Health inspection·June 14, 2023

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. Title 22 § 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. HSC § 1418.91 (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. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 5/9/2023, the Department of Public Health (State Survey Agency [SSA]) made an unannounced visit to the facility to investigate a complaint related to resident-to-resident physical abuse. The facility failed to implement it policy regarding Abuse-Reporting & Investigations and report to the SSA-Department of Public Health, an alleged resident-to-resident altercation that occurred on 4/22/2023 between Residents 1 and 2. As a result, there was a delay in the SSA investigation and specifics of the alleged incident could not be obtained placing Resident 1 at risk for further abuse. a. A review of Resident 1's Admission Record indicated Resident 1, was originally admitted to the facility on 1/17/2023 and was re-admitted on 4/10/2023 with diagnoses including neoplasm (a new and abnormal growth of tissues) of the bone, diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and generalized muscle weakness. A review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 2/7/2023, indicated Resident 1 was moderately impaired in cognitive skill (thought processes) for daily decision making and one-person assistance with staff on activities of daily living (ADLs-bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene). b. A review of Resident 2's Admission Record indicated Resident 2, was originally admitted to the facility on 4/20/2023 with diagnoses including metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), atrial fibrillation (AF-an irregular rapid heart rate that commonly causes poor blood flow) and protein-calorie malnutrition (lack of sufficient nutrients in the body). A review of Resident 1's MDS, dated 4/27/2023, indicated Resident 2 was moderately impaired in cognitive skill for daily decision making and one-person assistance with staff on ADLs. During an interview with the Licensed Vocational Nurse 6 (LVN6) on 5/9/2023 at 1:45 p.m., LVN6 stated that there was a report from the outgoing night shift nurse that Resident 2 had thrown water to Resident 1 on 4/22/2023. During an interview with the Certified Nursing Assistant 4 (CNA4) on 5/9/2023 at 2:06 p.m., CNA4 stated that it was endorsed by the outgoing night shift CNA on 4/22/2023 that Resident 2 got up and pour a pitcher of water to Resident 1 on 4/22/2023. CNA4 also stated that it was verified by the terrified Resident 1. During a concurrent interview and record review with Registered Nurse 3 (RN3) on 5/9/2023 at 2:49 p.m., RN3 stated that on 4/22/2023, the incoming nurse (Licensed Vocational Nurse 4 [LVN4]) reported to RN3 that the outgoing night shift nurse endorsed to LVN4 that Resident 2 poured water on Resident 1's face on 4/22/2023. RN3 stated that Resident 1 was interviewed and stated that Resident 1 did not feel comfortable and safe being with Resident 2. RN3 also stated that there was no documentation was done by the night shift nurse regarding the incident. During an interview with the LVN4 on 5/9/2023 at 3:01 p.m., LVN4 stated that there was an altercation on 4/22/2023 between Resident 1 and Resident 2 that was endorsed to her by the outgoing night shift nurse. LVN 4 also verified that incident was not documented at that time. LVN4 stated that the night shift nurse and LVN4 should have documented regarding the issue to be able to monitor residents. During an interview with Resident 1 on 5/10/2023 at 10:50 a.m., Resident 1 stated that she remembered it around 3 a.m., Resident 2 was hiding in the bed then started screaming that she owns the place and all of Resident 1's belongings were hers (Resident 2's). Resident 1 stated that Resident 2 threw water all over her since there was water everywhere. Resident 1 also stated that she felt helpless and still worries at times since she was screaming for help for a long time. During a concurrent interview and record review with the Director of Nursing (DON), on 5/10/2023 at 12:16 p.m., the DON stated that any suspected abuse or neglect issues should be documented and reported as soon as possible to him and/or the administrator so they can immediately investigate and notify the incident to the SSA, Ombudsman and police if applicable. DON stated that he was not made aware of the incident between Resident 1 and Resident 2 on 4/22/2023. DON also stated and verified that no documentation was done regarding the incident. A review of the facility's policy and procedures (P&P), titled, "Abuse-Reporting & Investigations," revised 3/2018, indicated that the facility will protect the health, safety, and welfare of Facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source and suspicion of crimes are promptly reported and thoroughly investigated. A review of the facility's P&P, titled, "Resident Safety," revised 4/15/2021, indicated Facility will provide a safe and hazard free environment. A review of the facility's Job Descriptions (JD), titled, "Charge Nurse (CN)," undated, indicated that CN will initiate investigation of accidents and unusual occurrences and make necessary written report to the DON as established in the facility's P&P. A review of the facility's JD, titled, "Certified Nursing Assistant (CNA)," undated, indicated that CNA will report any resident abuse immediately. The facility failed to implement it policy regarding Abuse-Reporting & Investigations and report to the SSA-Department of Public Health, an alleged resident-to-resident altercation that occurred on 4/22/2023 between Residents 1 and 2. As a result, there was a delay in the SSA investigation and specifics of the alleged incident could not be obtained placing Resident 1 at risk for further abuse. The above violation had a direct relationship to the health, safety, and security of Resident 1.