Other·May 16, 2023

Class "B" Citation Failure to Report an allegation of abuse HSC 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. HSC 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. 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. On February 16, 2023, at 11:30 a.m., an unannounced visit was conducted to the facility to investigate an allegation of abuse involving Patient A. It was determined that the facility failed to ensure Patient A's allegation of physical abuse was reported immediately or within 24 hours to the State Survey Agency (SSA, CDPH - California Department of Public Health). Patient A alleged that her roommate (Patient B) hit her, which caused bleeding to her face and head. The facility was made aware of the alleged physical abuse to Patient A on February 10, 2023, and did not report the alleged incident to the SSA. This failure had the potential to result in delayed protection of Patient A and the implementation of corrective action, placing the patient at risk for further abuse. On February 16, 2023, Patient A's record was reviewed. Patient A was admitted to the facility on May 23, 2019, with diagnoses which included limitation of activities due to disability, schizophrenia (a mental health condition), and legal blindness (field of vision very narrow or blurry). A review of Patient A's "Minimum Data Set (MDS- standardized assessment tool for the management of care)," dated February 2, 2023, indicated Patient A had a "BIMS (brief interview for mental status- screening tool to assess mental capability)," score of 15 out of 15 (score of 15 indicates cognitively intact). A review of Patient A's "Progress Notes," dated February 11, 2023, at 1:51 a.m., indicated, around 11:25 p.m., on February 10, 2023, Patient A approached the nursing station with bleeding to her face and head. Patient A stated she was lying down in bed when her roommate (Patient B) approached her and started to hit her. On February 16, 2023, at 11: 55 a.m., the Administrator was interviewed. The Administrator stated he did not report the incident to CDPH. The Administrator stated he was contacted about the incident but felt he did not need to report to CDPH because Patient B had been in multiple altercations. On February 16, 2023, at 2 p.m., Patient A was observed and interviewed. Patient A stated her roommate hit her when she was lying down in bed. Patient A had light yellow/green and light red/purple discoloration to the right side of her face. On February 16, 2023, Patient B's record was reviewed. Patient B was admitted to the facility on December 7, 2022, with diagnoses including dementia (memory loss and judgement), schizophrenia, and bipolar disorder (mood swings). A review of Patient B's MDS dated December 14, 2022, indicated Patient B had a BIMS score of 15 out of 15. On February 16, 2023, at 2:18 p.m., Patient B was interviewed. Patient B was unable to answer simple questions. On February 16, 2023, at 4:42 p.m., the Administrator was interviewed. He stated he spoke to management, and the incident should have been reported. He stated any incident regarding alleged abuse should be reported to State Licensing (CDPH), the Police Department, and the Ombudsman. A review of the facility policy and procedure titled, "Abuse Investigating and Reporting," revised in 2017, indicated, "...Reporting...1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/ licensing the facility; b. The local/state Ombudsman...e. Law enforcement officials...2. An alleged violation of abuse...will be reported immediately, but not later than: a. two (2) hours if alleged violation involves abuse or has resulted in serious bodily injury..." A review of the facility policy and procedure titled, "Resident-to-Resident Altercations," revised on December 2016, indicated, "...If two residents are involved in an altercation, staff will...report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy..." It was determined the facility failed to ensure Patient A's allegation of abuse by her roommate was reported immediately or within 24 hours. Patient A alleged her roommate (Patient B) hit her, which caused bleeding to her face and head. The facility was made aware of the alleged physical abuse to Patient A on February 10, 2023, and did not report the alleged incident to the SSA. This failure had the potential to result in delayed protection of Patient A and the implementation of corrective action, placing the patient at risk for further abuse. The failure of the facility to report the alleged abuse had a direct or immediate relationship to the health, safety, or security of the patients.