Other·March 28, 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 based on interview and record review that the facility failed to ensure an allegation of physical abuse involving Patient G was reported to the California Department of Public Health (CDPH - State Agency) immediately after the facility was made aware of the alleged abuse. The facility was made aware of the alleged physical abuse on January 23, 2025. This failure resulted in a delayed investigation by CDPH and had the potential to expose the patient to further abuse. On January 28, 2025, at 10 a.m., during an interview with the Infection Preventionist (IP), the IP stated an allegation of abuse was discussed during the stand-up meeting on January 24, 2025, that Patient G reported to the licensed nurse at around 9 p.m., on January 23, 2025, that a Certified Nursing Assistant (CNA) pushed her. The IP stated the facility decided not to report to CDPH, Patient G's allegation of abuse as it was determined as a false allegation. On January 28, 2025, at 4:15 p.m., during an interview with the Director of Medical Records (DOMR), the DOMR stated Patient G’s allegations on not having food and being pushed by a CNA was discussed during the stand-up meeting with all the department heads on January 24, 2025. The DOMR stated it was decided not to report to CDPH, Patient G's allegation of abuse. On January 28, 2025, at 4:40 p.m., a review of Patient G’s admission record indicated the patient was admitted to the facility on November 16, 2024, with diagnoses which included cerebral atherosclerosis (condition where plaque builds up in the arteries in the brain, narrowing them and reducing blood flow) and depressive disorder (a mental health condition with low moods, loss of interest or pleasure in activities, with symptoms that interfere with daily functioning). A review of Patient G's “Minimum Data Set (MDS - a resident assessment tool),” dated November 23, 2024, indicated the patient had a Brief Interview of Mental Status (BIMS-tool to evaluate cognitive impairment) score of 13 (cognitively intact). A review of Patient G’s “ SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among residents) Communication Form,” dated January 23, 2025, at 9:55 p.m., indicated, “...behavioral symptoms...false allegations about staff...resident making false allegations, told (family member) that she is being locked up, has no food and that the CNA pushed her...” On January 29, 2025, at 2:10 p.m., during an interview with Patient G and her family member (FM), Patient G stated she received a shower from the hospice nurse last week, and two people she had not met before came in, grabbed her under each arm and pulled her out of bed to take a shower. The patient stated she told them to stop. On January 29, 2025, at 4:30 p.m., during an interview with the Director of Nursing (DON) and the Administrator (ADM), the DON and the ADM stated they were not aware about the allegation of physical abuse made by Patient G. The ADM and the DON stated they should have reported the allegation of abuse if they had known about it. A review of the facility’s policy titled, “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating,” dated September 2022, indicated, “...All reports of resident abuse...are reported to local, state, and federal agencies (as required by current regulations) and are thoroughly investigated by facility management. Findings...are documented and reported...if resident abuse...is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law...The administrator or the individual making the allegation immediately reports...suspicion to the following persons or agencies...the state licensing/certification agency...the local/state ombudsman...adult protective services...law enforcement officials...notices include...the type of abuse that is alleged...date and time the alleged incident occurred...the name(s) of all persons involved in the alleged incident...what immediate action was taken by the facility...upon receiving an allegation of abuse...the administrator is responsible for determining what actions (if any) are needed for the protection of residents...All allegations are thoroughly investigated...the investigator notifies the ombudsman that an abuse investigation is being conducted...the ombudsman is notified of the results of the investigation...within 5 business days of the incident, the administrator will provide a follow-up investigation report...” Based on interview and record review that the facility failed to ensure an allegation of physical abuse involving Patient G was reported to CDPH immediately after the facility was made aware of the alleged abuse. The facility was made aware of the alleged physical abuse on January 23, 2025. This failure resulted in a 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.