Health inspection·August 29, 2023

The following reflects the findings of the California department of Public Health during the investigation of a facility reported incidents 847700 and 847701. Health & 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. On 7/7/23, an unannounced visit was conducted at the facility to investigate a Facility Reported Incident regarding alleged abuse towards two long-term care residents (Resident 1 and Resident 2). Resident 1 was an 80-year-old male, admitted at the facility on 5/17/16. He had diagnoses of Parkinson's disease (a brain disorder that causes uncontrollable movements), Chronic Kidney Disease (kidneys cannot filter as well as they should), Obstructive and Reflux Uropathy (urine is unable to drain through the urinary tract), benign prostatic hyperplasia (enlarged prostate gland) and Peripheral Vascular Disease (narrowed blood vessels causing reduced blood flow). Resident 2 was a 66-year-old male, admitted to the facility on 12/15/22. He had diagnoses of End Stage Renal Disease (kidneys no longer work), Dependence on Renal Dialysis (treatment to clean the blood), Dysphagia (difficulty swallowing) and Dependence on Supplemental Oxygen (needs extra oxygen to breath). Based on interview and record review, the facility failed to implement their policy on "Abuse Investigation and Reporting" when the facility did not report an allegation of abuse within 24 hours to the California Department of Public Health (CDPH) for two of four sampled residents (Resident 1 and Resident 2). This failure resulted in delayed investigation of the suspected abuse and potential for continued abuse towards Resident 1 and Resident 2. Findings: During a review of Resident 1's "Self-Report: Suspected Abuse Investigation" (SAI), dated June 27, 2023, the SAI indicated, "[Certified Nurse Assistant (CNA) 1] reported to the [Director of Staff Development (DSD)] on 6/27/23 that when [CNA 1] worked on Saturday 6/24/23 . . .[CNA 1] witnessed [Licensed Vocational Nurse (LVN) 1] standing in the doorway of [Resident 1's room], [CNA 1] went on to state that it appeared she [LVN 1] was yelling at resident [1] . [CNA 1] stated that [LVN 1] had aggressive body language and her [LVN 1's] tone of voice was intimidating. [CNA 1] states that she couldn't recall what [LVN 1] was saying but [LVN 1's] tone and body language caught [CNA 1's] eye from down the hallway. " During a review of Resident 1's "Minimum Data Set" (MDS - an assessment tool), section C, dated April 5, 2023, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS - assesses mental processes) score of 15 (score of: 13-15 cognitively intact, 8-12 moderate impairment, 0-7 significant impairment). During a review of Resident 2's SAI, dated June 27, 2023, the SAI indicated, "[CNA 1] stated on 6/24/23 she witnessed [LVN 1] administer po [by mouth] medications to resident [2] while [Resident 2] was laying [sic] flat, [CNA 1] stated that [LVN 1] very quickly gave [Resident 2] the pills and quickly followed with water, [CNA 1] stated that the resident [2] struggled keeping up with [LVN 1] because [LVN 1] failed to announce she was giving [Resident 2] meds and [Resident 2] is blind. " During a review of Resident 2's MDS, Section C, dated May 3, 2023, the MDS indicated, Resident 2's BIMS score was 15. During an interview on 7/10/23, at 12:08 p.m., with Assistant Director of Nursing (ADON), ADON stated, CNA 1 reported the alleged abuse incidents to the DSD on 6/27/23, but the alleged abuse incidents occurred on 6/24/23 (three days before reporting). ADON stated, she reported the alleged abuse incidents to CDPH on 6/27/23 (three days later from the incident date). During an interview on 7/10/23, at 4:04 p.m., with CNA 1, CNA 1 stated, she witnessed LVN 1 (on 6/24/23) in the doorway of Resident 1's room when LVN 1's body language and tone of voice seemed aggressive towards Resident 1. CNA 1 stated, she could not remember exactly what LVN 1 said, it was something like "What? What else do you want?" CNA 1 stated, LVN 1 sounded "intimidating" and acted like Resident 1 was "bugging her." CNA 1 stated, she witnessed another alleged incident the same day, of LVN 1 towards Resident 2 in Resident 2's room when LVN 1 administered medication and water to Resident 2 while Resident 2 was laying down causing Resident 2 to struggle to swallow. CNA 1 stated, she did not report the alleged abuse incidents immediately. CNA 1 stated, these incidents occurred on 6/24/23, but CNA 1 waited to report on 6/27/23 to her supervisor. CNA 1 stated, "I could have figured it out, I could have gotten the number off of the bulletin board and called CDPH myself. " During a review of the facility's policy and procedure (P&P) titled "Abuse Investigation and Reporting," dated July 2017, the P&P indicated, "Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility. 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of an unknown source and misappropriation of property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury: or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury." In violation of the above cited, the facility failed to report an abuse allegation timely to the CDPH. This failure resulted in a delay of the investigation and potential continued abuse towards Resident 1 and Resident 2. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and Resident 2, and constitutes a class "B" citation.