Other·September 14, 2022

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 facility reported incident #CA00792446. An unannounced visit was made to the facility on 7/12/22 to investigate a resident-to-resident altercation. The Department determined the facility failed to report an allegation of suspected physical abuse of Patient A by Patient B within 24 hours as required, when a physical abuse claim was first made on 7/1/22 and the facility reported it on 7/7/22. This failure resulted in a delay of the state survey agency investigating an allegation of abuse, which had the potential to put patients' health and safety at risk. Findings: A review of Patient A's Admission Record indicated Patient A was admitted to the facility in the Summer of 2022 with diagnoses which included difficulty in walking, muscle weakness, and dementia (a general term for loss of memory, language, problem- solving and other thinking abilities that are severe enough to interfere with daily life). A review of Patient B's Admission Record indicated Patient B was admitted to the facility in the Spring of 2022 with diagnoses which included dementia. On 7/7/22, the Department received a report alleging Patient A was pushed out of his wheelchair by Patient B. The alleged date of the allegation was documented as 7/1/22. A review of Patient A's progress note, dated 7/7/22, at 4:52 p.m., indicated, "...Alleged abuse reported between [Patient A] and another resident [Patient B]..." A review of Patient A's progress note, dated 7/7/22, at 5:30 p.m., indicated, "...[Patient A's] fall incident on July 1st...[Patient A] verbalized that somebody pushed him that is why he fell..." During an interview on 7/15/22, at 10:23 a.m., certified nursing assistant (CNA) 1 stated on 7/1/22 she went outside to the back patio and found Patient A lying on the ground and Patient B was standing behind Patient A's wheelchair. CNA 1 further stated Patient A told her later that day while in his room that a tall white man had pushed him out of his wheelchair. CNA 1 explained she reported Patient A's incident as an alleged abuse allegation to the charge nurse right away. During a phone interview on 7/15/22, at 12:11 p.m., licensed nurse (LN) 1 confirmed CNA 1 had reported to her on 7/1/22 about Patient A's alleged abuse allegation against Patient B. LN 1 further confirmed she did not document or report the abuse allegation. LN 1 stated she thought since the alleged allegation was not witnessed it did not have to be documented or reported. LN 1 further stated it was a mistake and she should have reported the incident as abuse to her supervisor and Administrator right away. During an interview on 7/15/22, at 10:42 a.m., the Social Service Director (SSD) confirmed LN 1 did not report the abuse allegation between Patient A and Patient B and it should have been done. The SSD stated the risk for not reporting an abuse allegation could be harmful to the resident. The SSD stated all abuse allegations needed to be reported right away to the appropriate agencies and had to be documented. During an interview on 7/15/22, at 10:50 a.m., the Director of Staff Development (DSD) stated she expected all staff to report any abuse allegations immediately. During an interview on 7/15/22, at 10:56 a.m., the Administrator (ADM) acknowledged LN 1 failed to report Patient A's claim against Patient B on 7/1/22 as an abuse allegation. The ADM stated it should have been done because LN 1 was a mandated reporter. Review of facility policy titled, "ELDER AND DEPENDENT ADULT SUSPECTED ABUSE & REPORTING," dated 11/28/17, indicated, "...Mandated reporters shall report any such incidents by staff, visitors, or residents...All suspected/alleged or witnessed abuse...shall be immediately reported..." Therefore, the Department determined the facility failed to report an allegation of suspected physical abuse of Patient A by Patient B within 24 hours as required, when a physical abuse claim was first made on 7/1/22 and the facility reported it on 7/7/22. This failure had direct or immediate relationship to the health, safety, or security of patients.