Other·April 26, 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. On February 14, 2024, an unannounced visit was made to the facility to investigate an allegation of sexual abuse. It was determined that the facility failed to report an allegation of sexual abuse involving Patient 1 and Patient 2 to the California Department of Public Health (CDPH). The facility was made aware of the allegation of sexual abuse on February 3, 2024. This failure of the facility to report the allegation of sexual abuse had the potential to result in the allegation not to be investigated, placing the patient at risk for further abuse. A review of Patient 1's "ADMISSION RECORD," dated February 14, 2024, indicated Patient 1 was admitted to the facility on July 28, 2023, with diagnoses which included right sided weakness/paralysis, due to a history of stroke. A review of Patient 1's Brief Interview for Mental Status (BIMS- test for cognitive functioning), dated February 3, 2024, indicated, the patient had a score of 7 (Severe cognitive impairment). A review of Patient 1's "Progress Notes," dated February 3, 2024, at 2:43 p.m., indicated, "...Called and notified pt's (patient's) (family member) ...from early incident...nurse witnessed... in dining room...she observed during shift that "another pt (Patient 2) had inappropriately touched pt (name of Patient 1)..." A review of Patient 2's "ADMISSION RECORD," dated February 14, 2024, indicated, Patient 2 was admitted to the facility on November 9, 2023, with diagnoses which included congestive heart failure (heart does not pump blood well enough for the body's needs). A review of Patient 2's BIMS, dated December 20, 2023, indicated, the patient had a score of 12 (moderate cognitive impairment). On February 14, 2024, at 12:30 p.m., an interview was conducted with the facility Administrator (Admin). The Admin stated Patient 1's family member stormed into his office on February 9, 2024, and Patient 1's family member asked, "why didn't you tell me (Patient 1) was sexually abused." The Admin stated Patient 1's family member referred to an incident which happened in the dining room, when Patients 1 and 2 were observed holding hands, by Licensed Vocational Nurse (LVN) 1 on February 3, 2024. The Admin stated Patient 1 had her hand on top of Patient 2's hand. The Admin stated both Patients 1 & 2's hands were placed on Patient 1's right thigh; however, LVN 1 separated both patients and informed the charge nurse (LVN 2). The Admin further stated, he was not notified of the incident involving Patients 1 and 2 and neither was the DON (Director of Nursing) on February 3, 2024. The Admin further stated, he should have reported to CDPH when Patient 1's family member brought up the allegation. On February 14, 2024, at 12:47 p.m., LVN 1 was interviewed. LVN 1 stated, on February 3, 2024, approximately at 12 p.m., she observed Patient 1 sitting "really close to him (Patient 2)," side by side; and she observed Patient 2 had his hand between Patient 1's legs. LVN 1 stated, it seemed the position of Patient 2's hand was inappropriate. LVN 1 stated, "I don't think she (Patient 1) knew what was going on." LVN 1 stated she reported the incident to the charge nurse (LVN 2). On February 14, 2024, at 2 p.m., LVN 2 was interviewed. LVN 2 stated, the incident happened on February 3, 2024, between 11-12 p.m. LVN 2 stated she saw LVN 1 come out of the dining room upset. LVN 2 stated, LVN 1 reported witnessing Patient 2's hand in between Patient 1's legs. LVN 2 stated, she told LVN 1 to inform the charge nurse of the incident (between Patients 1 and 2). LVN 2 stated, the person who witnessed the incident should report to the state (CDPH). On February 14, 2024, at 4 p.m., an interview was conducted with the Social Services Director (SSD), and the SSD stated she found out on February 5, 2024, through the communication board (communication via electronic charting to department heads and nursing staff) the incident involving Patients 1 and 2, who were witnessed holding hands and their hands were in Patient 1's lap. The SSD stated, she did not report (to the authorities), because she wanted to investigate to see if it was reportable. She stated she did not report the incident to the Admin, the abuse coordinator, since she assumed the Admin read the communication board. The SSD stated, she would report abuse "right away" to the abuse coordinator, the DON, or file the report herself to the authorities, to CDPH, to the Ombudsman, and to APS (Adult Protective Services) if needed. On February 14, 2024, at 4:35 p.m., an interview was conducted with the DON, who stated, we are all mandated reporters and if she saw or heard something that was reportable, she would report it immediately. On March 1, 2024, at 9:22 a.m., an interview was conducted with Patient 1's Family Member (FM). The FM stated on February 3, 2024, LVN 1 reported witnessing Patient 2's hands in-between Patient 1's legs in the dining room. The FM further stated, "I kinda let it go (Patients 1 & 2's hands in Patient 1's lap)," because she thought it was reported by the facility to CDPH. The FM stated on February 9, 2024, she asked the Admin of what happened with Patient 1's sexual abuse, and the FM stated the Admin said, "What abuse?" The FM stated the Admin said there was no abuse after their investigation, then she realized the sexual abuse allegation was not reported to the authorities by the Admin and or the facility. A review of the facility's Policy & Procedure, titled, "Abuse Prevention and Mandated Reporting," revised, August 2021, indicated, " ...Purpose: To ensure that resident's rights are protected by providing a method for the prevention of any type of resident abuse ... Policy ...Each resident has the right to be free from ... reasonably (sic) suspicion of abuse ... Reporting ...Facility staff members are required to report incidents of known or suspected abuse as follows ...Suspected abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported within two hours ...If events that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made within twenty-four hours ..." It was determined based on interview and record review, that the facility failed to report an allegation of sexual abuse involving Patient 1 and Patient 2 to CDPH. The facility was made aware of the allegation of sexual abuse on February 3, 2024. This failure of the facility to report the allegation of sexual abuse had the potential to result in the allegation not to be investigated, placing the patient at risk for further abuse. This violation had a direct or immediate relationship to the health, safety, or security of all patients.