Health inspection·November 10, 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. 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 December 3, 2020, at 11:20 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint regarding an injury of unknown origin. It was determined that the facility failed to ensure that Patient A's allegation of physical abuse was reported immediately or within 24 hours. Patient A alleged that a certified nursing assistant (CNA) handled her roughly which resulted in a skin tear and a bruise. This failure had the potential to result in the delayed implementation of action placing the patient at risk for further abuse. On December 3, 2020, at 1:08 p.m., the facility's "Abuse Log," was reviewed for the month of November 2020. No allegations of abuse were listed on the log for the month of November 2020. On December 3, 2020, a review of Patient A's facility electronic medical record (EMR) was conducted. Patient A was originally admitted to the facility on January 31, 2019, and re-admitted on August 24, 2020, with diagnoses that included poly-osteoarthritis (disease that affects the joints in human body), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), generalized anxiety (severe, ongoing anxiety that interferes with daily activities) and legal blindness. A review of Patient A's facility, "History and Physicals," (H&P) dated April 24, 2020, indicated, "This patient has the capacity to understand and make decisions." A review of Patient A's facility, "Minimum Data Set," (MDS- standardized assessment for the management of care) dated 9/20/2020, indicated a "BIMS," (brief interview for mental status- screening tool to assess mental capability) score of 13 out of 15 (scores 13-15 indicates cognitively intact). On December 3, 2020, a review of Patient A's EMR identified an entry dated November 28, 2020, titled, "Incident Note," which indicated, "Note text: Md (doctor) made aware (sic) patient right hand bruise and ordered may apply ice pack on right hand to decrease skin bruise/discoloration for 21 days and re-evaluate. Noted and carried out. Patient alert and oriented, 2/10 pain (pain scale; 0 = no pain, 10 = worse pain experienced), no bleeding noted, no swelling noted, no s/s (signs or symptoms) of infection noted. Family (son's name) made aware of pt (patient) condition, right hand bruise 7.5 cm (centimeter) X 7.5 cm, bruise and right dorsal (top of the hand) scab 0.5 cm X 0.6 cm treatment as ordered, care plan and skin evaluation updated. Will continue to monitor." This entry was authored by a licensed vocational nurse (LVN 1). On December 3, 2020, at 2:20 p.m., an interview was conducted with Patient A in the presence of Patient B. Patient A stated, "Last Friday night November the 27th," in the dark part of the night either late night or early morning a CNA came and assisted her to the bathroom. Patient A stated that she was not sure exactly what time it was, because she stated, "I am blind". Patient A stated that she had never had the CNA before and had not had her since that night. Patient A continued that the CNA was a woman and that she had been "very rough," with her. Patient A stated that on the way to the bathroom the CNA cut her right hand with her nail. Patient A continued to explain how "horrible" the event had been and how "rough" the CNA had been with her. Observation of Patient A's right hand indicated a small area of bruising with a scab the approximate size of a dime. On December 3, 2020, at 2:30 p.m., an interview was conducted with Patient A, in the presence of Patient B and LVN 2. Patient A explained the events on November 27, 2020, and stated that she was "fearful that night that the CNA would come back and hurt her." Patient A stated that she was "afraid" to use the call light for assistance. Patient A continued to explain how "rough" the CNA had been, and that the CNA had "jerked her around." Patient A stated, "I told people" about the incident. Patient A stated that facility staff had checked her hand and stated "they" saw the cut and blood on her right hand. Patient A was unable to identify who had assessed her injury. On December 3, 2020, at 2:43 p.m., an interview was conducted with LVN 2. LVN 2 stated that he had been made aware of Patient A's allegations that a CNA had handled her roughly. LVN 2 failed to indicate when Patient A had informed him of the incident. LVN 2 was asked if he had reported the allegation of abuse to the abuse coordinator. LVN 2 stated that he worked at the facility part-time and that when he had returned to the facility, the event had already been investigated. LVN 2 continued that he had not reported it but that someone else had. On December 3, 2020, at 2:53 p.m., an interview was conducted with the facility's Administrator (AD). The AD was asked who the facility abuse coordinator was. The AD confirmed that he was the facility's abuse coordinator. The AD was asked if Patient A's allegation of abuse against the facility CNA had been reported to him. The AD stated that "this was the first he had heard of it." The AD was asked again if he had received any information or notification of the allegations made by Patient A that a CNA had been rough and hurt her. The AD continued that he had not known anything about the event. The AD was then asked the facility's expectation to report "any" allegation of abuse. The AD stated that any allegation of abuse should be reported to a charge nurse so the charge nurse could send the staff member home. The AD continued that it would be expected that the charge nurse would then notify the Director of Nursing (DON) within two hours. The AD stated the DON would then report it to him, and he would report it to the (California) Department of Public Health (CDPH). On December 3, 2020, at 3:23 p.m., an interview was conducted with the DON. The DON was asked if she had been informed of Patient A's allegation of abuse. The DON stated that she had not been notified of any allegation of abuse made by Patient A. The DON stated that on her days off she remotely reviewed the nurses' charting. The DON said she had reviewed the progress note that documented Patient A's injury to her right hand and had wondered what had happened. The DON continued that early Sunday morning November 29th, she went to the facility and went directly to check on Patient A. The DON stated that Patient A had told her that a CNA she had never had before, helped her to the bathroom. The DON continued that Patient A had told her that upon returning to the bed from the bathroom the CNA had "tossed" her back into bed. She stated that an investigation into the allegation was conducted. The DON was asked the expectation for reporting allegations of abuse, and she stated that the staff were expected to report to her within two hours of any allegation of abuse. The DON was asked why the allegation had not been reported to CDPH. The DON stated that it had not been reported to CDPH because Patient A continued to change her story, and that the patient had only alleged that the CNA had "tossed" her back into bed. A review of a facility polity titled, "Patient Abuse, Neglect or Mistreatment," revised November 2018, indicated, "1. Any alleged violation involving mistreatment, misappropriation of property, abuse...of a patient shall be immediately reported to the Administrator, Director of Nursing, or designee(s)...4.The Administrator or designee will notify the patient's representative, and any State or Federal agencies of allegation within 2 hours." A review of a facility policy titled, "Abuse Prohibition Program," revised November 2017, indicated, "Reporting: All cases of abuse must be reported to the Administrator within 2 hours of the report of suspected abuse, neglect...The agency mandated by your state must be notified within 2 hours of suspected abuse..." Therefore, it was determined the facility failed to ensure that Patient A's allegation of physical abuse was reported immediately or within 24 hours. Patient A alleged that a certified nursing assistant (CNA) handled her roughly which resulted in a skin tear and a bruise. This failure had the potential to result in the delayed implementation of action placing the patient at risk for further abuse. The failure of the facility to report the alleged abuse placed all patients at the facility in potential danger to their health, safety, and security.