Other·February 8, 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 two hours. HSC 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. On December 1, 2023, at 8:35 a.m., an unannounced visit was made to the facility for the investigation of an alleged abuse. It was determined based on interview and record review the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) immediately, but not later than 24 hours, after an allegation was made. On November 3, 2023, the facility was made aware of an allegation of physical abuse involving Patient 1. This failure has the potential for the allegation not to be investigated which placed the other patients at the facility at risk for abuse. On December 1, 2023, Patient 1's facility medical record was reviewed. Patient 1 was admitted to the facility on August 24, 2023, with diagnoses which included cellulitis (infection of the skin causing swelling, pain and warm to the touch) of right upper limb, difficulty walking, need for assistance with personal care, hypertension (force of blood against the artery wall is too high), anxiety disorder (mental health disorder with feelings of worry or fear that are strong enough to interfere with one's daily activities) and recurrent depressive disorder (mental health disorder with persistently depressed mood or interest in activities). A review of Patient 1's medical records indicated no documentation of the allegation involving Patient 1 being reported to CDPH. A review of the faxed document from (name of the medical group) dated November 3, 2023, with attention to the social services department of the facility indicated, "member filed grievance...with the following allegations: the nurse on that place treated her horrible...member then stated that she wake (sic) up and there where's (sic) a lot of blood on her private parts." The document also indicated to provide a written response regarding this issue by November 9, 2023. On December 1, 2023, at 10:35 a.m., during an interview with a Licensed Vocational Nurse (LVN 1), LVN 1 stated if she witnessed an abuse, she would report the incident to the Administrator and the Director of Nursing (DON). On December 1, 2023, at 12:25 p.m., during an interview with the Social Service Director (SSD). The SSD stated she received an email from the medical group's case manager and the email indicated a grievance was filed and that the patient (Patient 1) woke up and saw blood on her private area. The SSD stated the patient was discharged and she was not aware of reporting to CDPH an allegation of abuse involving a discharged patient. On December 1, 2023, at 12:36 p.m., during an interview with the DON. The DON stated the patient (Patient 1) was not in house, and therefore the facility did not report the allegation involving Patient 1 to CDPH. On January 5, 2024, at 12:10 p.m., during an interview, the DON stated she was not aware Patient 1's family called not until December 1, 2023. A review of the facility policy and procedure titled, "Abuse Investigation and Reporting", revised July 2017, indicated, "All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ("abuse") shall be promptly reported to local, state, and federal agencies...Findings of abuse investigations will also be reported...Reporting. 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source...will be reported by the facility administrator...to the following persons or agencies: the state licensing/certification agency...the Ombudsman...". It was determined based on interview and record review the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) immediately, but not later than 24 hours, after an allegation was made. On November 3, 2023, the facility was made aware of an allegation of physical abuse involving Patient 1. This failure has the potential for the allegation not to be investigated which placed the other patients at the facility at risk for abuse. This violation had a direct or immediate relationship to the health, safety, or security of all the patients.