Health inspection·October 10, 2024

Health and Safety Code §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. Code of Federal Regulation, Title 42, 483.12 Freedom from Abuse, Neglect and Exploitation. (c)(1) Reporting of Alleged Violations 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. It was determined based on interview and record review, the facility failed to report an alleged physical abuse involving Patient 1 to the California Department of Public Health (CDPH) within 24 hours of the facility's knowledge of the allegation. The facility was made aware of the suspected physical abuse on August 26, 2024. This failure to report an alleged physical abuse to CDPH resulted in delayed investigation of abuse and delay implementation of appropriate action which increased the risk of further abuse for Patient 1 and other patients at the facility. On August 28, 2024, at 7:05 a.m., an unannounced visit was conducted at the facility to investigate an allegation of abuse. A review of Patient 1’s record indicated the patient was admitted to the facility on October 3, 2023, with diagnoses which included Huntington’s Disease (a progress disease and results in progressive, involuntary movements, thinking and psychiatric symptoms) and muscular weakness. A review of the Minimum Data Set (MDS - an assessment tool) dated July 13,2024, indicated Patient 1 had a Brief Interview for Mental Status (BIMS - a cognitive screening tool) score of 05 (cognitively severely impaired). On August 28, 2024, at 7:30 a.m., during a concurrent observation and interview with Certified Nursing Assistant (CNA) 3. CNA 3 stated she has not witnessed any verbal or physical abuse or staff or patients in her four (4) years working at the facility. She stated if she witnessed any kind of abuse, she would report the incident immediately to the licensed nurse. On August 28, 2024, at 8 a.m., during an interview with the Registered Nurse (RN) supervisor, the RN Supervisor stated if there were incidents of a resident to resident or staff altercation, she would immediately notify the Administrator, the Director of Nursing (DON), the physicians, the family, the Ombudsman, CDPH, and the Sheriff. In addition, the RN Supervisor stated she would document these altercations and would update the patient’s care plan. On August 28, 2024, at 8 a.m., during concurrent interview and record review with the DON, the DON stated on August 26, 2024, at approximately 1 p.m., the two student nurses and the Director of the CNA Program expressed concerns about alleged physical abuse involving a patient and a CNA. The DON stated the student nurses witnessed a CNA (CNA 1) slapped Patient 1’s leg, during patient’s transfer to a shower chair. The DON stated the alleged incident was not reported as the allegation was found to be unsubstantiated (not supported or proven by evidence). On August 28, 2024, at 11:05 a.m., during an interview with the Social Service Director (SSD), the SSD stated the student nurses expressed concern of abuse when they witnessed CNA 1 slapped Patient 1’s leg just as Patient 1 was trying to hit and kick the CNA. On August 28, 2024, at 1:15 p.m., during an interview, the DON stated the alleged physical abuse should have been reported to CDPH, as indicated in the facility policy and procedure. A review of the facility’s policy and procedure titled, “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating.” dated October 2023, indicated, “…All reports of resident abuse…are reported to local, state, and federal agencies (as required by current regulations)…1. If resident abuse…is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. the state licensing/certification agency responsible for surveying/licensing the facility…within two hours of any allegation involving abuse…” Based on interviews and record reviews, the facility failed to report an alleged physical abuse to the CDPH within 24 hours of the facility's knowledge of the allegation. The facility was made aware of the alleged physical abuse on August 26, 2024. This failure to report an alleged physical abuse to CDPH resulted in delayed investigation of the abuse and delayed implementation of appropriate action which increased the risk for further abuse for Patient 1 and other patients at the facility. Violation of the above regulations, either jointly or separately, had a direct relationship to the health, safety, or security of Patient 1.