Health inspection·November 15, 2024

Highland Springs Care Center Complaint: CA00741364 linked with CA00741212 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. On June 24, 2021, at 10:17 a.m., an unannounced visit was conducted at the facility for the investigation of a quality-of-care issue and an allegation of physical abuse involving two patients (Patients 1 and 2). It was determined that the facility failed to ensure that an allegation of physical abuse involving Patients 1 and 2 was reported immediately or within 24 hours. Patient 1 and Patient 2 had a physical altercation on June 16, 2021, and the alleged physical abuse was not reported to the California Department of Public Health (CDPH) within 24 hours. On June 24, 2021, Patient 1's admission record was reviewed. Patient 1 was admitted to the facility on April 29, 2021, with diagnoses which included dementia (a loss of memory and judgement) and history of falling. A review of Patient 1’s facility “History and Physical,” dated April 29, 2021, indicated the patient has fluctuating capacity to understand and make decisions. On June 24, 2021, at 12:27 p.m., an interview was conducted with the Administrator (Adm). The Adm stated she had checked the video camera footage and had interviewed staff on the alleged altercation involving two patients. She stated during her interviews, staff had stated that on June 16, 2021, Patient 1 had an altercation with Patient 2. The Adm stated the review of video coverage on June 16, 2021, showed Patient 1 had pushed Patient 2 while she was in her wheelchair. She stated Patient 2 then struck Patient 1. The Adm stated the Certified Nursing Assistant (CNA) notified her on June 24, 2021 of the incident involving Patient 1 and Patient 2. She stated a Licensed Vocational Nurse (LVN), and the Registered Nurse (RN) were aware of the altercation on June 16, 2021, as well. She stated all staff are mandatory reporters of abuse and should have notified the abuse coordinator and/or CDPH of the patient-to-patient altercation when it happened on June 16, 2021. On June 24, 2021, Patient 2's admission record was reviewed. Patient 2 was admitted to the facility on June 23, 2020, with diagnoses which included schizophrenia (a mental disorder that affects the ability to think and behave clearly). A review of Patient 2's "History and Physical," dated February 5, 2021, indicated the patient was able to make decisions for activities of daily living. On June 24, 2021, at 12:58 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated staff notified the abuse coordinator on June 24, 2021, that Patient 1 and Patient 2 had an altercation on Wednesday, June 16, 2021. She stated the patient-to-patient altercation should have been reported Wednesday June 16, 2021, to the abuse coordinator and to CDPH. On June 24, 2021, at 2:20 p.m., an interview was conducted with the Social Services Designee (SSD). The SSD stated patient-to-patient altercations would be considered abuse and should be reported to the nurses so they can assess the patients involved. The SSD further stated that abuse should be reported to the Adm, who was the facility abuse coordinator, and the incident should be reported to CDPH within two hours. On June 28, 2021, at 12:35 p.m., a telephone interview was conducted with CNA 1. CNA 1 stated that on June 16, 2021, she heard screaming from the patient's room as she was walking pass the nurses’ station. The CNA stated she ran to the area and the patients (Patient 1 and Patient 2) were already separated by another CNA. CNA 1 stated that she asked the LVN what happened, and the LVN stated the patients got "into a fight." CNA 1 stated a patient-to-patient altercation should be reported to the abuse coordinator. On June 28, 2021, at 1 p.m., a telephone interview was conducted with LVN 2. LVN 2 stated that Patient 1 and Patient 2 had an altercation on June 16, 2021. She stated she did not see Patient 2 hit Patient 1; so LVN 2 thought the altercation was just "verbal." She stated when there was a patient-to-patient altercation, staff were to notify the RN supervisor, who would then notify the DON. LVN 1 stated that she did not report the altercation. On June 28, 2021, at 1:10 p.m., a telephone interview was conducted with RN 1. RN 1 stated that she was working on June 16, 2021, when she heard yelling. She stated when she arrived at the area, Patient 1 and Patient 2 were already going their separate ways. She stated the CNA had already separated the patients. She stated she did not document or notify the abuse coordinator of the altercation. The facility document titled, "Abuse & Mistreatment of Resident," undated, was reviewed. The document indicated, "...Purpose: To uphold a resident's right to be free from verbal, sexual, and mental abuse..."abuse" is defined as the willful infliction of injury..."verbal abuse" is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents...within their hearing distance...Facility shall institute procedures of identifying unusual occurrences and events, such as suspicious bruising of residents...which may constitute abuse...any incidences of occurrences that may constitute abuse shall be recorded...extensive efforts shall be carried out in the investigation...of unusual occurrences and/or events that may constitute abuse, including those injuries incurred by the residents for which the origin of such injury is "unknown"...Facility shall ensure reporting of all alleged and substantiated violations to the state agency and all other agencies as required...a "mandated reporter" is any person who has assumed full or intermittent responsibility...This includes administrators, supervisors, and any staff...It is the facility's policy for any "mandated reporter" working in a facility to report abuse to their supervisor as well as the CDPH...Facility shall report the incident by notifying the CDPH within 2 hours of the knowledge of such incident..." Based on interview and record review, the facility failed to ensure that an allegation of physical abuse involving Patients 1 and 2 was reported immediately or within 24 hours. Patient 1 and Patient 2 had a physical altercation on June 16, 2021, and the alleged physical abuse was not reported to the CDPH within 24 hours. The violation of the facility to report the alleged abuse placed all patients at the facility in potential danger to their health, safety, and security.