Other·February 29, 2024

California Code, Health, and Safety Code - 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. (b) A failure to comply with the requirements of this section shall be a class “B” violation. On December 28, 2023, at 9:50 a.m., an unannounced visit was conducted at the facility to investigate an allegation of abuse. It was determined based on interview and record review the facility failed to ensure an allegation of abuse involving a facility staff and several patients (Patients 1, 2, 3, 4, 5, and 6) were reported to the California Department of Public Health (CDPH) immediately after the allegation was made. The facility staff (Certified Nursing Assistant- CNA 1) alleged witnessing physical abuse involving a facility staff (CNA 2) and six patients on December 2, 2023. This failure had the potential to place the patients at the facility at risk for further abuse. On December 28, 2023, at 10:32 a.m., a concurrent observation and interview was conducted with Patient 1. Patient 1 was in her room, lying in bed and alert. Patient 1's response during the interview was unclear. A review of Patient 1's record indicated the patient was admitted to the facility on November 11, 2023, with diagnoses which included right hemiplegia (paralysis on the right side of the body), cerebral aneurysm (a bulge in the wall of a blood vessel), and dysphagia (difficulty swallowing). A review Patient 1's "History and Physical (H&P)," dated November 11, 2023, indicated ... "resident can make needs known but cannot make medical decisions ..." On December 28, 2023, at 11:00 A.M., a concurrent observation and interview was conducted with Patient 2. Patient 2 was observed on his wheelchair outside the Social Service Director 's office. Patient 2 declined an interview. A review of Patient 2 ' s record indicated the patient was admitted to the facility on September 15, 2022, with diagnoses which included schizoaffective disorder (mental illness), bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and hypothyroidism (low thyroid hormone). A review Patient 2 's "H&P," dated August 12, 2023, indicated ..."patient has capacity to make decisions ..." On December 28, 2023, at 1:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated all facility staff should report suspected abuse, immediately or within two hours to the Administrator, to CDPH, to the Ombudsman and to the Police Department. The DON further stated the Administrator (ADM) is the facility ' s Abuse Coordinator. In addition, the DON stated she did not receive any report of abuse involving a staff member. On December 29, 2023, at 9:15 a.m., an interview was conducted with CNA 1. CNA 1 stated he witnessed a CNA (CNA 2) being abusive towards multiple patients on December 2 and 3, 2023, during the evening shift. He disclosed that he witnessed CNA 2 verbally abusive to Patient 4, talking down at Patient 3, mocking Patient 2, laughing at Patient 6, mocking the private part of Patient 1, and treating Patient 5 like a child. CNA 1 also stated CNA 2 was not using privacy screens (curtains) when providing care to the patients. CNA 1 stated he filed a complaint related to the abuse he witnessed to CDPH on December 14, 2023 (12 days after CNA 1 said he witnessed the abuse). CNA 1 further stated he should have reported the abuse immediately to CDPH, after witnessing the abuse on December 2 and 3, 2023. On January 4, 2024, at 11:00 a.m., a concurrent observation and interview was conducted with Patient 3. Patient 3 was observed in his room, lying in bed, alert and oriented. Patient 3 stated he did not have any concerns with care and the staff. A review of Patient 3 ' s record indicated Patient 3 was re-admitted to the facility on December 30, 2023, with diagnoses which included dementia (loss of memory), anemia (low red blood cells) and type 2 diabetes mellitus (high blood sugar). A review of Patient 3 ' s "H&P," dated September 7, 2023, indicated ... "resident does not have the capacity to understand and make decisions ..." On January 4, 2024, at 11:12 a.m., a concurrent interview and observation was conducted with Patient 4. Patient 4 was observed in her room and sitting on a wheelchair. Patient 4 stated she did not have concerns about her care and the staff. A review of Patient 4 ' s record indicated the patient was admitted to the facility on January 20, 2023, with diagnoses which included dementia, hypertension (high blood pressure), and hyperlipidemia (high cholesterol). A review of Patient 4' s "H&P," dated January 19, 2023, indicated..."resident does not have the capacity to understand and make decisions ..." On January 4, 2024, at 11:20 a.m., a concurrent observation and interview was conducted with Patient 5. Patient 5 was alert, sitting on his Geri-chair in the activity room. Patient 5’s responses during the interview were unclear. A review of Patient 5’s record indicated the patient was admitted to the facility on September 1, 2021, with diagnoses which included dementia, post-traumatic stress disorder (PTSD- mental condition triggered by a terrifying event) and type 2 diabetes mellitus. On January 4, 2024, at 12:35 p.m., a concurrent observation and interview was conducted with Patient 6. Patient 6 was alert, sitting on a wheelchair inside the patient's room. Patient 6 stated he did not have problems with the staff or his care. A review of Patient 6’s record indicated the patient was admitted to the facility on November 14, 2018, with diagnoses that included dementia, PTSD, and hypertension. A review of Patient 6’s “H&P,” dated March 8, 2023, indicated… “resident does not have the capacity to understand and make decisions…” The facility ' s policy and procedure titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," dated April 2021, was reviewed. The policy indicated, " ... if resident abuse, neglect, exploitation, misappropriation of resident property ... is suspected, the suspicion must be reported immediately to the administrator and to other officials according to the state law ...immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury..." It was determined based on interview and record review the facility failed to ensure an allegation of abuse involving a facility staff and several patients (Patients 1, 2, 3, 4, 5, and 6) was reported to CDPH immediately after the allegation was made. The facility staff (CNA 1) alleged witnessing physical abuse involving the facility staff (CNA 2) and six patients on December 2, 2023. This failure had the potential to place the patients at the facility at risk for further abuse. Violation of the above regulations, either jointly or separately, had a direct relationship to the health, safety, or security of the patients at the facility.