Other·March 21, 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. CFR 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. On February 7, 2024, at 11:30 a.m., an unannounced visit to the facility was made to investigate an allegation of abuse and quality of care issues. Based on interview and record review, it was determined that the facility failed to report an allegation of physical abuse involving Patient 1 and a staff member (Certified Nursing Assistant/CNA). Patient 1 alleged of being hit in the back of the head with a closed fist by the staff member on October 15, 2023. The alleged physical abuse involving Patient 1 was not reported to the California Department of Public Health (CDPH). 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 records indicated he was admitted on August 2, 2021, with diagnoses which included traumatic brain injury (TBI - a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), right side subdural hematoma (bleeding between the brain and the skull) and multiple fractures. A review of Patient 1’s “History and Physical,” dated August 3, 2021, indicated he was not oriented. On February 7, 2024, at 12:37 p.m., during an interview, Patient 1 stated he was hit in the head by a staff member a couple of months ago. Patient 1 provided the name of the alleged staff, however; the patient was unable to remember if he reported the incident to any of the facility staff. A review of Patient 1’s “Progress Notes,” dated October 15, 2023, at 8:12 p.m., indicated “…accusing staff of threatening or hitting him Q (every), shift no episode…” On February 7, 2024, at 2:20 p.m., during an interview with the Director of Nursing (DON). The DON stated he was the abuse coordinator, and he stated Patient 1 did not report being threatened or being hit by a staff. The DON stated he did not receive a report from the staff that Patient 1 was threatened or was hit. The DON stated the incident should have been reported to the state survey agency and should have been investigated. The DON confirmed the staff alleged of physical abuse by Patient 1 worked at the facility; however, was unavailable for interview. On February 7, 2024, at 2:52 p.m., during an interview, the Licensed Vocational Nurse (LVN) stated that Patient 1 had fabricated stories about being threatened and being hit by staff members. The LVN stated she would always document that Patient 1 fabricated stories accusing staff of threatening and hitting him. The LVN stated she did not know if the allegation was fabricated or true and did not know what she should have done. A review of the facility staffing dated October 15, 2023, indicated the alleged staff member was on the schedule to work the day of the alleged physical abuse incident. A review of the facility’s policy and procedure titled “Abuse Prevention,” revised April 2021, indicated “…to be handled in a manner that prevents further abuse and promotes the health and welfare of all concerned individuals…REPORTING 1. Anyone who observes abusive/assaultive behavior or has reason to believe the behavior occurred is to immediately report the behavior to the Charge Nurse (or Clinical Nurse Manager). Failure to report the observed abuse may be interpreted to also be abuse. 2. The Charge Nurse or Clinical Nurse Manager must IMMEDIATELY contact the Abuse Prevention Coordinator…The Mandated Reporter, (an individual who holds a professional position that are required by law to report suspected or known instances of abuse to state agencies and local law enforcement), or the Director of Subacute /his or her designee i.e. RN Nurse Manager, RN Charge Nurse, Social Worker, etc. must notify the local law enforcement agency immediately no later than two (2) hours by telephone. A written report…must be submitted within two (2) hours to the local law enforcement agency, Licensing and Certification Office and Ombudsman…” It was determined that the facility failed to report an allegation of physical abuse involving Patient 1 and a staff member (CNA). Patient 1 alleged of being hit in the back of the head with a closed fist by the staff member on October 15, 2023. The alleged physical abuse involving Patient 1 was not reported to CDPH. 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.