Health inspection·September 22, 2023

§483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual’s obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. §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. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 22 CCR §72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On 8/10/2023, the State Survey Agency (SSA) made an unannounced visit to the facility to conduct a complaint and facility reported incident investigations about abuse and quality of care/treatment allegations. The facility failed to report an allegation of family to resident abuse within two hours to the SSA for Resident 2. On 8/4/2023, Resident 2 notified Licensed Vocational Nurse 1 (LVN 1) that Family Member 1 (FM 1) stole her money. The alleged abuse was not reported until 8/15/2023. As a result, this had the potential to delay the investigation and place Resident 2 at risk for further abuse. A review of Resident 2's Admission Record indicated the facility admitted the 72-year-old female resident on 9/7/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (DM-uncontrolled elevated blood sugar), and hypertension (uncontrolled elevated blood pressure). A review of Resident 2's History and Physical, dated 6/12/2023, indicated the resident can make needs known but cannot make medical decisions. A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/31/2023, indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 2 required extensive assistance from staff for activities of daily living (bed mobility, dressing, toilet use and personal hygiene). Resident 2 was always incontinent (unable to control) of bowel and bladder functions. During an interview on 8/11/2023 at 11 a.m., Licensed Vocational Nurse 1 (LVN 1) stated on 8/4/2023 Resident 2 reported that Family Member 1 (FM 1) stole her money. LVN 1 stated she did not report to the Administrator (ADM) because the incident was from the past. LVN 1 stated she should have reported it because it is an allegation of abuse. During an interview on 8/11/2023 at 12:18 p.m., Assistant Administrator (AADM) stated if resident mention any allegation of abuse, it should be reported to ADM and Social Service (SS) because we are mandated reporter, and it is to protect the safety of the resident. During an interview on 8/11/2023 at 4:18 p.m., the Director of Nursing (DON) stated, LVN 1 should have reported allegation of financial abuse to the ADM for the wellbeing and resident safety. DON stated even if the incident was from years ago, they must report and investigate. During an interview on 8/15/2023 at 11:11 a.m., the ADM stated he was not informed on Friday 8/11/2023 of the allegation of abuse. ADM stated they will make the report today and add another allegation that Resident 2 also reported that FM 1 stole resident's car too. A review of facility's policy and procedure titled, "Abuse Prevention and Prohibition Program, " dated 10/24/2022, indicated, "Facility Staff will report known or suspected instances of abuse to the Administrator, or his/her designee. All mandated reporters will report reasonable suspicion of a crime against a resident when it is objectively reasonable for a person to entertain a suspicion of conduct that appears to be financial abuse.... The Administrator will report allegation of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property or other incidents that qualify as a crime. i. Immediately, but no later that 2 hours after forming the suspicion-of the alleged violation involves abuse or results in serious bodily injury to the State Survey Agency, law enforcement and the Ombudsman (representatives that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences)." The facility failed to report an allegation of family to resident abuse within two hours to the SSA for Resident 2. On 8/4/2023, Resident 2 notified LVN 1 that FM 1 stole her money. The alleged abuse was not reported until 8/15/2023. As a result, this had the potential to delay the investigation and place Resident 2 at risk for further abuse. The above violations had a direct or immediate relationship to the health, safety, and security of Resident 2.