Other·December 5, 2022

Sunnyvale Post Acute Center Class B Citation Provider Number: # 555792 Complaint: # CA00811561 Exit date: 11/15/2022 Anna Garofalo, HFEN The following reflects the findings of the California Department of Public Health during the investigation of: Complaint # CA00811561 Event ID: 7DTP11 Representing the Department, HFEN #27007 State Citation B was written Class B Citation - Patient Care Citation F607 §483.12(b) Abuse Freedom from Abuse, Neglect, and Exploitation §483.12(b) The facility must develop and implement written policies and procedures. The REQUIREMENT is not met as evidenced by: Citation During a complaint investigation on 11/15/2022, the California Department of Public Health determined the facility failed to follow their own abuse policy related to notifying the State of an allegation of abuse. On 11/14/2022 at 12:36 p.m., the California Department of Public Health (CDPH) received a facsimile (FAX) from the Department of Aging and Adult Services reporting an allegation of sexual abuse between two patients. The reporting party filing this report was the Sunnyvale Police Department. Clinical record review for Patient 1 was conducted on 11/15/2022. Patient 1 was admitted to the facility with diagnosis including Alzheimer's Dementia (a brain disorder that slowly destroys memory and thinking skills), Bipolar Disorder (mood swings) and Major Depression. Review of Patient 1's Minimum Data Set (MDS-a comprehensive assessment) indicated a brief interview for mental status (BIMS) level at a three (3-severly impaired cognition), no behaviors were identified, and his mobility was independent. Patient 1's Social Service History Review dated 7/7/2022 at 8:41 p.m., indicated he "wanders into other patient's rooms and attempts to leave the facility." Review of Patient 1's physician orders dated 9/4/2022, showed an order to have a Wanderguard (a device placed on a patient to notify the staff of any attempts to leave the facility). Another physician order dated 11/10/22 at 10:12 p.m., showed an order to monitor Patient 1's behavior whereabouts/wandering around into patient rooms. Patient 1's care plan review showed a problem dated 11/12/2022 to monitor episodes of unfitting behavior-visiting and touching other patients. Clinical record review for Patient 2 was conducted on 11/15/2022. Patient 2 was admitted to the facility with diagnoses of Huntington's Disease (progressive breakdown of nerve cells in the brain impacting functional abilities and usually results in movement, thinking and psychiatric disorders) and unspecified psychosis (mental disorder characterized by a disconnection from reality). Patient 2's MDS dated 9/12/2022, showed he had a BIMS level of 0, rarely/never understood. Clinical record review for Patient 3 was conducted on 11/15/2022. Patient 3 was admitted with diagnoses including traumatic subdural hemorrhage (brain injury) with left hemiparesis (weakness). His MDS dated 10/18/2022 indicated a BIMS score of 9 (moderately impaired cognition) and he required assistance of two staff members for his bed mobility. On 11/15/2022 at 11:06 a.m., an interview was conducted with Certified Nursing Assistant (CNA) G. She stated Patient 1 was alert and oriented and able to make his needs known. CNA G stated Patient 1 "walks around the facility independently." She said Patient 1 was recently moved from Room X to Room Y. When CNA G was asked about Patient 2, she stated Patient 2 was not alert and oriented and needed total assistance from the staff for his care. She stated Patient 2 was unable to make his needs known, "does not communicate and has no behavior issues." In addition, she stated the staff must anticipate Patient 2's needs. An interview was conducted on 11/15/2022 at 11:20 am, with Registered Nurse (RN) H. She stated Patient 1 was oriented to person only but was able to make his needs known. RN H stated Patient 1 had no behaviors and ambulated independently. She stated she was unaware of any inappropriate touching of staff or patients. RN H stated Patient 2 was oriented to person only, was nonverbal but "can nod his head if asked specific yes or no questions." During an interview on 11/15/2022 at 11:30 am, Visitor A stated Patient 2 was unable to make his needs known. She stated she "has observed Patient 1 constantly walking around the facility." Visitor A stated Patients 1 and 2 used to be roommates and she was scared for Patient 2 after she observed Patient 1 touching another patient (Patient 3). She said a few days ago, she witnessed Patient 1 in Patient 3's room with Patient 1's right hand inside Patient 3's brief and he was kissing Patient 3's groin area. Visitor A stated she notified a nurse and another staff member (could not remember the name). She said her family called the police station and notified them of the incident. In addition, she stated, when she asked what the Administrator was going to do about this, she stated Patient 1 was moved to another room, away from Patient 2. Visitor A continued to state when she asked Patient 2 if Patient 1 ever touched him, Patient 2 stated "yes" and appeared scared when he saw Patient 1. On 11/15/2022 at 12:25 pm, Patient 1 was observed ambulating in his room, making his bed. He was able to answer simple questions. No staff member was present with Patient 1. An interview was conducted on 11/15/2022 at 12:33 with Certified Nursing Assistant (CNA) B. He stated Patient 1 was forgetful and was always looking for his dog, son, daughter by looking under other patient's bedrooms. CNA B stated Patient 1 wanders into other patient's rooms but not every day. He stated he had never seen Patient 1 touch any patient or staff. Continued interview with CNA B: Patient 2 was nonverbal, had involuntary shaking and was unable to make his needs known. He stated the staff had to anticipate all of Patient 2's needs. On 11/15/2022 at 12:40 pm, an interview was conducted with the Social Service Assistant (SSA). He stated the SW that was involved with Patient's incident was not in the facility today. The SSA stated Patient 1 was not alert and oriented and was severely demented with sundowner's syndrome. He stated Patient 1 "walks around the facility looking for his children." The SSA stated Patient 1 "goes into other patients' rooms trying to help, acting like a CNA." When the SSA was asked about any recent incident involving Patient 1, he stated about a week ago, he heard Visitor A witnessed Patient 1 in Patient 3's room. He stated the visitor stated Patient 1 had undone Patient 3's brief and attempted to put his face (Patient 1) in Patient 3's crotch area. He continued to state the Staffing Coordinator also witnessed this incident. The SSA stated Patient 3 "is currently in the hospital." When the SSA was asked what measures were put in place after this incident, he stated Patient 1's family member and doctor were notified and Patient 1's family member was to give consent for a psychotropic medication and a psychological evaluation. He stated Patient 2 is nonverbal, just mumbles and sometimes "can shake his head yes or no to questions." He stated any allegation of abuse should be documented. On 11/15/2022 at 1 pm, Patient 1's Case Manager (CM) was interviewed. He stated he was made aware of Patient 1's behavior with Patient 3 and Patient 1's doctor was notified. The CM stated Patient 1's family member did not consent for the new psychotropic medication, so the facility was just monitoring Patient 1's behavior and keeping him engaged with activities. On 11/15/2022 at 1:09 pm, the Director of Staff Development (DSD) was interviewed. She stated she "helps with completing Patient's care plans;" however, she did not do Patient 1's care plan and could not explain the care plan problem dated 11/12/2022, related to "episodes of unfitting behavior." On 11/15/2022 at 1:30 pm, an interview was conducted with the Staffing Coordinator. She stated on 11/7/2022, Visitor A stated Patient 1 was in Patient 3's room with his head on Patient 3's private area, kissing it. The Staffing Coordinator stated she immediately went to Patient 3's room and witnessed Patient 1's head on top of Patient 3's private area. Patient 3's blanket was open, and the curtains were open. The Staffing Coordinator stated she did not see any movement of Patient 1's head on Patient 3's private area. She stated Patient 3 was lying in bed awake, not moving. She stated she immediately took Patient 1 out of Patient 3's room and took him to the nurses' station. She stated she notified the SSA of this incident and he told her that he would notify the SW. The Staffing Coordinator stated Patients 1 and 2 were roommates. In addition, she stated she "is aware Patient 1 walks around the facility every day, entering other patients' rooms, but doesn't do anything in their rooms." An interview was conducted on 11/15/2022 at 1:45 pm, with Licensed Vocational Nurse (LVN) C. She stated Patient 1 was alert but demented and "never stops walking around the facility." LVN C stated on 11/7/2022, Visitor A was walking past Patient 3's room and told her she had seen Patient 1 kissing Patient 3's private area. She stated Patient 3 was forgetful and confused. LVN C stated on 11/7/2022, after this incident, Patient 1 was moved to either Room Z or X (she could not remember the exact room), but she told the DSD that that area had more patients that were bedbound, so they transferred Patient 1 to Room Y, close to the nurses' station. LVN C stated she still sees Patient 1 walking up and down the hallways. On 11/15/2022 at 1:55 pm, Patient 1 was not observed in his room. An interview was conducted on 11/15/2022 at 2:04 pm with the Administrator. When he was asked if this incident on 11/7/2022 with Patient 1 and Patient 3 was reported to the State Agency (California Department of Public Health), he stated "no" because the patient was cognitive decline. He stated he did not see this incident as an allegation of abuse. When the Administrator was asked to see his investigation related to this incident, he stated the whole investigation "is on the computer." He stated he interview the Staffing Coordinator but was unable to show specific documentation related to the interview. He stated he did not have individual interview; but the incident was put in a summary form on the computer. The Administrator stated Patient 1 "has Alzheimer's Dementia and likes to assist other patients, like pushing the patients in their wheelchairs." He stated after this incident, interventions that were put in place were: redirection with activities, SS visits, behavior monitoring every 2 hours, pharmacological intervention, room change to Y to be closer to the nurses' station. A follow up interview was conducted on 11/15/2022 at 3:50 pm with the Administrator in his office. An observation on his desk showed a police business card. When he was asked if the police came out to do an investigation regarding the incident with Patient 1 and Patient 3, he stated "yes, but the police did not say anything." When the Administrator was asked if even with the police coming out to the facility if he felt this incident should have been reported to the State, he stated "no." He stated he felt this incident was not reportable. Review of the facility's Policy and Procedure titled "Reporting Abuse to State Agencies and Other Entities/Individuals, revised date August 2011, shows "All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies" as may be required by law. Should a suspected violation or substantiated incident of .... abuse (including patient to patient abuse) be reported, the facility Administrator or his/her designee, will promptly notify the following persons or agencies (verbally and written of such incident within twenty-four hours of the occurrence and will provide a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. In violation of the above cited standards, the facility failed to follow their own abuse policy related to notifying the State of an allegation of abuse. This violation had a direct or immediate relationship to the health, safety, or security of the patients.