Other·October 17, 2024

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 resident 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. It was determined that the facility failed to report an allegation of verbal abuse involving Patient 1 and a Certified Nursing Assistant (CNA) 2 to the California Department of Public Health (CDPH) within 24 hours. The facility staff was aware of the alleged verbal abuse on August 25, 2024, and was not reported to CDPH until September 4, 2024 (10 days after the facility was made aware of the alleged abuse). This failure resulted in a delayed investigation of the alleged abuse and causing a delay in implementation of corrective actions which placed Patient 1 at risk for further potential abuse. On September 5, 2024, at 9:25 a.m., an unannounced visit was made to the facility to investigate an abuse allegation. A review of Patient 1's Admission Record, indicated the patient was admitted to the facility on July 16, 2024, with diagnoses which included urinary tract infection (an illness in any part of the urinary tract, the system of organs that makes urine). A review of Patient 1's "Change of Condition (COC) Assessment form," dated August 30, 2024, indicated, "...allegedly (sic) verbally abused by CNA..." A review of Patient 1's "Licensed Progress Notes," dated August 30, 2024, indicated, "CNA reported to Administrator that another CNA had shaken the resident's (Patient 1's) bed, antagonized her, stuck her (CNA) finger in her (Patient 1) face & (and) told her to ‘Shut your mouth’ at around 2130 (9:30 p.m.) on Sunday August 25th..." On September 5, 2024, at 12:37 p.m., during an interview with the Director of Nursing (DON), the DON stated a CNA (CNA 1) reported an alleged verbal abuse involving Patient 1 and CNA 2. The DON stated CNA 1 claimed witnessing CNA 2 shaking the bed of Patient 1 and telling the patient to shut her mouth. She stated CNA 1 did not report the incident involving Patient 1 and CNA 2 to the Administrator immediately. On September 5, 2024, at 1:35 p.m., during an interview, the Administrator stated on August 28, 2024, at 8 p.m., he received a call from a CNA (CNA 1), alleging CNA 2 of verbally abusing Patient 1. The Administrator stated he did not report the CNA's allegation against CNA 2, as he was waiting on the CNA's (CNA 1) written statement of the allegation. The Administrator stated he did not report the allegation made by CNA 1 against another CNA until September 4, 2024. A review of the facility's policy titled, "Abuse Allegation Reporting," updated, February 10, 2019, indicated, "...All allegations involving abuse of any type will be reported immediately to the Administrator/Abuse Coordinator or designee...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, neglect, exploitation or mistreatment, including injuries of unknown source...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 body 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/Abuse Coordinator or designee and to other official (including to the State Survey Agency, local law enforcement entity, local Ombudsman, and adult protective service where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures...The Administrator/Abuse Coordinator or designee will report all allegations of abuse according to the Abuse Allegation Investigation time frames..." Based on interview and record review, it was determined the facility failed to report an allegation of verbal abuse involving Patient 1 and CNA 2 to CDPH within 24 hours. The facility staff was aware of the alleged verbal abuse on August 25, 2024, and was not reported to CDPH until September 4, 2024 (10 days after the facility was made aware). This failure resulted in a delayed investigation of the alleged abuse causing a delay in implementation of corrective actions which placed Patient 1 at risk for further abuse. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients.