Other·July 18, 2024

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. It was determined that facility failed to report an allegation of verbal abuse involving two patients (Patients 1 and 8) to the California Department of Public Health (CDPH) within 24 hours. The facility was aware of the alleged verbal abuse on May 19, 2024, and did not report the alleged verbal abuse until May 24, 2024 (5 days after the incident was identified). This failure had the potential to result in delayed investigation of the incident, and implementation of corrective actions which could subsequently place the patients for further abuse. On May 24, 2024, at 5:36 p.m., the CDPH received a Facility Reported Incident (FRI) for an allegation of verbal abuse. A review of Patient 1's medical records titled, "Admission Record," indicated the patient was admitted on December 5, 2023, with diagnoses of diabetes mellitus type 2 (a chronic condition that affects the way the body uses sugar), peripheral vascular disease (condition in which arteries outside the heart become narrowed or blocked), and congestive heart failure (the heart cannot pump or fill adequately). A review of Patient 1's "History and Physical" dated December 7, 2023, indicated he had the capacity to make decisions. A review of Patient 1's "SBAR (situation, background, assessment, recommendation) Communication Form and Progress Note" dated May 24, 2024, at 11:32 p.m., indicated, "...Residents were arguing, and roommates were verbally abusive towards [Patient 1] Residents were calmed and reassured that everything was ok. residents made up and altercation stopped..." A review of Patient 8's medical record titled, "Admission Record," indicated he was admitted June 14, 2023, with diagnoses of cellulitis (infection of the skin and the tissues beneath the skin), of the buttock, venous insufficiency (occurs when leg veins don't allow blood to flow back up to the heart), and epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain). A review of Patient 8's "History and Physical" dated June 15, 2023, indicated he was alert and oriented to person, place, and time. A review of Patient 8's "Nurses Notes" dated May 24, 2024, at 8:27 p.m., indicated Late Entry: Per [Patient 8] another resident called him a "stupid man" x 2. Per [Patient 8] he verbalized to other resident not to call him a "stupid man" and that's (sic) the other resident asked [Patient 8] to go outside. [Patient 8] states that felt threaten (sic) when asked to go outside by other patient." On May 30, 2024, at 11:49 a.m., during an interview, the Administrator disclosed she interviewed the two patients involved in an altercation. She stated she was informed about the patients' altercation on May 24, 2024, and she filed the report to the CDPH the same day (May 24, 2024). She stated an in-service was provided to the staff on immediate notification to the Administrator for verbal, and/or any type of abuse. On May 30, 2024, at 12:43 p.m., during an interview, Patient 8 stated he was in the hallway and Patient 1 called him a "stupid man" and kept repeating that he was a stupid man. Patient 8 stated he asked the patient (Patient 1) not to speak to him that way, and when Patient 1 asked to take it outside, he agreed. Patient 8 stated the nurses separated the two of them. On May 30, 2024, at 1:39 p.m., during an interview accompanied by a Certified Nursing Assistant (CNA 2) to translate for the patient, Patient 1 stated on May 19, 2024, he went out into the hallway to get a snack from the nurse, when Patient 8 started yelling at him. Patient 1 stated he was unsure what Patient 8 was yelling about, but felt it was because he was Mexican. Patient 1 denied calling Patient 8 a stupid man. On May 30, 2024, at 1:58 p.m., an interview was conducted with CNA 2. CNA 2 stated if she witnessed any abuse, she would report it to the Administrator right away, within two hours. On May 31, 2024, at 6:14 p.m., an interview was conducted with the Registered Nurse (RN). The RN stated all allegations of abuse need to be reported within two hours to the Administrator, the police, the Ombudsman, and the CDPH. On May 31, 2024, at 6:46 p.m., an interview was conducted with CNA 3. CNA 3 stated the altercation between Patient 1 and Patient 8 occurred on May 19, 2024, in the evening. CNA 3 stated Patient 1 was asking the nurse for a snack, when CNA 3 heard Patient 8 asked Patient 1 what he said to the nurse. CNA 3 stated both Patient 1 and Patient 8 started screaming at each other. CNA 3 stated she was not assigned to Patient 1, but she separated the two patients. CNA 3 stated other nurses saw the incident involving the two patients and they should have reported it to the Administrator. A review of the facility's policy and procedure titled "Abuse Investigation and Reporting" revised February 2024, indicated, "...All reports of resident abuse...shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly Investigated by facility management...Role of the Administrator...1. If an incident or suspected incident of resident abuse...is reported, the administrator will assign the investigation to an appropriate individual...5. The administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented... ...Reporting...l. All alleged violations Involving abuse, neglect, exploitation, or mistreatment ...will be reported by the facility administrator, or his/her designee, to the following persons or agencies per regulations: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record... e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director...2. An alleged violation of abuse, neglect, exploitation, or mistreatment...will be reported to the proper agencies as guided per regulations...b. twenty-four (24) hours of the alleged violation AND has not resulted in serious bodily injury...3. Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone..." Based on interviews and record reviews, facility failed to report an allegation of verbal abuse involving two patients (Patients 1 and 8) to the CDPH within 24 hours. The facility was aware of the alleged verbal abuse on May 19, 2024, and did not report the alleged verbal abuse until May 24, 2024 (5 days after the incident was identified). This failure had the potential to result in delayed investigation of the incident, and implementation of corrective actions which could subsequently place the patients 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.