Other·August 9, 2024

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. 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 . On April 19, 2021, at 10:45 a.m., an unannounced visit was conducted at the facility for the investigation of a quality-of-care complaint. It was determined that the facility failed to ensure that an allegation of physical abuse made by Patient 1 against a facility staff was reported to California Department of Public Health (CDPH) immediately or within 24 hours after the allegation is made on April 7, 2021. Patient 1 alleged a staff member of hitting him, causing bruises to his forearms. This failure had resulted in the delayed investigation of the allegation, which placed the patient at risk for further abuse. On April 19, 2021, a review of Patient 1's facility record was conducted. Patient 1 was admitted to the facility on March 9, 2021, with diagnoses which included unspecified psychosis (a mental condition with delusions and hallucinations), post-traumatic stress disorder (PTSD-difficulty recovering after a traumatic experience), and major depressive disorder. A review of Patient 1’s facility “History and Physical,” dated March 9, 2021, indicated, “This patient has fluctuating capacity to understand and make decisions. Reason: Dementia…” On April 19, 2021, at 10:50 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the Long-Term Care (LTC) Ombudsman came to the facility a week ago to investigate a complaint that a staff member hit a patient. The DON stated she did not report the allegation of physical abuse to CDPH. On April 19, 2021, at 12 p.m., an interview was conducted with the Social Services Designee (SSD). The SSD stated the first time the facility became aware of the allegation that a staff member had hit a patient, was after the Ombudsman had visited the facility. She stated LVN 1 who was accused of hitting the patient worked part time, and on weekends. The alleged staff member had not provided care to Patient 1 on April 3, 2021. On April 20, 2021, at 1:30 p.m., a telephone interview was conducted with the LTC Ombudsman. The LTC Ombudsman stated she went to the facility on April 7, 2021, due to an allegation that Patient 1 was hit by (name of staff) which caused bruising. The LTC Ombudsman stated she spoke with the DON regarding Patient 1's allegation that a staff member hit him, which caused bruising. She stated she informed the DON that Patient 1 accused (staff member's name) of hitting him. The LTC Ombudsman stated the DON informed her the staff member was Licensed Vocational Nurse (LVN) 1. On April 20, 2021, at 1:40 p.m., a follow up telephone interview was conducted with the DON. The DON stated the facility was unaware of the allegation of physical abuse until the LTC Ombudsman came. She stated the facility did not investigate the allegation of physical abuse and did not report the allegation to CDPH. She stated she did not report the allegation because LVN 1 did not provide care to Patient 1 on April 3, 2021. On April 20, 2021, at 2:30 p.m., a telephone interview was conducted with LVN 1. LVN 1 stated he was Patient 1's medication nurse on April 3, 2021. He stated he did not provide direct patient care to Patient 1. LVN 1 stated he was unaware of Patient 1's allegation of abuse until April 19, 2021. He stated if a patient accused a staff member of hitting them, it should be reported to the abuse coordinator as soon as possible, or within two hours. The facility document titled, "Abuse Prohibition Program," (Undated), was reviewed. The document indicated, "…It is the policy of the facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse…Residents will not be subjected to abuse by anyone including, but not limited to, facility staff…The facility will identify and investigate all suspicions or allegations of abuse…Should there be an allegation of any kind of abuse occurred in the facility, the Administrator would report such findings…within 2 hours to the Ombudsman and to the L & C Program (CDPH Licensing and Certification)…" The facility failed to ensure that an allegation of physical abuse made by Patient 1 against a facility staff was reported to California Department of Public Health (CDPH) immediately or within 24 hours after the allegation is made on April 7, 2021. Patient 1 alleged a staff member of hitting him, causing bruises to his forearms. This failure had resulted in the delayed investigation of the allegation, which placed the patient at risk for further abuse. This violation had a direct or immediate relationship to the health, safety, and security.