Health inspection·November 15, 2024

42 CFR §483.12 (c) Freedom from Abuse, Neglect, and Exploitation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. 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. H&S § 1418.91 (a) A long-term health care facility shall report all incidents of alleged 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 10/1/2024 the California Department of Public Health (CDPH) received a Facility Reported Incident indicating Resident 2 physically abused Resident 1. On 10/8/2024, the CDPH conducted an unannounced visit at the facility to investigate the Incident. The facility failed to: 1.Implement its abuse Policy and Procedure (P&P) titled, "Abuse Investigation and Reporting" which indicated all allegations of abuse would be reported to the State Licensing/Certification Agency immediately, but no later than two hours. As a result, there was a potential for a delay in the investigation by the CDPH. Resident 1 was a 64-year-old male, admitted to the facility on 2/24/2024 and readmitted on 2/28/2024. Resident 1's diagnoses included heart failure (heart disorder which causes the heart to not pump the blood efficiently), End Stage Renal Disease ([ESRD] irreversible kidney failure), and hypertension ([HTN] high blood pressure). A review of Resident 1's History and Physical (H&P) dated 3/1/2024 indicated Resident 1 had the capacity to make decisions. A review of Resident 1's Minimum Data Set ([MDS], a federally mandated resident assessment tool), dated 9/3/2024, indicated Resident 1 had no cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 required partial/moderate assistance (staff does less than half the effort) for Activities of Daily Living (ADLs) such as lower body dressing, personal hygiene, and transfers (ability to transfer to and from the bed or chair). A review of Resident 1's SBAR ([Situation, Background, Assessment, Recommendation] Communication Form (a communication tool used by healthcare workers when there is a change in condition among the residents) dated 10/1/2024, indicated Resident 2 hit Resident 1 on both of his cheeks with closed fists (on 10/1/2024) at approximately 12:25 a.m. Resident 2 was a 58-year-old male, originally admitted to the facility on 7/18/2024 and readmitted on 9/26/2024. Resident 2's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), diabetes ([DM] a disorder characterized by difficulty in blood sugar control and wound healing) and HTN. A review of Resident 2's MDS dated 7/24/2024 indicated Resident 2 had moderate cognitive impairment. The MDS indicated Resident 2 required partial/moderate assistance from staff for ADLs such as oral hygiene, dressing and transfers. A review of Resident 2's H&P dated 7/30/2024 indicated Resident 2 had the capacity to make decisions. A review of Resident 2's SBAR Communication Form dated 10/1/2024 indicated Resident 2 physically assaulted his roommate (Resident 1) on 10/1/2024 at approximately 12:25 a.m. During an interview on 10/8/2024 at 10:52 a.m., Resident 2 stated (on 10/1/2024), Resident 1 punched him while lying in bed for refusing to turn the television off. During a concurrent record review and interview on 10/8/2024 at 1:55 p.m., with the Director of Nursing (DON), the facility's "Report of Suspected Dependent Adult/Elder Abuse" fax submitted to the CDPH was reviewed. The DON stated the Charge Nurse (unnamed) notified her regarding the altercation between Resident 1 and Resident 2 on 10/1/2024 at around 12:00 a.m. The DON stated the report was sent to the State Agency on 10/1/2024 at 2:02 p.m. (approximately 14 hours later). The DON stated, the abuse incident should have been reported to the State Agency within two hours, but it was not because she wanted to investigate the incident first. During an interview on 10/8/2024 at 2:50 p.m., the Administrator (ADM) stated, the DON informed him of the abuse incident on 10/1/2024 at 2:50 a.m. The ADM stated, incidents involving abuse should be reported (to the State Agency) within two hours. The ADM stated the incident between Resident 1 and 2 was not reported within two hours because staff (unnamed) were gathering statements, and nurses may not have been aware they could complete the report. The ADM stated, abuse should be reported timely to ensure residents were kept safe. A review of the facility's P&P titled, "Abuse Investigation and Reporting" dated 7/2017 indicated all alleged violations involving abuse would be reported by the facility Administrator, or his/her designee to the State Licensing/Certification Agency immediately, but no later than two hours. The facility failed to: 1. Implement its abuse P&P titled, "Abuse Investigation and Reporting" which indicated all allegations of abuse would be reported to the State Licensing/Certification Agency immediately, but no later than two hours. As a result, there was a potential for a delay in the investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of residents.