Health inspection·July 11, 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. The following citation is written as a result of facility reported incident #CA00898421. An unannounced visit was made to the facility on 5/9/24 to investigate an allegation of abuse. The Department determined the facility failed to: Implement State law related to alleged and suspected resident abuse and abuse reporting. During review of Resident 1's Face Sheet (a document with information), the Face Sheet indicated Resident 1 was his own responsible party and he was admitted to the facility in April of 2024 with multiple diagnoses including Chronic Lymphocytic Leukemia of B-Cell Type (a type of blood cancer) and Vesicointestinal Fistula (a form of tube between the bladder and the bowel). A review of Resident 1's Progress notes, Nurses Progress Note, dated 5/6/24, at 2:01 a.m., indicated, "0145 [1:45 a.m.] CNA (Certified Nursing Assistant) heard commotion in room 7... [name of Resident 1] walked over to tell roommate to stop talking loudly and roommate grabbed [name of Resident 1]'s hand (roommate laying in bed at this time), and [name of Resident 1] pulled own hand away accidentally touching roommate in the face." During review of Resident 2's Face Sheet (a document with information), the Face Sheet indicated Resident 2 was his own responsible party and he was admitted to the facility in January of 2024 with multiple diagnoses including Prepatellar Bursitis, Right Knee (condition that causes the front of your knee to swell) and Cellulitis of Left Lower Limb (a skin infection caused by bacteria). A review of Resident 2's Progress notes, Nurses Progress Note, dated 5/6/24 at 2:00 a.m., LATE ENTRY, Indicated, "At 0145 CNA heard commotion in room 7. CNA and LN (Licensed Nurse) entered room and saw [name of Resident 1} standing over {name of Resident 2]...Upon interview with [name Resident 2], he stated he doesn't know what happened...Head to toe assessment faint discoloration noted to left eye 5x7 cm, along with below left eye laceration...[name of ambulance company] picked up [name of Resident 2] at approx [approximately] 3 a.m. VSS remained stable. Cont [continue] to deny pain at this time." During an interview on 5/9/24, at 11:18 a.m., with Director of Nursing (DON), DON stated he was made aware of the incident by text message. The DON added that the Ombudsman, CDPH, and Police were notified. When asked what time the agencies were notified, DON said he need to check with [name of Administrator]. During an interview on 5/9/24, at 12:03 p.m., with Licensed Nurse (LN) 1, LN 1 stated she received abuse training and that it needs to be reported to the abuse coordinator within two hours. She added, "verbal, physical, psychological, and financial abuse needs to be reported to the state right away." During an interview on 5/9/24, at 12:08 p.m., with Social Services Director (SSD), SSD stated she received training for abuse and reporting and added that allegations of abuse must be reported within two hours. During an interview on 5/9/24, at 12:19 p.m., with Director of Staff Development (DSD), DSD stated she "expects staff to follow the policy and procedure, to notify the abuse coordinator immediately when they suspect or witnessed any type of abuse, and to follow the procedures to report abuse at the right time." She added that the incident between Resident 1 and Resident 2 should have been reported to the state within two hours. During an interview on 5/9/24, at 12:42 p.m., with the Administrator (ADM), ADM stated that the DON notified him of the incident at 7:30 a.m. and confirmed that the state was not notified within 2 hours of the alleged abuse incident. In a review of "E-mail communication" (messages distributed by electronic means) with the DON, dated 5/14/24 at 3:18 p.m., the E-mail indicated, "[name of staff] sent me a text when it occurred around 1:52 AM...I was home when [staff] informed me, I contacted [Administrator's name] when I saw the text at 0730 am." A review of the facility's Abuse Investigation Report, [Resident 1's name vs. Resident 2's name], dated 5/6/24, indicated, "On May 6, 2024 at approximately 1:50 a.m. at Cedarwood Post-Acute, [name of CNA] made the [name of nurse supervisor] aware of a res-res abuse after she heard elevated voices and entered room 7...DON called [Administrator's name (NHA)] to report occurrence when DON was made aware of the situation...Nurse written up for not calling and waking up DON/NHA to report abuse...CDPH was called at 9:16 a.m. about this and they informed me to fax it over." A review of the document "Fax Transmission Result" dated 5/6/24 at 8:23 p.m. PDT (Pacific Daylight Time), indicated the 24-hour SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) [Resident 1' name].pdf (short for portable document format files) was successfully sent to the following phone numbers; +1 (916) 263 5841 Monday, May 06, 2024 at 11:21 PM, +1 (916) 376 8914 Monday, May 06, 2024 at 11:22 PM, and +1 (916) 808 0636 Monday, May 06, 2024 at 11:23 PM. A review of the document, "Resident Abuse Investigation Report Form," indicated "Date Incident Occurred: 4/6/24 Time: 01:45am...Date Incident Reported: 4/6/24 informed at 7:30am, contacted CDPH at 9:16am Time: 09:16am..." A review of the facility's policy titled, "Reporting Allegations of Abuse/Neglect/Exploitation", dated 1.1.2024, indicated, "5. Alleged violation: A situation or occurrence that is observed or reported by staff, resident, relative, visitor or others...8. Reporting/Response: The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required...Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation: ...1. The Facility will: ...h. Notify the appropriate agencies immediately: as soon as practically possible, no later than two hours after observing, obtaining knowledge of, or suspecting the alleged abuse or neglect." 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 clients.