Other·October 17, 2022

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 8/8/22, an announced visit was conducted at the facility to investigate a complaint regarding alleged abuse towards one long-term care resident (Resident 1). Resident 1 was a 63-year-old female, admitted to the facility on 3/8/22. Resident 1's diagnoses included alcohol abuse with alcohol induced psychotic disorder (a rare complication of chronic alcohol abuse following sudden termination of alcohol use, characterized by visual, auditory, or tactile hallucinations paired with intact orientation and stable vital signs) alcoholic cirrhosis of the liver (damage to liver tissue caused by years of alcohol abuse), and chronic viral hepatitis (occurs when your body is not able to fight off the hepatitis [inflammation of the liver] virus and the virus does not go away). The facility failed to ensure staff implemented their policy of reporting abuse, or suspected abuse, in a timely manner, and adhere to the Health & Safety Code 1418.91 (a) (b). Based on interview and record review, the facility failed to ensure staff reported an allegation of physical abuse timely for one of four sampled residents (Resident 1). This failure resulted in a delay of the investigation. During a review of Resident 1's "Minimum Data Set (MDS - assessment tool)," dated 6/22/22. The MDS indicated, Resident 1's "Brief Interview for Mental Status" (BIMS) score was 15 (a score of 13 to 15 suggests resident is cognitively intact). During a review of Resident 1's "Nurses Notes," (NN) dated 8/5/22, at 1:40 PM, the PN indicated, "RN/DSD [Registered Nurse/Director of Staff Development] reported that (Resident 1) needs an X-ray for right shoulder due to pain. . ." During a review of NN, dated 8/5/22, at 3:19 PM, the NN indicated, "At 12:30 Pm.,[sic] (Resident 1) alert and responsive on bed complaining of pain on her right shoulder. She said a staff hurt her because of the tv remote she was keeping. Bed-1 CNa [sic] (Certified Nursing Assistant 1) wants the TV on and the CNA pulled her linens to look for the remote and causing her shoulder pain. . ." During an interview on 8/8/22, at 4:14 PM, with the Director of Staff Development (DSD), DSD stated on Friday (8/5/22) Resident 1 asked her for a medication for shoulder pain. DSD stated Resident 1 told her CNA 1 pulled her blanket and sheet and hurt her shoulder. DSD stated she called Resident 1's Medical Doctor (MD), and he ordered an X-ray. DSD stated, "I am sorry I did not report it, but I wanted to see what (CNA 1) had to say and then, I also wanted to see the X-ray results." DSD confirmed it has been three days since Resident 1 made the allegation and stated the incident should be reported to CDPH (California Department of Public Heath) timely. During an interview on 8/8/22, at 5:12 PM, with Administrator, Administrator stated he believes the incident happened on Thursday (8/4/22) night shift and was reported to the DSD on Friday (8/5/22) at 12:30 PM. Administrator stated, "I have already communicated to her (DSD) that she should have reported at that time (the allegation was made)." During a review of the facility's policy and procedure (P&P) titled, "Abuse Prevention Policy," undated, the P&P indicated, "VI. Reporting and Response Procedure:1. If a Resident incident of abuse is reported, discovered, or suspected, where the health, welfare or safety of the resident is involved, this facility will take the following steps: . . . All health practitioners and all other employees of this facility are mandated reports. 2. An employee who has observed or has knowledge of an incident that reasonably to be an abuse or has been told by an elder or dependent adult that he/she has experienced behavior constituting abuse shall report the incident to the appropriate authorities. 3. Mandated reporters are to make report based on the following conditions after January 1, 2013: a. If suspected abuse results in serious bodily injury, then the facility must do the following: i. Report the incident immediately no later than two hours by telephone to (local law enforcement). . .L&C (Licensing & Certification). . .Ombudsman. . ." In violation of the above cited, the facility failed to ensure staff reported an abuse allegation timely. This failure resulted in a delay of the investigation. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and constitutes a class "B" citation.