Health inspection·March 21, 2025

Complaint numbers: CA00940960, CA00941908, and CA00944609 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, § 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. Based on interview and record review, the facility failed to report an allegation of physical abuse involving Patient 1, to the California Department of Public Health (CDPH), immediately after the allegation was made. The facility was made aware of the alleged physical abuse on December 20, 2024. This failure resulted in delayed investigation by CDPH and had the potential to expose the patient to further abuse. On January 30, 2025, at 10:13 a.m., an unannounced visit was conducted at the facility for a complaint investigation on abuse. On February 3, 2025, a review of Patient 1’s admission record indicated the patient was admitted to the facility on July 3, 2024, with diagnoses which included traumatic subdural hemorrhage (bleeding between the skull and brain caused by trauma), multiple sclerosis (a long-lasting disease of the central nervous system disorder) and cerebral palsy (temporary paralysis or weakness of the facial muscles on one side of the face). A review of Patient 1’s “History and Physical Examination,” dated July 5, 2024, indicated Patient 1 had the capacity to understand and make decisions. A review of Patient 1's “Minimum Data Set (MDS- a clinical assessment tool),” dated December 20, 2024, indicated Patient 1 had a Brief Interview for Mental Status (BIMS- a screening tool used to assess a patient’s cognitive status) score of 15 (cognitively intact). A review of Patient 1’ s “SBAR (Situation, Background, Appearance, Review and Notify- a clinical assessment and communication tool) Communication Form,” created on December 20, 2024, at 4 p.m., indicated, “…WOKE UP 12/19/24 SAID SOMEONE WAS PULLING HER HAIR…” Further review of the document indicated, “Interview with (name of Patient 1) 1530 (3:30 p.m.) 12/20/24. Victim stated on 12/19/24 7:30 -8 p.m. the perp (perpetrator), another female resident came to room on a wheelchair, parked by the foot of the victim’s bed. Perp then pulled the victim’s hair and started punching the victim on her face. Victim stated she got punched by (sic) multiple times, unable to count exact number...Victim unable to give the name of the perp, gave facial features...” On February 4, 2025, at 2:30 p.m., during an interview with the Director of Nursing (DON) and the Nurse Consultant (NC). The DON stated he was aware of the SBAR created on December 20, 2024, and he remembered talking to the patient about the alleged abuse. The DON stated the details of the story always changes, and since the allegation was not substantiated, the physical abuse allegation was not reported to CDPH, the Ombudsman or law enforcement. The DON further stated the incident was not reported since there was no proof Patient 1 was abused. However, the DON stated the facility’s abuse protocol indicated the allegation of abuse reported by Patient 1 should have been reported to CDPH. In a concurrent interview, the NC stated the incident involving Patient 1 was an allegation of abuse and should have been reported to the state agencies. A review of the facility’s policy and procedure titled, “Abuse Investigation and Reporting,” revised July 2017, indicated, “…All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (“abuse”) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management…Reporting…All alleged violations involving abuse…will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:…The State licensing/certification agency responsible for surveying/licensing the facility…The local/State Ombudsman…The Resident’s Representative…Adult Protective Services…Law enforcement officials…The resident’s Attending Physician; and…The facility Medical Director…An alleged violation of abuse…will be reported immediately, but not later than:…Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or…Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury…” Based on interview and record review, it was determined that the facility failed to report an allegation of physical abuse involving Patient 1, to CDPH, immediately after the allegation was made. The facility was made aware of the alleged physical abuse on December 20, 2024. This failure resulted in delayed investigation by CDPH and had the potential to expose the patient to 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.