON, the DON confirmed he had received an email on 1/5/24 with a complaint that Resident 1 had her snacks eaten by her roommate and that the email stated Resident 1 had felt unsafe. The DON confirmed he had not submitted an SOC 341 (a document used to report alleged abuse) to California Department of Public Health (CDPH). During a review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" [undated], the P&P indicated, "All reports of resident abuse ...or theft/misappropriation of resident property are reported to local, state and federal agencies ...within 24 hours of an allegation that does not involve abuse or result in serious bodily injury." A review of a facility P&P titled "Abuse-Prevention Program", revised February 2020, indicated, "Policy... This facility does not condone any form of resident abuse...Prevention...The facility will prohibit all types of abuse...by identification...monitoring of residents with needs and behaviors which might lead to conflict...physically aggressive behavior..." Therefore, the Department determined the facility failed to report an allegation of abuse immediately or within twenty-four hours after the facility's Social Services Director received an email and was made aware of the allegation. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.