Other·September 21, 2023

Health & Safety Code 1418.91(a) and 1418.91(b) (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 7/6/23 at 10 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding an allegation of financial abuse from a staff member (MS1) towards Resident 1. Resident 1 is an 83-year-old male with diagnoses of Cerebral Palsy (is caused by abnormal brain development or damage to the developing brain that affects a person's ability to control his or her muscles), generalized muscle weakness, and glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve). Based on interview and record review, the facility failed to follow its policy on "Abuse Investigation and Reporting" for one of three sampled residents (Resident 1) when the facility did not report an allegation of financial abuse to the California Department of Public Health (CDPH). This failure had the potential for Resident 1's allegation of financial abuse to not be investigated and be at risk for continued abuse. Findings: During an interview on 7/5/23 at 10:45 a.m. with Resident 1, Resident 1 stated, a few weeks ago, approximately the end of June 2023, Maintenance Staff (MS) 1 borrowed 200 dollars from him. Resident 1 stated, (MS) never gave him his money back. Resident 1 stated, he informed Maintenance Director (MD) his money was missing, a week after it was borrowed and not returned by MS 1. During a review of Resident 1's Brief Interview for Mental Status (BIMS: assessment used to determine mental status), dated 5/31/23, the BIMS indicated, a score of 14 (a score of 13-15 indicates the resident is cognitively intact). During an interview on 7/5/23 at 11:50 a.m. with MD, MD stated, around two weeks ago, approximately the last week of June 2023, Resident 1 informed him, MS 1 borrowed 200 dollars and MS 1 never gave the money back to Resident 1. MD stated, he notified the Administrator and Social Services (SS) about the allegation of financial abuse the same day, he was notified by Resident 1. During an interview on 7/5/23 at 12:05 p.m. with SS, SS stated, she was informed by MD around the last week of June 2023, Resident 1 had 200 dollars missing. SS stated, she did not report the allegation of financial abuse to the CDPH. SS stated, the Administrator normally does the investigation and reporting for abuse allegations. SS stated, she did not have any documentation regarding the allegation of financial abuse by Resident 1. During an interview on 7/5/23 at 12:15 p.m. with Administrator, Administrator stated, he did not report the allegation of financial abuse because, "It was not clear that the money was gone". Administrator stated, he spoke with MS 1 who denied borrowing money. Administrator stated, the facility did not report the allegation of financial abuse to the CDPH. During a review of Resident 1's Progress notes, dated 6/1/23-7/6/23, the Progress Notes was reviewed. There was no documentation regarding the allegation of financial abuse by Resident 1. During a review of the facility's policy and procedure (P&P) titled, "Abuse Investigation and Reporting" dated 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. . . 5. The administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident." In violation of the above cited, the facility failed to report an abuse allegation timely to the CDPH. This failure had the potential for Resident 1's allegation of financial abuse to not be investigated and be at risk for continued abuse. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and constitutes a class "B" citation.