Health inspection·August 24, 2023

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 7/12/23 the California Department of Public Health (CDPH) received a Facility Reported Incident indicating Resident 2 grabbed his roommate’s (Resident 1) shoulder and possibly struck Resident 1. On 7/17/2023, the CDPH conducted an unannounced visit at the facility. The facility failed to: 1. Report an allegation of abuse between Resident 1 and Resident 2 no later than two hours. As a result, there was a potential for a delay in the investigation by the State agency and placed Resident 1 at risk for continuous abuse by Resident 2. Resident 1 was an 82-year-old male, admitted to the facility on 5/19/2022, with diagnoses including dementia (group of conditions characterized by impairment in brain function affecting memory and judgment) with mild mood disturbances, major depressive disorder (mood disorder causing persistent feeling of sadness and loss of interest) and generalized anxiety disorder. A review of Resident 1’s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 5/18/2023, indicated Resident 1 had intact cognition (thought process) and required supervision for most of the Activities of Daily Living (ADL’s) including bed mobility, transfer, walking, eating and toilet use. A review of Resident 1’s Nurse Notes dated 7/11/2023 at 12:53 a.m. indicated that on 7/10/2023 at 7:25 p.m., Resident 1 was talking with a friend (Resident 5) and Resident 2 came from behind and punched Resident 1 at the back of his head and left cheek with a closed fist without reason. The note indicated the incident was witnessed by Resident 5 and Resident 1 had to be escorted out of the room. Resident 2 was a 76-year-old male, admitted to the facility on 6/13/2019 with diagnoses including Alzheimer’s disease (brain disorder that causes gradual decline in memory), dementia with psychotic disturbances (false beliefs that make it hard for someone to think clearly) and schizophrenia (severe brain disorder that can cause disorganized thinking). A review of Resident 2’s MDS, dated 5/17/2023, indicated Resident 2 had severe cognitive impairment and required supervision for most ADL’s including bed mobility, transfer, walking and eating. A review of Registered Nurse (RN) 2’s Statement dated 7/10/2023, the Statement indicated RN 2 heard a resident (Resident 5) call for help and saw Resident 2 grabbing Resident 1’s shoulder from behind with his fist raised ready to hit Resident 1. The Statement also indicated Resident 5 stated Resident 2 had already struck Resident 1 from behind 3 times. Resident 1 stated he was struck once by Resident 2. A review of the facility’s email dated 7/11/2023, indicated the report of the incident between Resident 1 and Resident 2 was sent to State Agency on 7/11/2023 at 5:27 p.m. During interviews on 7/18/2023 ta 9:23 a.m. and 9:50 a.m. with Resident 1, Resident 1 stated (on 7/10/2023), he was speaking to his neighbor (Resident 5), when Resident 2 came up from behind him and hit him on the left side of his face. Resident 1 stated he did not feel safe, and that Resident 2 also tried to hit a nurse when he (Resident 2) did not want to take a shower two days prior to the incident on 7/10/2023. During an interview on 7/18/2023 at 1:24 p.m. with the Administrator (ADMN), the ADMN stated abuse was any kind of harm presented towards someone which could include neglect, exploitation, sexual and emotional harm. The ADMN stated he had reported the incident because Resident 1 said he was hit, and it was confirmed that two staff members had to remove Resident 2 away from Resident 1. The ADMN stated it was important for incidents to be reported to the State Agency so that a thorough investigation could be conducted and to keep residents safe. During an interview on 7/19/2023 at 1:42 p.m. with the Director of Nursing (DON), the DON stated the facility did not have to report the allegation of abuse to the State Agency within two hours because Resident 1 had no injuries or evidence of abuse. A review of the facility’s undated Policy and Procedure (P/P) titled, “Policy and Procedure for Reporting Suspected Crimes under the Federal Elder Justice Act”, the P/P indicated the following: 1. When staff suspect a crime had occurred against a resident, they must report the incident. 2. Staff must report a suspicion of a crime to the State Survey Agency, local enforcement, and/or the Ombudsman within a designated time frame by email, fax, or telephone. 3. The reporting individual would notify local law enforcement immediately by phone and the Ombudsman, Law Enforcement and Licensing Agency within two hours by fax when an incident involved abuse or serious bodily injury. A review of the facility’s undated P/P titled, “Reporting Abuse to Facility Management”, the P/P indicated the following: When an alleged or suspected case of mistreatment, neglect, injuries of unknown source or abuse was reported, the facility administrator, or his/her designee, may notify the following persons or agencies of such intent: a. The State licensing/certification agency responsible for surveying/licensing the facility. b. The local/State Ombudsman. c. The Resident’s Representative (Sponsor) of Record. d. Law Enforcement Officials. e. The Resident’s Attending Physician; and f. The Facility Medical Director. The facility failed to: (c) Report an allegation of abuse between Resident 1 and Resident 2 no later than two hours. As a result, there was a delay in the investigation by the State agency. This violation presented a direct or immediate relationship to the health, safety, security, or welfare of Resident 1.