Health inspection·March 15, 2024

The following reflects the findings of the California department of Public Health during the investigation of a complaint number 869208 and 880306. 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 11/9/23, 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 60-year-old male, admitted to the facility on 7/13/23. Resident 1"s diagnoses included Paroxysmal atrial fibrillation (a type of irregular heart beat) with rapid ventricular response (when the rapid contractions of the atria [upper chambers in the heart] make the ventricles [lower chambers of the heart] beat too fast, when the ventricles beat too fast, the heart cannot receive enough blood) and acute/chronic respiratory failure (shortness of breath due to a condition when there is a decrease in the ability to exchange oxygen and carbon dioxide between the lungs and bloodstream). Based on interview and record review, the facility failed to report two separate allegations of abuse, for one of four sample residents (Resident 1). These failures resulted in delayed investigation of abuse for Resident 1 and had the potential for Resident 1 to be at risk for further abuse. Findings: During an interview on 11/8/23 at 1:47 p.m. with Family Member (FM 1), FM 1 stated Resident 1 told her certified nursing assistant (CNA 5) hit him and called him a "mother fucker". FM 1 stated on Wednesday [10/25/23] she reported the abuse to Registered Nurse Manager (RNM). FM 1 stated, "I told [RNM] [Resident 1] is telling me he is being abused." FM 1 stated this all started three weeks ago. FM 1 stated RNM and Registered Nurse (RN 1) went to Resident 1's room and Resident 1 told RNM and RN 1 about the alleged abuse. During a review of Resident 1 ' s "Minimum Data Set," (MDS - an assessment tool) dated 10/9/23, the MDS indicated, Resident 1' s BIMS (Brief Interview for Mental Status) score was 14 out of 15 (13 to 15 points indicates intact cognition). During a review of Resident 1's MDS section "G" "Functional Status," (FS) dated 7/11/23 the FS indicated Resident 1 was totally dependent for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), transfers (hoe a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), dressing, eating,, toilet use, and personal hygiene. During an interview on 11/9/23 at 9:06 a.m. with Resident 1, Resident 1 stated CNA 4 called him "queer". Resident 1 stated he has not reported it. Resident 1 stated CNA 5 hit his leg, Resident 1 believes CNA 5 hit him intentionally to hurt him. Resident 1 stated he reported CNA 5 for hitting him to RNM. During an interview on 11/9/23 at 12:15 p.m. with RNM, RNM stated no allegations of abuse were made to her. RNM stated around a week and a half ago Resident 1's sister called me in Resident 1's room and Resident 1 stated he felt CNA 5 did not like him. RNM stated she removed the CNA 5 from Resident 1 care. RNM stated she did not document the conversations. RNM stated Resident 1's daughter came in yesterday (11/8/23) and reported Resident 1's roommate and CNA 4 were talking and joking around toward Resident 1. RNM was made aware of Resident 1's allegation (CNA 5, hitting Resident 1 intentionally to hurt him, and CNA 4 calling Resident 1 a "queer"). RNM stated, "Maybe I did not ask the right questions." During an interview on 11/9/23 at 12:41p.m. with RN 1, RN 1 stated RNM told her not to assign a certain CNA to Resident 1 because Resident 1 reported CNA (CNA 5) was mean and hurt Resident 1's legs. RN 1 stated Resident 1 reported his leg hurts when (CNA 5) reposition Resident 1's legs. RN 1 stated Resident 1 reported CNA 5 was not gentle when repositioning. During a concurrent interview and record review on 1/18/24 at 9:46 a.m. with RNM, RNM confirmed the abuse allegations for Resident 1 were not reported. RNM stated "I assumed because you (Health Facility Nurse Evaluator) were already out here, I thought that was all I had to do." RNM reviewed the facility's policy and procedure (P&P) titled, "Procedure: Abuse, Elder and Dependent Adult," revised 10/7/22. revised 10/7/22. RNM confirmed he P&P indicated, "It is the policy of this facility that any instance of physical or verbal abuse, or any reportable abuse as is listed in this policy, . . . Physical a. Any physical threat or act in which the resident is struck, hit, slapped, . . . Physical abuse could also result in purposeful rough treatment of a resident. 2. Verbal a. Making any statement which causes the resident to be degraded, embarrassed or otherwise attacks the resident right to be treated with dignity." RNM stated, "My misunderstanding of what was going on." RNM stated she has not read the P&P. During a review of the facility's P&P titled, "Procedure: Abuse, Elder and Dependent Adult," revised 10/7/22, the P&P indicated, "B. It is the policy of this facility that any instance of physical or verbal abuse, or any reportable abuse as is listed in this policy, involving a resident will be reported in accordance with Section 15632 of the Welfare and Intuitions Code of the State of California. Section 15632 requires: 1. Any care custodian, health practitioner . . . who has knowledge of or observe a dependent adult in his or her professional capacity or within the scope of his or her professional capacity or within the scope of his or her employment who he or she knows has been a victim of physical abuse or has injuries under circumstances that abuse has occurred, to report the known or suspected instance of physical abuse to an adult protective services or local law enforcement agency immediately or as soon as practically possible by telephone and to prepare and send a written report thereof within (2) two working days of the abuse."2. Such reports must be made either the Long-Term Care Ombudsman Office, State Licensing Agency, or the Local Law Enforcement Agency when the abuse is alleged to have occurred in a Long-Term Care Facility . . . A. There are 7 types of the abuse which are considered reportable: 1. Physical a. Any physical threat or act in which the resident is struck, hit, slapped, . . . Physical abuse could also result in purposeful rough treatment of a resident. 2. Verbal a. Making any statement which causes the resident to be degraded, embarrassed or otherwise attacks the resident right to be treated with dignity." In violation of the above cited, the facility failed to ensure suspicions and allegations of abuse were reported timely. This failure resulted in a delay of the investigations and had the potential for Resident 1 to be at risk for further abuse. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and constitutes a class "B" citation.