Health inspection·December 28, 2023

HSC 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a patient of the facility to the department immediately, or within 24 hours. HSC 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. On October 18, 2023, at 12:00 p.m., an unannounced visit to the facility was conducted to investigate a complaint related to an allegation of physical abuse. As a result of the investigation, California Department of Public Health (CDPH) determined that the facility failed to report an allegation of physical abuse involving Patient 1 against Patients 3 and 4 to CDPH. The facility was made aware of the allegation of physical abuse on October 13, 2023. This failure of the facility to report the allegation of physical abuse had the potential to result in the physical abuse allegation not to be investigated and placed the patient to continue feeling vulnerable and threatened by Patients 3 and 4. A review of Patient 1's record indicated, the patient was admitted to the facility on February 26, 2021, with diagnoses which included hemiplegia, affecting left limb dominant side (inability to move one side of the body). A review of Patient 1's Minimum data Set (MDS- an assessment tool) dated October 26, 2023, indicated the patient has a BIMS (Brief Interview for Mental Status- a tool to assess level of cognition) score of 5 (moderately impaired cognition). A review of Patient 1’s “Change of Condition,” dated October 13, 2023, at 5:58 p.m., indicated, “…Video camera was checked and confirmed that the resident was not involved in an altercation with another resident. A review of Patient 1's “Health Status Note,” dated October 13, 2023, at 6:03 p.m., indicated, “During IDT (Interdisciplinary Team)…Resident (Patient 1) verbalized of (sic) being tapped on the chest by another resident…Resident was hitting his chest when he was explaining that he was tapped on his chest…Resident is upset from Friday where he was backing into another resident and the resident stopped the w/c (wheelchair) with her feet…” A review of Patient 1's "Behavior note,” dated October 16, 2023, at 1:19 a.m., indicated, “…Rest alert, awake…continues on charting for confabulation of being hit by another res in chest, zero behavior noted this evening, res in good spirit…” There was no documented evidence that the facility staff reported the allegation of physical abuse made by Patient 1 against another patient during the IDT meeting on October 13, 2023, to CDPH. On October 18, 2023, at 1:29 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Patient 2 (Family member of the alleged victim-Patient 1) reported that on October 5, 2023, Patient 1 alleged to being hit on the chest by another patient. The DON stated there was an activity staff who was present the day the alleged physical abuse to have occurred. The DON stated Patient 1 was not hit by any patient. The DON stated the allegation was not reported because there was no physical altercation that took place, and there was no physical abuse observed by staff as Patient 2 had alleged. The DON further stated on October 16, 2023, Patient 2 informed the police about the allegation without informing the staff. The DON stated Patient 1 was assessed with no injury and was monitored for false accusations. On October 18, 2023, at 3:41 p.m., an interview was conducted with the Social Service Director (SSD). The SSD stated Patient 1 did not directly say that he was struck on the chest by any patient until it was mentioned by Patient 1 during the IDT meeting on October 13, 2023. The SSD stated Patient 1’s family member (Patient 2) interpreted that Patient 1 was alleging Patients 3 and 4 hit his chest during an activity, the week of October 13, 2023; or the week prior (October 5, 2023). The SSD stated Patient 1's family member (Patient 2) reported the allegation to law enforcement on October 16, 2023. However, the SSD stated it was after the staff already explained the situation to Patient 2. The SSD stated Patient 1 stated he was tapped and there was no abuse noted for Patient 1. On October 23, 2023, at 2:35 p.m., an interview was conducted with the Activity Aide (AA). The AA stated she was conducting an activity on October 5, 2023, when Patient 1 was observed attempting to back up from the front row, and Patient 3 (alleged perpetrator) tapped the left shoulder of Patient 1 to inform him that he (Patient 1) almost contacted the foot of Patient 3. The AA stated Patient 1 is hard of hearing and that he understands lip movement and sign language. The AA stated she informed Patient 1 that he needed to stop moving further back and she guided him away from contacting Patient 3. The AA stated at no time did she observe Patient 3 tapped or hit the chest of Patient 1. In addition, she stated Patient 1 did not claim he was struck by another patient during that time. The AA stated if a patient alleged being struck or had indicated they were abused, she would report the allegation immediately to the supervisor. The AA stated allegations of abuse should be reported within two hours. The AA stated no abuse occurred during the activity on October 5, 2023, and she did inform her supervisor about the incident involving Patient 1 and Patient 3. On November 16, 2023, at 3:50 p.m., an interview was conducted with the Licensed Vocational Nurse (LVN). The LVN stated she was present during the IDT meeting on October 13, 2023, when Patient 1 alleged he was tapped on the chest and then began hitting his chest, stating he was hit on the chest. The LVN stated the staff, the patients, and the camera all revealed that Patient 1 was not hit by anyone on October 5, 2023, during an activity to when he claimed the allegation occurred. The LVN stated abuse allegations should be reported within two hours to the physician, to CDPH, to the Ombudsman, and to the family; however, in this case, there was nothing to report because there was no actual abuse. The LVN stated they were not able to substantiate the allegation and so they did not report the incident. A review of the facility policy and procedure titled, "Abuse Investigation and Reporting," dated November 2017, indicated, "...All alleged violations involving abuse, neglect, exploitation...are reported immediately...But not later than 2 hours..." As a result of the investigation, CDPH determined that the facility failed to report an allegation of physical abuse involving Patient 1 against Patients 3 and 4 to CDPH. The facility was made aware of the allegation of physical abuse on October 13, 2023. This failure of the facility to report the allegation of physical abuse had the potential to result in the physical abuse allegation not to be investigated and placed the patient to continue feeling vulnerable and threatened by Patients 3 and 4. The failure of the facility to report the alleged abuse had a direct or immediate relationship to the health, safety, or security of patients.