Health inspection·February 23, 2023

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 complaint #CA00819523. An unannounced visit was made to the facility on 1/20/23 to investigate an allegation of abuse. The Department determined the facility failed to: Implement State law related to alleged or suspected Resident abuse and abuse reporting. On 1/5/23, the Department received a report from the facility describing an incident between Residents 1 and 2 that involved possible abuse. Resident 1 was admitted to the facility in the fall of 2018 with weakness of one side, depression, memory impairment and mental illness. A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 12/16/22, indicated Resident 1 had moderate memory impairment and was independent in most Activities of Daily Living (ADL's). Resident 2 was admitted to the facility in the winter of 2022 with difficulty walking, muscle weakness and memory impairment. A review of Resident 2's MDS, dated 12/14/22, indicated moderate memory impairment. Resident 2 required extensive assistance with most activities of daily living. During a review of a facility document (FD), dated 12/25/22, the FD indicated, "On 12/24/22 @ approx. 6:24 pm [Resident 2] accidentally ran into [Resident 1] with his wheelchair, hitting his left handgrip into [Resident 1] right chest. [Resident 2] started swearing at [Resident 1] and [Resident 1] started swearing back at [Resident 2] and proceeded to hit him in his chest using his right hand. The nurse and the receptionist tried to separate Resident, but [Resident 2] was holding onto [Resident 1] wheelchair and not wanting to let go. [Resident 1] hit [Resident 2] again..." The FD indicated, "CDPH...Date Faxed 1/3/2023." During an interview on 1/17/23, at 11:45 am, with the Administrator (ADM) and the Director of Nurses (DON) both stated that they did not know why the incident on 12/24/22 was not reported within two hours, as required. The ADM and DON both stated they were aware of the reporting requirement. During a telephone interview on 1/18/22, at 3:45 pm, with Licensed Nurse (LN) 6, LN 6 stated that both the ADM and the DON were notified by her of the incident on 12/24/22 between Resident 1 and Resident 2 and stated that she was aware of the two-hour reporting requirement and was not aware the ADM or DON had not reported to CDPH. A review of the facility policy and procedure titled, "Abuse Prohibition Policy and Procedure," dated 2/23/21, indicated, "Upon receiving information concerning a report of suspected or alleged abuse, mistreatment... the CED [Center Executive Director] or designee will perform the following... Report allegations involving abuse (physical, verbal, sexual, mental) not later than two (2) hours after the allegation is made...Notify...Licensing District Office...as required..." The Department determined the facility failed to: Implement State law related to alleged or suspected Resident abuse and abuse reporting.