Health inspection·August 22, 2022

Health and Safety Code 1418.91 (a) (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) (b) A failure to comply with the requirements of this section shall be a class "B" violation. 42 CFR 483.12 (c) (1) (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, nor 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 S ervices where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. It was determined through interview and record review, that the facility failed to ensure an allegation of physical abuse involving Patient 1 and Patient 2, was reported immediately to California Department of Public Health (CDPH) within 24 hours after the allegations were made. This failure to notify CDPH had the potential to result in delayed identification and implementation of appropriate actions and placed the patient at risk for further abuse. On July 15, 2020, at 9:07 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. A review of Patient 1's record indicated that the patient was admitted to the facility on February 7, 2020, with diagnoses which included schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood). Patient 1 had the capacity to understand and make decisions. A review of Patient l's progress notes titled, "Health Status Note," dated May 16, 2020, indicated, "...Clt (client) was shoved by peer on the rt (right) arm..." A review of Patient 1's progress notes titled, "Program Counselor Note," dated May 18, 2020, indicated, "...PC (program counselor) followed up with client in regards to being shoved on the rt (right) arm by female roommate. When asked if she could elaborate as to what occurred '...I (Patient 1) flipped her off and she (Patient 2) pushed me (Patient 1) so I defended myself and pushed her back.' Client then continued to state ' I (Patient 1) ran out of the room and told staff so nothing else would happen. I (Patient 1) know I should of (sic)just ran out of the room and not pushed her back but the doorwas (sic) closed so I had to defend myself.' ..." A review of Patient 2's record indicated that the patient was admitted to the facility on September 30, 2019, with diagnoses which included schizoaffective disorder. A review of Patient 2's progress notes titled, "Behavior Note," dated May 16, 2020, indicated, "...At approx. (approximately) 1650 (4:50 p.m.), yelling was heard in female hallway. Staff responded immediately and upon arrival (name of Patient 2)'s roommate was found in the hall and (name of Patient 2) was in the room with the door shut screaming and yelling. Female peer reported to staff that (name of Patient 2) was accusing her of stealing some of her things. Client stated (name of Patient 2) pushed me in the right arm I returned a push back in self-defense ..." There was no documentation to indicate the incident was reported to state agencies. On July 16, 2020 at 4:35 p.m., the Director of Nursing (DON) was interviewed. She stated she was not aware of the abuse allegation involving the two patients. The DON stated she could not recall any incident that happened in May involving these two patients (Patient 1 and Patient 2). She stated the facility practice on abuse reporting was for the staff to report any incident to the charge nurse, and then to her (DON). The DON stated she would gather information related to the incident reported by the staff to determine whether the incident was reportable or not. The DON stated the charge nurse would complete the abuse reporting form and fax the completed form to the state agency. In a concurrent review of Patient l's record, the DON stated the patient had an incident on May 16, 2020, and she stated she (Patient 1) did have a reportable incident. The DON stated she did not have the incident report regarding the altercation between Patient 1 and Patient 2. On August 25, 2020, at 9:38 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, she stated that any allegation of abuse should be reported. LVN 1 stated whether the abuse happened or not, the allegation of abuse had to be reported to the state agency, as soon as possible. On September 1, 2020, at 2:20 p.m., a Registered Nurse Supervisor (RNS) was interviewed. The RNS stated he remembered the incident involving Patient 1. He stated Patient 1 reported to a Certified Nursing Assistant (CNA) that she was shoved by another patient. The RNS stated there was an allegation of abuse.He stated he reported the incident to the DON and the Administrator. The RNS stated he was informed by the administrator that the incident was not reportable. A review of the facility policy and procedure titled, "Abuse Procedure," dated April 2017, indicated, "...Client to Client Abuse Procedure...Whenever client to client abuse is alleged, witnessed, reported or suspected to have occurred staff will implement the following steps to assure client safety...Complete SOC 341 form, call in report to...CDPH within 2 hours, Fax completed SOC 341 form to LTC (Long Term Care) Ombudsman, Law Enforcement and CDPH preferably by end of shift and no later than 24 hours..." Therefore, the facility failed to ensure an allegation of physical abuse involving Patient 1 and Patient 2, was reported immediately to California Department of Public Health (CDPH), within 24 hours after the allegations were made. The failure of the facility to report an allegation of physical abuse has an immediate relationship to the health, safety, or security of the patients.