Other·April 13, 2023

On 1/25/23, an announced visit was conducted at the facility to investigate a complaint regarding an allegation of abuse towards one long-term care patient (Patient 4). 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. The facility admitted Patient 4, a 74-year-old-female, on 11/5/2021, with diagnoses that included hemiplegia (the loss of movement to one side of the body) and hemiparesis (partial body weakness) following a stroke (brain damage caused by lack of oxygen). Patient 4 was a retired teacher and had a Brief Interview for Mental Status (BIMS, cognitive assessment, score 13 cognitively intact; 12-8 cognitively impaired, 7-0 severely impaired) score of 7 out of 15. Patient 4 had a diagnosis of panic attacks. The facility failed to adhere to the Health and Safety Code 1418.91 (a) (b) when the allegation of financial abuse was not reported to the department within 24 hours. Based on observation, interview and record review, the facility failed to follow its policy and procedure(s) titled, "Unusual Occurrence Reporting" and "Mandated Reporter" when the facility failed to report an allegation of fiduciary (person that manages money and property to benefit another person) abuse to the State Survey Agency for Patient 4. This failure had the potential to result in new and/or continued abuse fiduciary abuse and cause harm to Patient 4 and other vulnerable residents. During a concurrent observation and interview on 1/25/23, at 10:01 AM, with Patient 4, in her room, Patient 4 stated, she was worried about her money. Patient 4 stated, her fiduciary was stealing her money, and was using her money without her permission. Patient 4 stated, her fiduciary had denied her access to her banking accounts and property. Patient 4 stated, she asked for help from the facility staff regarding her fiduciary's use of her money without her permission. Patient 4 stated, facility staff has not helped her. Patient 4 stated, she has never authorized Family Member (FM) 1 or FM 2 to make decisions for her and she can make her own decisions. Patient 4 stated, she asked facility staff for help in the past and a recently spoke to the facility Business office lady. During an interview on 1/25/23, at 10:46 AM, with Business Office Assistant (BOA), BOA stated, she was aware of Patient 4's complaints. BOA stated, the facility process for addressing an allegation of financial abuse was for social services along with administration to investigate and involve the ombudsman (patient advocate) and outside agencies such as law enforcement and the Department. During a telephone interview, on 2/2/23, at 9:38 AM, with Director of Nursing (DON), DON stated, Patient 4's allegation is "fiduciary abuse and the administrator is aware. " During a telephone interview, on 2/2/23, at 9:55 AM, with Administrator. Administrator stated, he was aware of when notified of a resident(s) abuse allegation the reporting process included the completion and sending of an SOC-341 (report of suspected dependent, adult/elder abuse) report. Administrator stated, Patient 4's allegations were reportable to the State Agency with completion of an SOC-341 report. Administrator stated, he was aware of Patient 4's abuse allegation and Administrator stated, he did not report Patient 4's abuse allegation. During a review of the facility's P&P titled, "Unusual Occurrence Reporting," dated revised December 2007, the P & P indicated, "Policy Statement: As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. Policy Interpretation and Implementation 1. Our facility will report the following events to appropriate agencies: . . . g. Allegations of abuse, neglect, and misappropriation of resident property; and h. Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors. 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulation. . .required by federal and state regulations. " During a review of the facility's P&P titled, "Mandated Reporter," undated, the P & P indicated, "Mandated Reporter: Observes, has knowledge of, or reasonably suspects abuse in a Long-Term Care Facility: Non-physical Abuse (Abandonment, abduction, financial abuse or neglect. . .Immediately or as soon as practically possible and Within 2 Working Days Written Report SOC-341. . .to at least one local law enforcement agency and to the Licensing and Certification Program of the California Department of Public Health. " The facility failed to report an allegation of fiduciary abuse. This failure had the potential to result in new and/or continued fiduciary abuse to vulnerable residents. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and constitutes a class "B" citation.