Health inspection·January 3, 2025

Ramona Rehabilitation and Post Acute Care Center CA00928335 Citation B- Failure to Report: 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. It was determined based on interview and record review, the facility failed to ensure an allegation of physical abuse involving Certified Nursing Assistant (CNA) 1 and Patient 1, was reported immediately or within 24 hours. The facility was aware of the alleged physical abuse on October 28, 2024, but was not reported to the California Department of Public Health (CDPH) until October 31, 2024. This failure resulted in delayed investigation by CDPH and had the potential to expose the patient to further abuse. On November 18, 2024, at 10:15 a.m., an unannounced visit was conducted at the facility to investigate an abuse allegation. A review of Patient 1's medical record indicated, the patient was admitted to the facility on August 26, 2024, with diagnoses which include pulmonary fibrosis (scar tissue in the lungs), chronic respiratory failure (difficulty breathing on your own), and anxiety (excessive and persistent worry). A review of Patient 1's "Minimum Data Set (MDS - an assessment tool)," dated September 2, 2024, indicated the patient had a Brief Interview for Mental Status (BIMs - assessment to monitor cognitive status) score of 11, which indicated mild cognitive impairment. On November 18, 2024, at 12:07 p.m., during an interview with CNA 2, he stated he was at the nurse’s station across Patient 1’s room, when he saw CNA 1 come out of the room with food and fluid on her clothes. CNA 2 stated he heard Patient 1 screaming that CNA 1 was hitting her and choking her. CNA 2 stated she assisted another CNA to clean up Patient 1 and he did not observe any scratch marks or discoloration on the patient's neck or body area. On November 18, 2024, at 1:57 p.m., during an interview with the Administrator (ADM), the ADM stated the allegation of abuse involving CNA 1 and Patient 1 was first reported by the Assistant Director of Nursing (ADON) on October 28, 2024, at 1:00 p.m. However, he reported the allegation of abuse to CDPH on October 31, 2024. The ADM stated he did not report the alleged abuse within the required time frame. A review of the facility’s policy and procedure titled, "Resident Abuse-Preventing, Reporting, and Investigating," dated October 2022, indicated “...All alleged violations of abuse...shall be reported to the Administrator of the facility...in accordance with State and Federal law through the following procedures: Upon any allegation of abuse the facility will-WITHIN 2 HOURS OF THE ALLEGATION: *Phone call to the Dept. of Public Health/Licensing...” Based on interview and record review, the facility failed to ensure an allegation of physical abuse involving CNA 1 and Patient 1, was reported immediately or within 24 hours. The facility was aware of the alleged physical abuse on October 28, 2024, but was not reported to the CDPH until October 31, 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.