Other·February 12, 2024

F609 Freedom from Abuse, Neglect, and Exploitation §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.

F610 Freedom from Abuse, Neglect, and Exploitation §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §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. Title 22 California Code of Regulations: § 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 12/20/2023, the California Department of Public Health (State Survey Agency [SSA]) made an unannounced visit to the facility to investigate a complaint related to sexual abuse of a resident. The facility failed to implement its abuse prevention policy by failing to report an allegation of a sexual abuse that occurred on 12/14/2023 within 2 hours or in accordance with state or federal law for Resident 2. As a result, there was a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 2. A review of Admission Record indicated Resident 2, a 68 years-old female was originally admitted to the facility on 11/20/2020 and readmitted on 6/2/2021, with diagnoses including spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine), type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and major depressive disorder (a mental disorder that have a persistent feeling of loss of pleasure or interest in life). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 11/14/2023, indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 2 required maximal assistance to total dependence from staffs for activities of daily living (ADLs - toileting hygiene, shower/bathe, lower body dressing, and personal hygiene). During an interview with Resident 2 on 12/20/2023 at 11:30 a.m., Resident 2 stated on 12/14/2023 at 8:12 a.m., she reported a sexual abuse from a staff in the facility she is currently residing to the Case Manager at the clinic. Resident 2 stated, the Social Services Department had talk to her about it. During an interview with Social Services Assistant 1 (SSA 1) on 12/22/2023 at 12:06 p.m., SSA 1 stated, Resident 2 have previous report about a staff being rough on her and they did an investigation on her allegation back in March 2023. SSA 1 stated, they did not do any investigations or reporting of Resident 2's current allegation of sexual abuse. SSA 1 stated, all allegations of abuse should be investigated and reported to the State Agency. During an interview with Administrator (ADM) on 12/22/2023 at 3:40 p.m., ADM stated, he is unsure if an allegation of abuse by residents should be reported each time, they report an abuse concern. ADM stated, Resident 2 had a previous allegation of abuse in March 2023 regarding a staff and the current allegation of abuse was not investigated and/or reported to the State Agency. A review of the facility's policy and procedure (P&P) titled, "Abuse Prevention Program" revised January 2011 indicated, "Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion..." A review of the facility's P&P titled, "Abuse Investigation and Reporting", dated November 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 (as defined by current regulation) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported... Suspected abuse, neglect, exploitation, or mistreatment will be reported within two hours." The facility failed to implement its abuse prevention policy by failing to report an allegation of a sexual abuse within 2 hours or in accordance with state or federal law for Resident 2. As a result, there was a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 2. The above violation had a direct relationship to the health, safety, and security of Resident 2.