Health inspection·January 2, 2025

§483.12(c) Reporting of Alleged Violations 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. 22CCR §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. HSC 1418.91 (a) Abuse Reporting (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. On 12/6/2024 at 12:28 p.m., The California Department of Public Health (CDPH) received a Facility Reported Incident concerning an allegation of Resident 1 being physically abused by Resident 2. On 12/11/2024, the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1. Implement its Policy and Procedure (P&P) titled “Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating” which indicated the facility will report within two (2) hours of an allegation of physical abuse to the CDPH and the Ombudsman (an agency who investigates, reports on, and helps settle complaints against the facility), after Resident 2 was alleged to have hit Resident 1 on 12/5/2024. This resulted in a delay of investigation by the State agency (CDPH) and placed Resident 1 at risk for further abuse. Resident 1 was a 90-year-old male, admitted to the facility on 3/1/2024 with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), cerebral infarction (also known as stroke – damage to tissues in the brain due to a loss of oxygen to the area) with hemiplegia ( paralysis on one side of the body) and metabolic encephalopathy (a brain disorder that occurs when a chemical imbalance in the blood affects the brain). A review of Resident 1’s History and Physical (H&P), dated 10/25/2024, indicated Resident 1 did not have the capacity for medical decision making. A review of Resident 1’s Minimum Data Set ([MDS] a resident assessment tool), dated 12/6/2024, indicated Resident 1’s cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) with oral hygiene, upper body dressing and personal hygiene. Resident 2 was a 70-year-old female, admitted to the facility on 5/30/2024 with diagnoses including encephalopathy (any disorder or damage that affects the brain’s structure or function), diabetes mellitus ([DM] – a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN] – high blood pressure). A review of Resident 2’s H&P, dated 7/4/2024, indicated Resident 2 had the capacity for medical decision making. A review of Resident 2’s MDS, dated 12/5/2024, indicated Resident 2’s cognitive skills for daily decision making was intact. The MDS indicated Resident 2 required supervision with oral hygiene, upper body dressing and personal hygiene. A review of Resident 1’s Progress Notes, dated 12/5/2024 at 7:30 p.m., indicated Resident 1 told the nurse she was hit by Resident 2. A review of the facility’s Report of Suspected Dependent Adult/Elder Abuse (SOC 341) faxed to CDPH on 12/6/2024 at 12:29 p.m. (approximately 30 hours after the allegation occurred), indicated on 12/5/2024 at 7:30 p.m., Resident 1 was hit by Resident 2. During a telephone interview on 12/11/2024 at 1:25 p.m., Licensed Vocational Nurse (LVN 1) stated Resident 1’s allegation of physical abuse occurred on 12/5/2024 at around 8:00 p.m. LVN 1 stated she documented the incident but did not report the allegation to the Administrator (the facility’s abuse coordinator). LVN 1 stated the Administrator was responsible for reporting any allegations of abuse to the CDPH and Ombudsman. LVN 1 stated the Administrator reported the allegation of physical abuse between Resident 1 and Resident 2 to the CDPH on 12/6/2024 (one day later). LVN 1 stated Resident 1’s allegation of abuse should have been reported to the Administrator, CDPH and Ombudsman for Resident 1’s safety. LVN 1 stated any allegations of abuse should be reported immediately or no more than 2 hours to the Administrator, CDPH, and Ombudsman. LVN 1 stated it was important to report allegations of abuse to the CDPH in a timely manner so they could start their investigation and also to protect the involved resident from further harm. During a concurrent interview and record review on 12/11/2024 at 2:22 p.m., with the Administrator, the facility’s undated P&P titled, “Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating,” was reviewed. The Administrator stated the P&P indicated, “The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: A) The state licensing/certification agency responsible for surveying/licensing the facility, B) The local/state Ombudsman… Immediately is defined as A) within two hours of an allegation involving abuse or result in serious bodily injury, or B) within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.” The Administrator stated this was the facility’s policy when it comes to abuse reporting as required by State and Federal law. The Administrator stated everyone was a mandated reporter when it came to abuse. The Administrator stated the facility was cited in the past by CDPH for late reporting of allegation of abuse. The facility failed to: 1. Implement its P&P titled “Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating” which indicated the facility will report within two hours of an allegation of physical abuse to the CDPH and the Ombudsman, after Resident 2 was alleged to have hit Resident 1 on 12/5/2024. This resulted in the delay of investigation by the State agency and placed Resident 1 at risk for further abuse. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.