Health inspection·January 21, 2021

F 610 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 22 CCR § 72315 (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 22 CCR § 72521 (c) Each facility shall establish at least the following: (6) Procedures for reporting unusual occurrences. 22 CCR § 72527 (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. WIC § 15630 (b)(1) Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63 , abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that he or she has experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63 , abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential Internet reporting tool, as authorized by Section 15658 , immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an Internet report shall be made through the confidential Internet reporting tool established in Section 15658 , within two working days. (A) If the suspected or alleged abuse is physical abuse, as defined in Section 15610.63 , and the abuse occurred in a long-term care facility, except a state mental health hospital or a state developmental center, the following shall occur: (i) If the suspected abuse results in serious bodily injury, a telephone report shall be made to the local law enforcement agency immediately, but also no later than within two hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse. (ii) If the suspected abuse does not result in serious bodily injury, a telephone report shall be made to the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse. The facility failed to follow the aforementioned regulations by: 1. Not immediately removing Registered Nurse 1 (RN 1) from direct patient care after the Director of Nursing was told that RN 1 hit Resident 1's knee twice with a bedside table. (A narrow rectangular table on wheels that spans the bed or can be placed over the lap when sitting in a chair. The height of the table can be adjusted up or down with the press of a lever) 2. Not reporting the abuse allegation to the Long-Term Care (LTC) Ombudsman, and the law enforcement agency. An Immediate Jeopardy situation (IJ, a situation in which a facility's actions places one or more residents/patients in jeopardy of being significantly harmed up to the point of possible death if not immediately corrected) was identified and called due to the failure of the facility to protect residents by allowing RN 1 to continue to provide resident care after the Director of Nursing was made aware of the incident involving Resident 1. The Director of Nursing (DON) was verbally notified of the IJ situation on 9/16/20 at 3:41 p.m. During a visit to the facility on 9/21/20, the facility initiated a plan of action and the IJ was removed on 9/21/20 at 3:44 p.m. 1. During an interview with Certified Nursing Assistant 3 (CNA 3) on 9/16/20 at 10:21 a.m., CNA 3 stated on 9/13/20, around 5:59 p.m., while she walked in the hallway towards the main nursing station, she heard a "commotion." CNA 3 stated she saw Resident 1 sitting in her wheelchair in the hallway, in front of Room C, which was adjacent to Resident 1's room (Room B). CNA 3 stated Resident 1 was facing the nursing station with her dinner tray, on top of her bedside table, stationed in front of her. CNA 3 stated she heard RN 1 telling Resident 1 to go back to her room to eat dinner and Resident 1 refused. CNA 3 stated she saw RN 1 and Resident 1 both trying to pull the bedside table towards themselves "like tug of war". RN 1 then grabbed the bedside table, pushed it "twice," and the metallic leg of bedside table hit against Resident 1's left knee "really hard," which made Resident 1 "cry hysterically." During an interview with CNA 3 on 9/16/20 at 10:21 a.m., CNA 3 checked her cell phone and stated she sent a text message to the Director of Staff Development (DSD) on 9/13/20, at 6:33 p.m., after she had witnessed RN 1 hit Resident 1's left knee with the bedside table. CNA 3 stated the DSD acknowledged the text message on 9/13/20, at 6:36 p.m. CNA 3 stated RN 1 stayed at the facility until the end of the shift on 9/13/20, at 11:30 p.m., and continued to enter resident rooms to provide direct resident care throughout the entire shift. During an interview with the DSD and in the presence of the Director of Nursing (DON) on 9/16/20 at 10:39 a.m., the DSD stated she informed the Administrator (ADM) and the DON about the incident between RN 1 and Resident 1 immediately after receiving a text message from CNA 3 on 9/13/20, at 6:33 p.m. During an interview with the DON on 9/16/20 at 9:55 a.m., the DON stated on 9/13/20, around 9 p.m., after learning of the alleged incident between RN 1 and Resident 1, she had asked RN 1 to stay away from residents and go to the "other side" of the facility to finish her charting for the shift. The DON stated she asked Registered Nurse (RN 2) to provide direct care to RN 1's assigned residents. During a follow up interview with the DON on 9/16/20 at 10:56 a.m., the DON stated she was "not able" to speak to CNA 2 and CNA 3 (the two witnesses of the incident) on the evening of 9/13/20. The DON stated separating RN 1 and Resident 1 was "enough" to do based on her investigation at that time. During an interview on 9/21/20, at 12:20 p.m., with the DON, the DON stated her cell phone records showed she had sent a text message to RN 1 on 9/13/20, at 9:44 p.m., to give RN 1 official notification of her suspension. During a concurrent interview and record review on 9/21/20, at 2:20 p.m., with the DON, RN 1's timecard dated 9/13/20, was reviewed. The DON confirmed the timecard indicated RN 1 stayed at the facility until 9/14/20, at 12:03 a.m., which was six hours after the alleged incident. During a phone interview on 9/17/20, at 9:17 a.m., with RN 1, RN 1 stated the DON only told her not to provide direct care to Resident 1; the DON had not told her to quit providing direct care to her other assigned residents (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19). RN 1 stated she administered 9 o'clock medications to a total of 13 other residents (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14) until 9:30 p.m. that evening. RN 1 stated she continued to provide direct resident care to her other assigned 18 residents (who were all in the same area of the building as Resident 1), including repositioning, helping with feeding, serving water and providing snacks. RN 1 stated she stayed at the facility until the end of her shift on 9/13/20. During a phone interview on 9/23/20, at 4:57 p.m., with Registered Nurse 2 (RN 2), RN 2 stated the DON had not directed her to provide care for RN 1's assigned residents on 9/13/20, and she had not provided care to RN 1's assigned residents. During a review of the facility's PNP titled, "Protection of Residents during Abuse Investigations," dated 12/2006, indicated, " ...Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed by the Administrator. Should the employee(s) be reassigned to non-resident care duties, such assignment will not be in any part of the building which the resident frequents ..." 2. During a phone interview on 9/21/20, at 2:27 p.m., with the LTC Ombudsman, the LTC Ombudsman stated the facility had not notified them via phone or fax about Resident 1's alleged abuse incident. The LTC Ombudsman stated it had been the State licensing agency that first told her about the alleged abuse incident. The LTC Ombudsman also stated she spoke with the DON on the morning of 9/16/20, but the DON did not mention the abuse allegation. During a follow up email communication on 10/2/20, at 4:28 p.m., with the LTC Ombudsman, the LTC Ombudsman confirmed they have not received a written report of Resident 1's alleged abuse incident from the facility. During a review of Resident 1's progress notes dated 9/13/20 through 9/21/20, the progress notes had no documentation the LTC Ombudsman and Law enforcement agency were notified of Resident 1's alleged physical abuse by RN 1 on 9/13/20. During a concurrent interview and record review on 9/16/20, at 12:10 p.m., with Social Services Director (SSD), the facility binder titled, "Abuse Report Binder," undated, was reviewed. The SSD confirmed the form in the binder titled, "Mandatory Abuse Reporting Guidelines," indicated the facility was required to notify the LTC Ombudsman, law enforcement agency, and the State Licensing Agency via phone and fax within 24 hours of an allegation of physical abuse with no serious bodily injury. Therefore, the facility failed to protect Resident 1, and the other residents assigned to RN 1 from further abuse by allowing RN 1 to continue working after the abuse allegation, and failed to report the abuse allegation to the LTC ombudsman and law enforcement.