Other·October 27, 2022

HSC 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. HSC 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. On August 12, 2022, at 10:50 a.m., an unannounced visit was conducted at the facility for the investigation of an abuse allegation. Based on interview and record review, it was determined that the facility failed to ensure an allegation of verbal abuse involving a Certified Nursing Assistant (CNA 1) and Patient 1, was reported immediately or within 24 hours to the California Department of Public Health (CDPH). This failure caused a delay in the investigation of the allegation by CDPH and had the potential to expose the patients in the facility to further abuse. On August 12, 2022, Patient 1's record was reviewed. Patient 1 was admitted to the facility on March 16, 2022, with diagnoses which included schizophrenia (a mental disorder that affects a person's ability to think, feel and behave), chronic obstructive pulmonary disease (COPD- a lung condition), and dementia (a mental disorder with personality changes and impaired reasoning). Patient 1 was discharged on July 8, 2022. A review of Patient 1's nursing progress note dated June 22, 2022, at 9:51 p.m., indicated, "... (Patient 1's family member) notified writer of possible verbal abuse towards (Patient 1). (Patient 1's family member) stated the CNA (Certified Nursing Assistant) assigned to (Patient 1) at the time said, "Get on the damn bed then."...CNA was sent home after writing her statement..." On August 12, 2022, at 11:07 a.m., an interview was conducted with the Administrator (Adm). The Adm stated while the CNA (CNA 1) was encouraging the patient (Patient 1) to go back to bed, the patient stated, "Did not want to get into the damn bed." The Adm added when the patient decided to go back to bed, the CNA then said to the patient (Patient 1), "I'll help you get into the damn bed." The Adm stated the CNA was counseled by the Director of Nursing (DON) and was sent home. He stated the remark from the CNA was considered a verbal abuse and was reported to CDPH. On August 12, 2022, at 12:50 p.m., the Adm. stated he was unable to locate the reporting information for the alleged verbal abuse on June 22, 2022. On August 12, 2022, at 1:40 p.m., during an interview with CNA 1, she stated staff should not use appropriate language towards patients. CNA 1 stated telling a patient to get into the "damn bed" is verbal abuse. On August 12, 2022, at 1:52 p.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated if a staff tells a patient to get into the "damn bed," it is considered as verbal abuse and should be reported to CDPH. On August 12, 2022, at 2:15 p.m., during an interview, the DON stated the CNA (CNA 1) told Patient 1 to "get into the damn bed". She stated the CNA (CNA 1) was counseled and was sent home early. The DON stated the alleged verbal abuse involving CNA 1 and Patient 1 should have been reported to CDPH. On August 12, 2022, at 2:50 p.m., during a follow-up interview, the Adm stated he was unable to find any documentation that the alleged abuse, identified by the facility on June 22, 2022, at 9:51 p.m., was reported to CDPH within 24 hours. Therefore, the facility failed to ensure an allegation of verbal abuse involving a Certified Nursing Assistant (CNA 1) and Patient 1, was reported immediately or within 24 hours to the California Department of Public Health (CDPH). This failure caused a delay in the investigation of the allegation by CDPH and had the potential to expose the patients in the facility to further abuse. This violation had a direct or immediate relationship to the health, safety, or security of patients.