Other·April 7, 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 1/29/21, an announced visit was conducted at the facility to investigate a complaint regarding an alleged abuse towards one long-term care patient (Patient 1). Patient 1 is a 64 year old male, who was admitted at the facility in 2008 with diagnoses that included Chronic Respiratory Failure (a long-term condition that happens when your lungs cannot get enough oxygen into the blood) and short-term memory loss. On 11/17/19 and 11/22/19, student nurses alleged observing Certified Nursing Assistant roughly providing care and verbal abuse to Patient 1. Alleged abuse was reported to the Director of Nurses (DON) on 11/22/19 but DON failed to report the alleged abuse to the Department. This violated the rights of Patient 1. The facility failed to adhere to the Health and Safety Code 1418.91 (a) (b). Findings: During an interview on 1/29/21, at 2:57 PM, with Clinical Manager (CM), CM stated approximately two years ago an allegation of abuse was investigated by the previous Director of Nurses (DON 1). CM stated several student nurses had witness Certified Nursing Assistant (CNA) disconnecting Patient 1's oxygen (a medical supplemental treatment that provides extra oxygen to breathe in) and made unprofessional comments. CM stated CNA's misconduct was reported to the Board of Nursing but was not sure if the allegation of abuse was reported to the proper authorities including, Ombudsman (a public advocate who represents the interest of the public) and California Department of Public Health (CDPH). During a review of the facility's "Internal Investigation Report" the report indicated on 11/22/19, Student 1 and Student 2 met with DON 1 to report their concerns regarding patient care of CNA which included: "Roughness to patient by [CNA] during hygiene cleaning. Using a wash cloth on the patients face roughly. [CNA] re-connected oxygen tubing to patient after it was disconnected from the patient during the process of turning the patient. [CNA] making statements of hating this place, hating the staff, and hating the patients." During a concurrent interview and record review, on 2/17/21, at 9:30 AM, with Director of Staff Development (DSD), DON 2, and CM, they reviewed the facility's Internal Investigation Report and confirm the allegation of abuse reported on 11/22/19 was not reported to proper authorities. During an interview on 2/23/21, at 8:30 AM, with Clinical Nursing Officer (CNO), CNO stated he was made aware of CNA's misconduct and reported the alleged misconduct to the Board of Nursing. CNO stated DON 1 did not follow the facility abuse policy and procedure and did not report the alleged abuse to the proper authorities. During a review of the facility's policy and procedure (P&P) titled, "Mandated Abuse Reporting-DP/SNF" undated, the P&P indicated, "POLICY: The Director of DP/SNF for [hospital name] will be held accountable for following the established guidelines for screening, training, preventing, identifying, investigating, protecting and reporting and/or responding to all alleged events of suspected abuse. Alleged Violation-is a situation or occurrence that is observed or reported by staff, resident, relative, visitors or others. . . Identification of Suspected Abuse: Any employee who suspects abuse of a resident by [hospital name] staff, who identifies any suspicious bruising, repeated occurrences, patterns and trends that may constitute abuse are to report such items to their supervisor immediately and complete an organization Occurrence Report in the PAVISSE, which will be forwarded to the unit's department director of [hospital name] Risk Management Department. The initial report (SOC 341) of suspected abuse must be completed and reported to the Ombudsman and CDPH within 24 hours of the event. During after hours, weekends or holidays, the Nursing House Supervisor will notify the DP/SNF Unit Director or designee of the event. The SOC 341 must be faxed to both the Ombudsman and CDPH. The hard copy of the SOC 341 will be mailed to CDPH within 24 hours of completing the form." This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and constitutes a class "B" citation.