Health inspection·February 21, 2025

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 patient of the facility to the department immediately, or within 24 hours. Health and Safety Code 1418.91(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(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. It was determined that the facility failed to report an allegation of abuse by a Restorative Nursing Assistant (RNA) towards Patient 3, to the California Department of Public Health (CDPH) immediately or within 24 hours after the allegation was made. The alleged abuse was reported to CDPH on December 7, 2024, four days after a facility staff was made aware of the abuse allegation by Patient 3’s family member (FM). This failure resulted in delayed investigation by CDPH and had the potential to expose the patient to further abuse. On December 23, 2024, at 1:10 p.m., during an interview with Patient 3, he stated he was standing on his walker when RNA 1 grabbed his buttocks and squeezed it more than twice. Patient 3 stated he did not know what to do, but he told his FM about the incident. On December 23, 2024, Patient 3’s admission record was reviewed. Patient 3 was admitted to the facility on July 2, 2024, with diagnoses which included cerebral infarction (dead tissue in the brain), chronic kidney disease (renal failure), depressive disorder (mental illness that causes severe mood changes), anxiety disorder (mental health disorder characterized by excessive feelings of worry), type 2 diabetes mellitus (problems regulating sugar in the blood), legal blindness (loss of vision), and congestive heart failure (condition where the heart does not pump well). A review of Patient 3’s “Minimum Data Set (MDS - an assessment tool),” dated October 9, 2024, indicated the patient had a Brief Interview for Mental Status (BIMS – assessment to monitor cognitive status) score of 11, which indicated mild cognitive impairment. On December 23, 2024, at 1:53 p.m., during an interview with Certified Nursing Assistant (CNA) 2, she stated three to four weeks ago, the patient (Patient 3) informed her that the patient’s FM was calling the state (CDPH) to report RNA 1 who touched Patient 3’s buttocks. CNA 2 stated she reported the patient’s allegation to the Director of Nursing (DON). CNA 2 further stated the facility’s process was to report allegations of abuse immediately to the charge nurse, the DON, and the state (CDPH) within two (2) hours. On December 23, 2024, at 4:18 p.m., during an interview, Patient 3's FM stated Patient 3 informed her on December 3, 2024, that RNA 1 squeezed his buttocks. Patient 3's FM stated she reported the allegation of abuse to the DON on December 3, 2024, verbally and then via text message. Patient 3's FM stated she contacted the DON again on December 4, 2024, to see if the DON had spoken with Patient 3 about the abuse allegation. On December 23, 2024, at 5:06 p.m., during an interview, the DON stated she was first made aware of the abuse allegation involving Patient 3 and RNA 1 on December 3, 2024, by Patient 3's FM. The DON stated she did not initiate an investigation at that time; and she did not report the incident to CDPH until December 7, 2024 (four days after the abuse allegation was reported to the DON by the FM). She stated she should have reported the alleged abuse to CDPH within the two hours of being informed. The DON stated she did not follow the facility’s process in reporting abuse. A review of the facility’s policy and procedure titled, “Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigation,” dated September 2022, indicated, “...All reports of resident abuse...are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. “...If resident abuse, neglect, exploitation, misappropriation of resident property, or injury. Is suspected. This suspicion must be reported immediately to the administrator and to other officials, according to the state law. Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury, or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury..." Based on interview and record review, the facility failed to report an allegation of abuse by a Restorative Nursing Assistant (RNA) towards Patient 3, to CDPH immediately or within 24 hours after the allegation was made. The alleged abuse was reported to CDPH on December 7, 2024, four days after a facility staff was made aware of the abuse allegation by Patient 3’s family member. This failure resulted in delayed investigation by CDPH and had the potential to expose the patient to further abuse. The failure of the facility to report the alleged abuse had a direct or immediate relationship to the health, safety, or security of the patients.