Other·May 9, 2023

“B” Citation Manorcare Health Services-Palm Desert Complaint Number: CA00818569 Health Facilities Evaluator Nurse: Cindy Steele 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 two hours. HSC 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. On January 12, 2023, at 1:16 p.m., an unannounced visit to the facility was conducted to investigate an allegation of physical abuse. It was determined that based on interview and record review, the facility failed to report an allegation of physical abuse to the State Survey Agency (SSA) within 24 hours. The facility was made aware of the alleged physical abuse on Patient 1 on December 15, 2022, and did not report the alleged incident to the SSA. This failure increased the risk for further abuse due to delayed notification to respond and advocate on behalf of Patient 1. A review of Patient 1’s medical record indicated she was admitted to the facility on November 17, 2020, with diagnoses of diabetes mellitus (diseases that result in too much sugar in the blood), paraplegia (partial or complete paralysis of the lower half of the body with involvement of both legs), major depressive disorder(mood disorder that causes a persistent feeling of sadness and loss of interest), and rheumatoid arthritis(chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility). On January 12, 2023, at 3:21 p.m., an interview was conducted with the Unit Manager (UM). The UM stated on December 15, 2022 (exact time unknown), Patient 1 had an allegation of abuse against a facility staff. The UM stated the police came out to investigate, and the allegation was unsubstantiated. The UM stated that they should have reported the abuse allegation to the facility Administrator, and CDPH within two hours (per Federal requirement). On January 12, 2023, at 3:38 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated on December 15, 2022, during the night shift (exact time unknown), he provided care to Patient 1. CNA 1 stated that Patient 1 stated that he turned her too fast, and he hurt her. CNA 1 stated Patient 1 did not specify where he hurt her, and the patient (Patient 1) called the police on him. CNA 1 denied hurting or abusing Patient 1. CNA 1 stated that the police officer interviewed him, and the facility told him not to come in for the next two days (during the facility's investigation). A review of Patient 1’s “Progress Notes,” dated December 15, 2022, at 10:03 p.m., and written by Licensed Vocational Nurse (LVN) 1, indicated, “This nurse (LVN 1) was called by CNA (CNA 1) to room (Patient 1's room number) as responded immediately , (sic) found resident (patient) talking on the phone in a loud voice apparently she was talking to her (family member), (sic) "I'm calling the police, Im (sic) going to press charge, he (CNA 1) hit me" CNA (CNA 1) was standing at bedside waiting to change resident (Patient 1) I (LVN 1) asked CNA to leave the room, I asked another CNA to call for RN (Registered Nurse) supervisor which she arrived right away (sic). RN supervisor and this nurse listened to her (Patient 1's) statement that CNA (CNA 1) squeezed and pushed her (Patient 1's) hand and took the phone out of her (Patient 1's) hand and put it on top of the dresser. RN supervisor notified DON (Director of Nursing) and administrator. after a while, sheriffs arrived and took both patient (Patient 1) and CNA (CNA 1) statements.” A review of Patient 1's record did not indicate further documentation related to Patient 1's abuse allegation, or the facility's investigation summary and conclusion of the alleged abuse. On March 16, 2023, at 11:51 a.m., a telephone interview was conducted with the Administrator, (ADMIN). The ADMIN stated the facility did not report the incident to CDPH because when Patient 1 was interviewed, the patient only stated CNA 1, "Looked weird," and did not mention that CNA 1 was abusive or that the CNA hurt Patient 1. The ADMIN stated an investigation was conducted and unsubstantiated. On April 4, 2023, at 2:20 p.m., during a telephone interview, LVN 1 stated she was Patient 1's nurse on December 15, 2022, during the 3-11 pm shift. LVN 1 stated later in the evening of December 15, 2022, (exact time unknown), she was called by CNA 1 to the patient’s (Patient 1) room. LVN 1 stated Patient 1 was talking and yelling at someone on the phone about CNA 1 abusing her. She stated Patient 1 was very upset and angry. LVN 1 stated she asked Patient 1 what happened, and the patient stated the CNA (CNA 1) hit her (Patient 1) hand. LVN 1 stated CNA 1 was present in the patient's room and did not say anything. LVN 1 stated she told CNA 1 to wait outside the facility until the police comes. LVN 1 stated the ADMIN was informed of the situation involving Patient 1 and CNA 1 by a nurse (name unknown). LVN 1 stated she assessed Patient 1, and there were no physical injuries found on the patient's hands. In addition, she stated Patient 1 denied any pain. A review of the facility’s policy and procedure titled, “Suspected resident (patient) abuse assessment, long-term care” revised August 19, 2022, indicated, “…Federal regulations governing long-term care provide residents (patients) with special protection from abuse and require the following conditions…The facility must ensure immediate reporting of all alleged involvement of mistreatment, neglect, or abuse…through established procedures, to the facility administrator and other officials (Including to the state survey and certification agency) in accordance with state law...State law requires health care professionals, including long-term care facility staff members, to report known or suspected abuse. Those who fail to report known or suspected abuse may be subject to penalties, as determined by state law. Reporting is particularly important in long-term care settings, because many residents are unable to self-report…Clinical alert: Don’t delay reporting abuse…Complete your state’s abuse reporting forms…If you know of, receive report of, or reasonably suspect abuse or neglect, alert your administration and call the state agency (CDPH) designated to receive abuse reports…” Based on interview and record review, the facility failed to report an allegation of physical abuse to the State Survey Agency (SSA) within 24 hours. The facility was made aware of the alleged physical abuse on Patient 1 on December 15, 2022, and did not report the alleged incident to the SSA. This failure increased the risk for further abuse due to delayed notification to respond and advocate on behalf of Patient 1. This violation had a direct or immediate relationship to the health, safety, or security of all patients.