Health inspection·April 12, 2023

The following reflects the findings of the California Department of Public Health during an Abbreviated Standard Survey facility reported incident #813768 and complaint #813512. The inspection was limited to the specific complaint investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the Department: 37697, HFEN A deficiency was written for Facility Reported incident #813768 and Complaint #813512 at F-Tag 610. Health & Safety Code 1418.91(a)(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. Based on interview and record review, the facility failed to report alleged abuse to the Department within 24 hours for one sampled resident (Resident 1). This resulted in the Department being unaware of the alleged abuse and for ongoing abuse to occur with no facility interventions. Findings: On 11/28/22, an unannounced visit was conducted at the facility to investigate a complaint regarding an allegation of abuse and neglect. Resident 1 was a 68 year-old female with diagnoses including: difficulty walking, history of a fractured left femur (thigh bone), depression, post-traumatic stress disorder (A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), pain, and requires assistance with personal care. During a review of Resident 1's Minimum Data Set (MDS) assessment (comprehensive assessment tool) dated 8/22/22, the "Brief Interview for Mental Status (BIMS - an assessment of a resident's cognitive function) score was reviewed. Resident 1 had a score of 10 which indicated the resident had moderately impaired cognition. The "Functional Status" indicated, Resident 1 required extensive one-person assistance with her bed mobility, dressing, and personal hygiene activities. During an interview on 11/28/22, at 2:49 PM, with Resident 1, Resident 1 stated, during a shower (unable to give date) Certified Nursing Assistant (CNA) 1 threw a shampoo bottle and the resident's clothes at her in a very hard manner. Resident 1 stated during the shower, CNA 1 "jerked" the resident's leg that had a fracture (left leg) up and down. Resident 1 stated the jerking caused her to experience pain and cry. Resident 1 stated she informed Licensed Vocational Nurse (LVN) 1 what had occurred in the shower, but nothing was done. Resident 1 stated the following day (no date given), CNA 1 entered her room and purposefully pressed on her left hip to cause pain. Resident 1 stated she told CNA 1 to stop because CNA 1 was hurting her, but CNA 1 continued to purposefully press on Resident 1's leg three to four more times. Resident 1 stated she reported this second incident to LVN 1 who assured her that she would not allow CNA 1 to provide care for her. Resident 1 was crying while recounting the incidents. During an interview on 11/28/22, at 3:15 PM, with LVN 1, LVN 1 stated, Resident 1 approached her approximately two weeks ago (no date given) and stated CNA 1 was physically and verbally abusive to her during a shower. LVN 1 stated she did not remove CNA 1 from providing care to Resident 1 after the allegation was made. LVN 1 stated she monitored CNA 1 the rest of the shift to ensure Resident 1 and other the residents were safe. LVN 1 stated the next day Resident 1 told her CNA 1 entered her room and was rough with her during care. LVN 1 stated she did not remove CNA 1 from the facility after the second allegation was made. LVN 1 stated she switched CNA 1's assignment so that she would not provide care to Resident 1, after the second allegation. LVN 1 stated she did not document any of the allegations or assessments of Resident 1 in the resident's medical record nor did she report the allegation of abuse. LVN 1 stated she did not initiate filing an SOC 341 (a form that documents information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult). LVN 1 stated, "I [LVN 1] allowed [CNA 1] to continue to provide care [to Resident 1 and other unidentified residents] because I [LVN 1] watched her [CNA 1] and she finished her shift with no complaints from other residents." During an interview on 11/28/22, at 4:03 PM, with Director of Nursing (DON), DON stated, she was not informed Resident 1 had reported alleged abuse by CNA 1. DON stated LVN 1 reported to her sometime last week (exact date not given) that Resident 1 was complaining of left hip pain. DON stated the facility ordered an x-ray of her hip due to a history of falling resulting in a fracture in October of 2022. DON stated her expectation is, "Any allegation of abuse we [facility] expect immediate reporting and the staff member accused of [abuse] we [facility] send them home." During a concurrent interview and record review, on 11/28/22, at 3:41 PM, with Director of Staff Development (DSD), the facility staffing schedule for 11/2022 was reviewed. DSD stated per the staffing schedule it appeared CNA 1 was changed room assignments on 11/21/22. DSD stated CNA 1 was last assigned Resident 1 on 11/20/22. DSD stated 11/20/22, was likely the date of the initial allegation of abuse in the shower by CNA 1 and 11/21/22, likely was the date of alleged incident of abuse in Resident 1's room. During an interview on 11/28/22, at 4:16 PM, with Administrator, Administrator stated, he was the abuse coordinator for the facility. Administrator stated he was not aware of the allegations of abuse submitted by Resident 1 to LVN 1 regarding CNA 1. Administrator stated his expectation is for staff to immediately report any allegation of abuse. Administrator stated any staff member accused of abuse is suspended immediately. Administrator stated the action by the facility is supposed to be immediate to ensure the safety of the residents and staff. Administrator confirmed CNA 1 was not removed from the facility after the initial allegation of abuse. Administrator confirmed CNA 1 should have been removed from the facility and not allowed to care for any other residents. During a review of the facility document titled "5 Day Summary Follow up" (DSFU), dated 12/2/22, the DSFU indicated, the facility was made aware of an allegation of abuse on 11/28/22 regarding an incident in the shower with Resident 1 and CNA 1 on 11/20/22 (eight days after allegation was made). The facility sent an SOC 341 to the Department on 11/28/22 (eight days after the initial allegation of abuse was made). During a review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," dated 4/2021, the P&P indicated, "Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse . . . The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives . . . Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to . . . facility staff . . . Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. . . Investigate and report any allegations within timeframes required by federal requirements. . . Protect residents from any further harm during investigations." During a review of the facility's P&P titled, ""Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," dated 9/2022, the P&P indicated, "All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. . . If resident abuse, neglect, exploitation, misappropriation of resident prope1ty or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. . . The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies . . . The state licensing/certification agency responsible for surveying/licensing the facility; The local/state ombudsman . . .The resident's representative . . . Law enforcement officials . . . The resident's attending physician . . .and The facility medical director. 'Immediately' is defined as . . . within two hours of an allegation involving abuse or result in serious bodily injury; or . . . within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. . . Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. . . Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents." In violation of the above cited, the facility failed to report alleged abuse and neglect to the Department within 24 hours for Resident 1. This failure resulted in alleged abuse to continue with no facility intervention and with the Department being unaware of alleged abuse. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents other than class "AA" or "A" violations and represents a Class B citation.