Other·October 15, 2021

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 24 hours (b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation is written as a result of a facility reported incident #CA752510. An unannounced visit was made to the facility to investigate a facility reported incident, received on 9/13/21, at 1:22 p.m., related to a resident's complaint of staff abuse. The Department determined the facility failed to report an allegation of abuse immediately, or within 24 hours as required, when Licensed Nurse (LN) 1 and LN 2 did not report alleged abuse of Resident 1 by certified nurse assistant (CNA) 1 on 9/10/21, per the facilities policy, and State law. This failure put Resident 1 and other residents in the facility at risk for abuse. Findings: Resident 1 was admitted to the facility with diagnoses which included bi-polar disorder (high energy mood with depressive episodes), and depression. Her Minimum Data Set (MDS, an assessment tool), dated 7/21/21, revealed Resident 1 had a Brief Interview for Mental Status (BIMS) score of "8", which indicted Resident 1 had mild cognitive impairment. During a concurrent observation and interview on 9/27/21, at 10:01 a.m., Resident 1 was lying in bed with a long, thin, faded bruise visible on her left forearm. When asked how she had gotten the bruise, Resident 1 stated two staff members were changing her at night and one of them stabbed a needle into her arm. When asked if she told anyone about the incident, Resident 1 stated she thought she told LN 1. Resident 1 was unable to remember the date of the incident. During an interview on 9/27/21, at 3:42 p.m., LN 2 stated on the evening of 9/10/21, CNA 1 and CNA 3 provided care to Resident 1. Afterwards, CNA 3 informed him Resident 1 alleged CNA 1 hit her. LN 2 explained when he entered Resident 1's room she was crying, and stated CNA 1 hit her while providing care. When asked, LN 2 confirmed Resident 1 had a visible bruise to her left forearm. LN 2 stated he did not document the alleged abuse in Resident 1's clinical record or report the incident to the administrator or state agency but should have. During an interview on 9/28/21, at 9:19 a.m., CNA 1 stated she was not Resident 1's CNA the evening of 9/10/21 but was asked by CNA 3 to help provide care to Resident 1. CNA 1 stated Resident 1 became combative during care and afterwards accused CNA 1 of hitting her. When asked if this was a reportable incident, CNA 1 stated yes and CNA 3 had reported the incident immediately to the charge nurse. During an interview on 9/28/21, at 10:43 a.m., LN 1 stated on 9/11/21, she noticed a bruise to Resident 1's left forearm and asked her what happened. Resident 1 stated she could not remember how she had gotten the bruise. On 9/12/21, LN 2 stated Resident 1 reported a CNA had hit her causing the bruise. When asked if she reported the allegation of abuse, LN 2 stated she did not, but should have reported it to the administrator immediately. During an interview on 9/28/21, at 11:02 p.m., the assistant director of nursing (ADON) confirmed during her investigation on 9/13/21, LN 1 and LN 2 did not follow the facility's protocol for reporting abuse. A review of the facility's policy and procedure titled, "ABUSE PREVENTION, INTERVENTION, INVESTIGATION & CRIME REPORTING POLICY", revised 11/2016, indicated, "...all employees will be trained on recognizing and identifying actual or suspected occurrences of abuse...It is the responsibility of all employees to immediately report to the facility administrator, and to other officials in accordance with Federal and State law, any incident of suspected or alleged abuse..." Therefore, the Department determined the facility failed to report an allegation of abuse immediately, or within 24 hours as required, when Licensed Nurse (LN) 1 and LN 2 did not report alleged abuse of Resident 1 by certified nurse assistant (CNA) 1 on 9/10/21, per the facilities policy, and State law. This violation had a direct or immediate relationship to the health, safety, or security of long-term care facility residents.