Other·May 25, 2023

Health and Safety Code 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. Health and Safety Code 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. Code of Federal Regulation, Title 42, section 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 patient 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 March 13, 2023, at 1:28 p.m., an unannounced visit at the facility was conducted to investigate an allegation of abuse. Based on interview and record review, it was determined the facility failed to report an allegation of verbal abuse involving Patient 1 to the California Department of Public Health (CDPH) immediately, but not later than 24 hours, after an allegation was made. The facility was made aware on February 23, 2023, of the allegation of verbal abuse involving Patient 1 and a Certified Nursing Assistant (CNA), which the facility did not report to the CDPH. This failure had the potential to result in a delay to protect Patient 1 from further abuse. A review of Patient 1's medical record indicated she was admitted on November 25, 2016, with diagnoses of heart failure (lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), chronic kidney disease (the gradual loss of kidney's ability to filter wastes and excess fluids from the blood), and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of Patient 1's "History and Physical," dated February 6, 2022, indicated she had the capacity to understand and make decisions. A record review of Patient 1's "Licensed Nurses Progress Notes, " (Director of Nursing [DON] notes) dated February 23, 2023, at 4:30 p.m., indicated, "Resident relayed to (name of family member) that her CNA last night (name of CNA 1) said cruel things to her causing her to pack up belongings & attempt to leave such as, 'your family doesn't love you'...'Shut the F---- up (expletive word)'...'you don't have a home anymore...'...Interviewed Licensed Staff & C.N.A.'s that worked last night & myself that was present until 8:30 p.m. No verbal comments as relayed to family by resident occurred. The resident was completely disoriented, aggressive, & uncontrollable last night as happens intermittently..." On March 13, 2023, at 3:54 p.m., an interview was conducted with the DON. The DON stated she received a phone call from Patient 1's family member (FM) on February 23, 2023, at approximately 4:30 p.m. The DON stated the FM reported that in the afternoon of February 22, 2023, a CNA (CNA 1) stated to Patient 1, she did not have a home anymore; that her family hates the patient; and the CNA told her to shut the "F--- up (an expletive word)". The DON stated on February 23, 2023, she interviewed all parties involved. The DON stated the alleged incident was not reported to the California Department of Public Health (CDPH). A review of the facility policy and procedure titled, "Abuse Allegation Reporting," revised February 10, 2019, indicated, "...as a mandated reporter, an employee who identifies suspected abuse committed against an individual who is a resident must ensure that all alleged violations involving abuse...are reported immediately, but no later than 2 hours after the allegation is made...to the Administrator/Abuse Coordinator or designee and to other officials (including to the State Survey Agency, local Ombudsman...) The conclusion of all abuse allegations will be reported to the State Survey Agency and Ombudsman within five working days of the incident..." It was determined based on interview and record review, the facility failed to report an allegation of verbal abuse involving Patient 1 to the CDPH immediately, but not later than 24 hours after an allegation was made. The facility was made aware on February 23, 2023, of the allegation of verbal abuse involving Patient 1 and a CNA, which the facility did not report to the CDPH. This failure had the potential to result in a delay to protect Patient 1 from further abuse. This violation had a direct or immediate relationship to the health, safety, or security of all patients.