Other·February 6, 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 10/28/22, an unannounced visit was conducted at the facility to investigate a complaint regarding an alleged incident of abuse towards two long-term care patients (Patient 1 and Patient 2). Patient 1, a 51 year old female, was admitted to the facility on 11/24/14, with diagnoses of left hemiplegia (paralysis), diabetes, major depressive disorder (persistent sadness), anxiety, and bipolar disorder (episodes of mood swings). Patient 1's Brief Interview for Mental Status (BIMS), dated 8/23/22, indicated, Patient 1 scored a 13 (13-15 cognitively intact). Patient 2, an 86 year old female, was admitted to the facility on 1/17/20, with diagnoses of dementia (impaired thinking that interferes with daily functioning), dysphagia (difficulty swallowing), left hemiplegia (paralysis), and Alzheimer (disorder that destroys memory and thinking skills). Patient 2's BIMS, dated 10/25/22, indicated, Patient 1 scored a 6 (cognitively impaired). 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 observation, interview, and record review, the facility failed to follow its abuse policy and procedure (P&P) for two of three sampled patients (Patient 1 and 2), when the facility failed to report an allegation of abuse. This failure had the potential for further abuse and psychosocial distress to Patient 1 and Patient 2. During an interview on 10/28/22 at 10:45 AM with the Assistant Director of Nurses (ADON) and Administrator, ADON stated, on 10/24/22, Patient 1 had received a visit from Public Guardian. During the visit, Patient 1 had made an allegation to the Public Guardian she (Patient 1) was physically abused by Certified Nursing Assistant (CNA) 1. ADON stated, the facility investigated the allegation. During a review of the facility investigation report dated 10/24/22 at 9:20 AM, the investigation report indicated, "Public Guardian spoke with DSD [Director of Staff Development, SS [Social Services], and DON [Director of Nurses] in regard to issues [Patient 1] had. [Patient 1] stated, to public guardian that her CNA [CNA 1] had pushed her in bed and was rough with her. They [public guardian] stated, [Patient 1] told them [CNA 1] held her down with both hands. . . Public Guardian then spoke with the roommate [Patient 2] and she told them that CNA [1] was also rough with her and would not change her brief. . ." During an interview on 10/28/22, at 12:08 PM, with ADON and Administrator, ADON stated, after the allegation was investigated and was concluded to be not true, the facility felt there was no need to report the allegations made by Patient 1 and Patient 2 to the proper authorities including state agency (California Department of Public Health), law enforcement, and Ombudsman (patient advocate). ADON and Administrator stated, the allegation made by Patient 1 and Patient 2 was not reported to the state agency, law enforcement, and Ombudsman. During a review of the facility's P&P titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" dated 9/22, the P&P indicated, "All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported." 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.