Health inspection·December 30, 2021

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 8/19/21, an announced visit was conducted at the facility to investigate an allegation of abuse for one long-term care patient (Patient 1). Patient 1 is a 74-year-old female, who was admitted at the facility on 6/19/21. Patient 1's admitting diagnoses included Pneumonia, Urinary Tract Infection (UTI), Type 2 Diabetes (disease where the body cannot maintain blood sugar levels under 100), Hypertensive Heart Disease (Heart problems caused by continued high blood pressure), Leukemia (type of cancer), Thrombocytopenia (blood clotting disorder), anemia (low red blood cell count), and Rhabdomyolysis (breakdown of muscle tissue, leads to kidney damage). Patient 1 had no mental health issues noted on the Admission Record. On 8/10/21, Housekeeper observed Certified Nursing Assistant (CNA) 1 telling Patient 1 to "go outside and leave her room." Housekeeper failed to report an allegation of abuse to her supervisor and to the California Department of Public Health (CDPH) within 24 hours. This failure had the potential to impede an abuse investigation and allow abuse to continue. The facility failed to adhere to the Health and Safety Code 1418.91 (a) (b). During a review of the facility's "Investigation of Abuse Report Form," dated 8/11/21 to 8/12/21, the Investigation of Abuse Report indicated, "[Patient 1] stated the following: "Yesterday 8/10/21 I was told by my [CNA 1] "go outside and get out of my room." I was so confused; I didn't understand why she was telling me to leave my own room. The Housekeeper [HSK 1] was there when my CNA told me this and I asked her, "why does she tell me to leave, I live here?" I felt very humiliated and hurt. . . everyone [staff] took good care of me except for [CNA 1] when she was having her bad days like the other day."" During an interview on 8/19/21, at 10:32 AM, with Social Services Director (SSD), SSD stated, Patient 1 said CNA 1 had told her to, "Go outside, why are you still here, go home." SSD stated, HSK 1 was present during this altercation. SSD stated, Patient 1 was visually upset, emotional, and crying when she was talking about the incident. SSD stated, she was made aware of the abuse allegation by Patient 1 on 8/11/21 prior to Patient 1 discharging home. During an interview on 8/19/21, at 11:47 AM, with HSK 1, HSK 1 stated, on 8/10/21, around 2:30 PM, she witnessed CNA 1 tell Patient 1 to get out of her room in a rude manner. HSK 1 stated, as Patient 1 walked out of her room, Patient 1 asked why she was being thrown outside. HSK 1 stated, CNA 1's tone of voice was inappropriate and elevated. HSK 1 stated, she felt CNA 1 had verbally abused Patient 1. HSK 1 stated, she did not report the incident to anyone because Patient 1 was going to tell someone. HSK 1 stated, she was a mandated reporter. HSK 1 stated, when she had knowledge or a concern of potential abuse, she was to report it immediately to her supervisor. HSK 1 stated again she did not report the abuse because she thought Patient 1 would report it. During a review of the facility's policy and procedure (P&P) titled, "Reporting Abuse to State Agencies, and Other Entities" undated, the P&P indicated, "All alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of unknown source be reported (in which abuse is suspected), the Nursing Supervisor or the Supervisor of the witness shall be responsible for completing an SOC 341 and reporting to the appropriate agency. . . If a Resident sustained no serious bodily harm . . . Within 24 hours . . . Submit a completed SOC 341 to the Ombudsman, law enforcement, and CDPH." The facility failed ensure staff reported an allegation of abuse. This failure had the potential to impede an abuse investigation and allow abuse to continue. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and constitutes a class "B" citation.