Other·June 21, 2023

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 4/25/23, an unannounced visit was conducted at the facility to investigate both a complaint and facility reported incidents regarding an alleged incident of abuse towards a long-term care resident (Resident 1). Resident 1 is a 76 year old male, was admitted to the facility on 9/8/21, with diagnoses of left side hemiplegia (paralysis), dementia (impaired thinking that interferes with daily functioning), muscle weakness, stiffness of left hand, and high blood pressure. Resident 1's Brief Interview for Mental Status (BIMS), dated 2/24/23, indicated a score of 5 (score of 0-7 severe impairment). 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 follow its abuse policy and procedure (P&P) for one of six sampled residents (Resident 1), when the facility failed to report and investigate an allegation of physical abuse in a timely manner. This failure had the potential for further abuse and delayed response to suspected abuse. During an interview on 4/25/23, at 9:24 AM, with Ombudsman (patient advocate), Ombudsman stated, on 4/14/23, she received a faxed SOC 341(a form used in filling a report of suspected abuse) from an unknown source. Ombudsman stated, the SOC 341 indicated on 4/14/23, it was witnessed a facility staff was "being rough" with Resident 1. Ombudsman stated, on 4/14/23, she visited the facility and spoke to the Administrator regarding the allegation of abuse. Ombudsman stated, the Administrator was not aware of the alleged staff to resident abuse but Administrator had indicated she would make the Director of Nurses (DON) aware and start the investigation. During a concurrent interview and record review, on 4/25/23, at 12:54 PM, with DON, DON stated, she was made aware of the abuse allegation on 4/24/23, when she had received a call from the Ombudsman. DON stated, she had spoken to the Administrator and was under the impression the allegation had already been investigated and reported. DON reviewed the facility "Abuse Log." DON confirmed the allegation of abuse made on 4/14/23, regarding Resident 1 had not been investigated and reported to proper authorities including the state agency, law enforcement, and Ombudsman. DON stated, the alleged abuse made on 4/14/23, should have been investigated and reported immediately. During an interview on 4/26/23, at 12:46 PM, with Administrator, Administrator stated, on 4/14/23, she recalls the Ombudsman visiting the facility. Administrator stated, the Ombudsman made a few rounds, talked to other residents, and before leaving the facility had talked to Administrator. Administrator stated, Ombudsman did not give her specifics but had only verbally told her that it was witnessed that an RNA (Restorative Nursing Assistant) was "being mean" to Resident 1 during lunch in the dining room on 4/14/23. Administrator stated, she did not talk to any RNA staff, did not talk to Resident 1, and did not talk to any other staff working on 4/14/23. Administrator stated, she did not investigate and/or notify proper authorities including the state agency, law enforcement regarding the alleged abuse made on 4/14/23. Administrator confirmed she was the facility's abuse prevention coordinator. During a review of the facility's P&P titled, "Abuse-Reporting & Investigations," dated 3/2018, the P&P indicated, "The facility will report all allegation of abuse and criminal activity as required by law and regulations to the appropriate agencies. The Facility promptly reports and thoroughly investigates allegations of resident abuse, mistreatment, neglect, exploitation, . . . The Administrator or designated representative will notify within two (2) hours notify, by telephone, CDPH, the Ombudsman and Law Enforcement. . ." In violation of the above cited, the facility failed to report an allegation of abuse to the state agency, local law enforcement and the Ombudsman. This failure resulted in a delay of the investigation. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and constitutes a class "B" citation.