Other·January 30, 2024

F609 Freedom from Abuse, Neglect, and Exploitation §483.12(c) (1)

F609 §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.

F610 Freedom from Abuse, Neglect, and Exploitation §483.12(c) (2)-(4)

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. § 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. On 12/19/2023, the California Department of Public Health (State Survey Agency [SSA]) made an unannounced visit to the facility to investigate a complaint related to resident neglect and quality of care and treatment of a resident. The facility failed to investigate and report allegations of neglect (failure to provide necessary care and services to avoid harm) of Resident 1 to the Department of Public Health, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility's policy and procedure within five (5) working days of the allegation. This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of neglect was investigated placing Resident 1 and all 84 residents in the facility at risk for further neglect. A review of Admission Record indicated Resident 1 was originally admitted to the facility on 8/24/2018 and readmitted on 11/22/2023, with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), major depressive disorder (a mental disorder that have a persistent feeling of loss of pleasure or interest in life), and acute and chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide). A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 11/29/2023, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs - toileting hygiene, shower/bathe, lower body dressing, and putting on/taking off footwear). During an interview with Resident 1 on 12/19/2023 at 11:44 a.m., Resident 1 stated, she (Resident 1) called the Police last week (12/14/2023) due to elderly abuse and neglect from one of the facility staff (unidentified) against Resident 1. Resident 1 stated, the facility staff did not provide proper care that day (12/14/2023) and the resident felt disrespected by one of the facility staff, so the resident called the Police. Resident 1 stated, the Police came and talked to her (Resident 1) and assisted the resident in filing a report but no one from the facility followed up with the resident about the report of abuse and neglect. During an interview with Licensed Vocational Nurse 1 on 12/19/2023 at 1:40 p.m., LVN 1 stated, on 12/14/2023, Resident 1 called the Police to report an elderly abuse case. LVN 1 stated, Registered Nurse 2 (RN 2) was assigned to Resident 1 and RN2 talked to the facility staff assigned to Resident 1 to interview. During an interview with Registered Nurse 2 on 12/19/2023 at 2:02 p.m., RN 2 stated, on 12/14/2023, Certified Nursing Assistant 2 (CNA 2) reported Resident 1 wanted to be transferred to a wheelchair from the bed but since the facility was short staffed that day, Resident 1 was asked to wait until CNA 2 was available to assist. RN 2 stated, suddenly, the Police walked into the facility and the Police notified RN 2 that the police received a report of elder abuse from Resident 1. RN 2 stated, confirmed not reporting the incidence to the facility's Abuse Coordinator, and should have reported it. RN 2 stated she (RN 2) did not document the incident in the Progress Notes either and should have documented it. During an interview on 12/19/2023 at 3:04 p.m., the Director of Nursing (DON) confirmed being aware of the police going to the facility because Resident 1 called the police. The DON stated the resident complained to the nurse supervisor about CNA 2's attitude. The DON denied being aware of Resident 2 reporting verbal abuse and confirmed the abuse allegation was not reported to the Department. The DON stated the facility protocol was to report allegations of abuse to the abuse coordinator (the administrator). The DON stated the resident's abuse allegation should have been reported. During an interview on 12/19/2023 at 4:08 p.m., the administrator confirmed seeing the police enter the facility and confirmed Resident 2's abuse allegation was not reported. A review of a facility policy and procedures (P&P) titled, "Abuse Prevention", reviewed on 9/11/2023 indicated, "It is the policy of this facility to protect its residents from acts of abuse, prevent mistreatment, neglect, abuse of residents and misappropriation of resident property." A review of a facility P&P titled, "Reporting Guidelines for State/Federal Agencies", reviewed on 9/11/2023 indicated, "It is the policy of this facility to comply with federal, state and other agency reporting requirements in a timely and appropriate manner... allegation of abuse: report to Department of Health - phone within 24 hours, written within 5 days." The facility failed to investigate and report allegations of neglect of Resident 1 to the Department of Public Health, Ombudsman, and to the local law enforcement in accordance with the facility's policy and procedure within five working days of the allegation. This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of neglect was investigated placing Resident 1 and all 84 residents in the facility at risk for further neglect. The above violation had a direct relationship to the health, safety, and security of Resident 1.