Health inspection·June 18, 2024

F 609 Reporting of Alleged Violations SS=E Reporting of Alleged Violations SS=E §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long -term care facilities) in accordance with State law through established procedures. §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. Based on interview and record review, the facility failed report abuse allegations that they had knowledge of for 3 of 3 sampled residents (Resident 10, 50 and 278), immediately or within 24 hours to the California Department of Public Health (CDPH) as required by regulation when: 1.A Certified Nursing Assistant (CNA) witnessed the Director of Nursing (DON) yell at and shake the wheelchair of Resident 10 and never reported this to CDPH and Resident 10 reported an altercation with her roommate that was never reported. 2. A CNA witnessed Resident 278 hit Resident 50 and this was not reported to CDPH for 3 days after the incident occurred. These failures to report resident abuse put the health, safety, and welfare of the residents at risk for further abuse and mistreatment. Findings: 1.During a review of the facility's policy and procedure (P&P) titled, "Abuse, Resident," dated 7/15/2022, included the following statement, For all intents and purposes, the word "patient(s)" refers to all customers receiving health care services in our facilities, including inpatients, outpatients, residents, and clients, the P&P indicated, each patient has the right to be free from abuse (verbal, sexual, physical and mental) including corporal punishment and isolation. Patients must not be subjected to any of the above by anyone, including, but not limited to, facility staff, other patients, consultants, volunteers, and other agencies that service the patient, family members, legal guardians, friends, or other individuals. Procedure: 5. Investigation: b) any person who becomes aware of a report of potential physical or mental abuse will inform the licensed nurse on duty. The licensed nurse will: ix) notify Chief Nursing Officer (CNO) - Skilled Nursing Facility (SNF) and Director of Quality (DIQ). X) notify ombudsman. Xi) call Department of Health Services Licensing and Certification no later than two hours after allegation is made. C) i) complete form State of California 341 (SOC 341). During a review of Resident 10's clinical record, Resident 10 was admitted to the facility on 10/20/23 with diagnoses that included high blood pressure, intellectual disability (limits to a person's ability to learn at an expected level and function in daily life), need for assistant at home and no other household member able to render care, and traumatic brain injury (sudden trauma causes damage to the brain). The most recent Minimum Data Set (MDS, a standardized resident assessment) dated 02/12/24, was reviewed and indicated that Resident 10 was cognitively intact (able to think and reason). During an interview on 5/7/24 at 11:00 am, with Confidential Informant (CI)1, CI1 stated the DON has a problem when anyone makes too much noise, including residents. The DON yells at people constantly. Resident 10 was hit by a car and has had a stroke and Resident 10's right side extremities are too weak to use adequately. Resident 10 has to wheel herself backwards to get around. About a month ago Resident 10 was wheeling herself down the hall and accidently bumped into another resident. The other resident yelled out. This was close to the DON's office and nurse's station. DON came out of her office yelling at Resident 10 about the incident. DON stated she cannot keep wheeling backwards. DON grabbed Resident 10's wheelchair and physically shook it and turned her around to try to make her steer to her frontwards. Resident 10 was so embarrassed and in tears. CI1 stated I am afraid for my job. I did not know who else to report it to but the DON. During an interview on 5/7/24 at 11:45 am, with CI2, CI2 stated Resident 10 told her the DON was yelling or speaking to her in a very loud manner and grabbing Resident 10's wheelchair. CI2 stated, I did not know this was a reportable incident. During an interview on 5/8/24 at 10:00 am, with CNA 4, CNA 4 stated, I do not know who the abuse coordinator is or if there is an abuse coordinator. During a concurrent interview and record review on 5/8/24 at 3:30 pm, with Social Services (SS), Resident 10's "Progress Note (PN)", dated 4/8/24 was reviewed. The PN indicated Resident 10 filed a grievance regarding her roommate and feeling unsafe. Resident 10 reported not being able to sleep and being scared to sleep as her roommate has thrown things at her in the middle of the night. SS stated, when she returned to work the next day, she found the grievance note from Resident 10 and reported it to the Charge nurse and DON. 2.During a review of Resident 50's clinical record, Resident 50 was admitted to the facility on 3/17/22 with diagnoses that included conduct disorder (behaviors), high cholesterol, and Dementia (forgetful). The most recent MDS was reviewed, dated 3/31/24, and indicated that Resident 50 was severely cognitively impaired. During a review of Resident 278's clinical record, Resident 278 was admitted to the facility on 4/15/24 with diagnoses that included behavioral disturbances, high cholesterol, and sleep apnea. During a record review of "State of California-Health and Human Services Agency. Unusual Incident/Injury Report" (SOC 341), dated 4/22/24 at 2:35 pm, the SOC 341 indicated, during a chart review from the weekend, a nursing note was discovered stating that on 4/19/24 at 4:57 p.m. a CNA witnessed Resident 278 hitting Resident 50 while walking in the hallway. This was reported 3 days after the altercation had occurred. During a concurrent interview and record review on 5/7/24 at 10:00 am, with DON, Resident 278's PN was reviewed. The PN indicated on 4/19/24 at 4:57 pm, Resident 278 hit Resident 50's head while walking on the hallway. During a concurrent interview and record review on 5/7/24 at 12:00 pm, with Director of Staff Development (DSD), the RELIAS (education for abuse for all staff) dated 2022, was reviewed. DSD confirmed in the RELIAS program Section 3: Screening and Reporting Abuse, Staff are educated to report suspected abuse immediately or within two hours to the abuse coordinator, DON, law enforcement, and the state of California (CDPH). On 5/09/2024 at 12:15 pm, during a concurrent interview and record review regarding abuse reporting with the Quality Manager (QM) the QM stated, "I interviewed the resident and she gave a real detailed account and it was virtually the same as the staff interviews. Staff didn't want to report it and we have to change that culture. Maybe a good thing can come out of this now that we know and they feel comfortable reporting. It should be a just culture and people shouldn't be afraid to say something if they see it." The QM confirmed the staff witness did not report the abuse of Resident 10 when the DON yelled and shook her wheelchair because there was not a culture that supported reporting. As to a written report the QM stated, "I looked and didn't find anything." On record review there was no regulatory required documentation that the facility reported the incident to the CDPH. Therefore, the facility's failure to report abuse put the residents at risk for continued abuse and mistreatment and had a direct affect on their health, safety and welfare.