Other·September 3, 2021

The following reflects the findings of the California Department of Public Health during the investigation of Facility Reported Incident Numbers: 737276 and 738089 and Complaint Number 738058. Representing the Department: 38993, HFEN State Citation B was written. Health & Safety Code §1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 5/26/21, an unannounced visit was made to the facility to investigate a complaint and two facility reported incidents regarding the potential abuse of Resident 1 and Resident 2. Based on interview and record review, the facility failed to ensure abuse was reported for one of four sampled residents (Resident 2) within 2 hours of staff having knowledge of the incidents. This failure had the potential for residents to be at risk for further abuse. Resident 2 was a 68-year-old female who was admitted to the facility on 9/30/2011. Diagnoses included hemiplegia [paralysis of one side of the body] following cerebral infarction, metabolic encephalopathy [memory loss, vertigo [dizziness] and generalized weakness], cerebral palsy [disorder of movement, muscle tone, or posture]. During a review of the SOC 341for Resident 2, dated 5/21/21, the SOC 341 indicated, "[CNA 5] on NOC's [night shift] stated that back in March she heard the 2 staff [CNA 3] & [and] [NA 1] talking in a resident room about a video they did that showed a resident who had fallen out of bed & was naked & that one of them slapped the resident on the butt. She [CNA 5] did not see the video and does not remember if the resident was [Resident 4] or [Resident 2]. . .Reported Types of Abuse. . .Physical. . .Psychological/Mental. . ." During an interview on 5/27/21, at 9:34 AM, with DSD, DSD stated, on 5/19/21, CNA 5 reported a conversation she had overheard in March between CNA 3 and NA 1, talking about a video that was made inside of a resident's room with the door closed and the resident was smacked on the butt. DSD stated, CNA 5 should have reported the incident immediately when she became aware of the video. During an interview on 6/14/21, at 3:06 PM, with CNA 5, CNA 5 stated, she was a member of a staff Snapchat group and CNA 3 posted a video of a resident who had rolled off the bed and likes to sleep naked. CNA 3 then went up to the resident and smacked her on the bottom. CNA 5 stated, the video was posted sometime after March and she did not report it to anyone and should have reported it when the video was posted. During an interview on 6/16/21, at 4:29 PM, with CNA 6, CNA 6 stated, he heard about two videos that contained a resident pushing a staff member in a wheelchair and a video of a resident that fell or almost fell being slapped on the butt. During an interview on 6/17/21, at 12:26 PM, with CNA 4, CNA 4 stated, she had heard about a video that contained CNA 3 slapping Resident 3 on the butt, but she had not seen the video. During a review of the facility's policy and procedure (P&P) titled, "Abuse Prevention/Prohibition" dated 11/18, the P&P indicated, Type of Abuse. . .5. Mental Abuse is defined as, but not limited to: humiliation, harassment, threats of punishment, or withholding of treatment or services." During a review of the facility's policy and procedure (P&P) titled, "Abuse Reporting and Investigation" dated 11/18, the P&P indicated, "The facility will report ALL investigations of abuse as required by law and regulations to the appropriate agencies within 2 hours. . .Allegations of abuse, neglect, mistreatment, or exploitation are to be reported to the Abuse Prevention Coordinator immediately." In violation of the above cited, the facility failed to report an abuse allegation of an individual to the Department within 24 hours of occurring. This failure had the potential to result in continued abuse of the individual and placed the other individuals at risk of abuse. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and constitutes a class "B" citation.