Other·December 28, 2021

The following reflects the findings of the California Department of Public Health during the investigation of a facility reported incident 752497. Representing the Department: 38993, HFEN State Citation B was written. 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 9/20/21, an unannounced visit was made to the facility to investigate a facility reported incident regarding the potential abuse of Resident 1. Based on interview and record review, the facility failed to ensure staff followed the policy and procedure for reporting abuse for one of three sampled residents (Resident 1). This failure had the potential for staff to abuse residents. Resident 1 was a 66-year-old female who was admitted to the facility on 2/18/2021. Diagnoses included hemiplegia and hemiparesis [paralysis of one side of the body] following cerebral infarction (stroke) affecting right dominant side, unspecified dementia without behavioral disturbance [memory disorders, personality changes and impaired reasoning], schizoaffective disorder, unspecified [combination of symptoms of schizophrenia (mental disorder characterized by continuous or relapsing episodes of psychosis) and mood disorder, such as depression or bipolar disorder]. During a review of the "Reported of Suspected Dependent Adult/Elder Abuse" (SOC 341), dated 9/11/21, the SOC 341 indicated, "She [Certified Nursing Assistant-(CNA) 1] was aggressive and rude. She didn't communicate to [Resident 1] what was happening. She yanked [Resident 1's] pants off so hard it almost pulled [Resident 1] off the bed. Tore her [Resident 1's] shirt of [sic] and I seen a hair chunk come out with it. [CNA 1] then began to intimidate [Resident 1] by pretending to throw a punch at her. . .before [CNA 1] left she threw the stuffed animal at [Resident 1's] face. . .Date/Time of incident(s) 9/10/21 7 PM-8 PM. . .Reported types of abuse. . .Physical. . ." During an interview on 9/20/21, at 11:52 AM, with Administrator, Administrator stated, on 9/11/21 in the afternoon, the SOC 341 was sent in anonymously by a CNA, who alleged CNA 1 abused Resident 1 in the evening of 9/10/21. Administrator stated, the staff member that assisted the CNA reported the allegation to the Assistant Director of Nursing (ADON) who then notified him of the allegation. During an interview on 9/20/21, at 2:51 PM, with CNA 2, CNA 2 stated, on 9/10/21 between 7 PM- 8 PM, she was called to assist CNA 1 with changing Resident 1. CNA 2 stated, while providing care to Resident 1, Resident 1 was screaming louder than she had screamed before. CNA 2 stated, CNA 1 said sometimes I just want to punch her [Resident 1] while making the motion with her fist. CNA 2 stated, CNA 1 pulled Resident 1's pants off with force and Resident 1 almost was pulled off of the bed and when CNA 1 took Resident 1's shirt off, a chunk of hair from her head came off with the shirt and CNA 1 threw a stuffed animal at Resident 1. CNA 2 stated, the next day when she came to work, she told Licensed Vocational Nurse (LVN) 1 what had happened at approximately 3 PM (19 hours after the incident) and filled out the SOC 341. During an interview on 9/23/21, at 2:01 PM, with Administrator, Administrator stated, per policy abuse was to be reported immediately and immediately was defined as within 2 hours. Administrator confirmed staff had knowledge of the abuse and did not report it within 2 hours. During a review of the In-Service Lesson Plan titled "Abuse-Mandated Reporter," undated, the Abuse-Mandated Reporter indicated, "Abuse must be reported immediately to the nursing home administrator." During a review of the facility's policy and procedure (P&P) titled "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" dated 4/21, the P&P indicated, "Reporting Allegations to the Administrator and Authorities. . .The administrator or the individual making the allegation immediately reports his or her suspicion. . ."Immediately" is defined as. . .a. within two hours of an allegation involving abuse or result in serious bodily injury. . ." In violation of the above cited, the facility failed to report an abuse allegation of an individual to the Department within 2 hours of occurring. This failure had the potential to result in continued abuse of the individual and placed the other individuals at risk of abuse. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and constitutes a class "B" citation.