Other·February 12, 2024

F609 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. §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 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. On 1/23/2024 at 9:25 am an unannounced visit was made to the facility to investigate an allegation regarding abuse of Resident 1. The facility failed to implement its abuse prevention policy by failing to report an alleged abuse related missing funds to the state agency (Department of Public Health) within 2 hours after the allegation was reported by Resident 1. This failure resulted in a delay of an onsite inspection by the Department of Public Health and had potential to place all 77 residents in the facility at risk of elder abuse through misappropriation of funds. A review of Resident 1's admission record indicated; facility originally admitted the 72 year old female on 08/24/2018 with diagnoses which included chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), morbid obesity (weight is more than 80 to 100 pounds above their ideal body weight), abnormality of Gait and mobility (an unusual walking pattern that may be caused by underlying health conditions) and weakness. A review of Resident 1's history and physical (H&P) dated.11/27/2023 indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care planning tool), dated, 12/13/2023 indicated Resident 1's cognitive (mental ability to make decisions for daily living) was moderately impaired, and mobility (process for determining how much a patient can move) was severely impaired. During an interview on 1/23/2024 at 12:36 p.m. Resident 1 stated on 9/15/2023 in the afternoon (unable to recall exact time), she (Resident 1) wrapped her Electronic Benefit Transfer (EBT- a state issued supplemental nutrition assistance card for low qualifying low-income participants) with a piece of paper to obscure it from view, placed the EBT card in an envelope addressed to Family 1 and handed the sealed envelope to Certified Nursing Assistant 4 (CNA4). Resident 1 then requested CNA4 place it in the outgoing mail to be mailed to Family 1. Resident 1 stated the EBT card had $743 on it. Resident 1 stated Family 1 received the EBT card on 9/21/2023. Resident 1 stated she instructed Family 1 to verify the balance on the EBT card, but Family 1 was unable because the EBT card was not accepting the personal identification number (PIN) on the card. Resident 1 stated she then changed the PIN number on the EBT card which required her personal information namely her date on birth (DOB) and/or last for digits of her social security number (SSN). Resident 1 stated she instructed Family 1 to verify the funds again and discovered the EBT card had a balance of only $3. Resident 1 stated upon further investigation she noticed the card was used twice on 9/16/2023 and 9/17/2023 with transactions of $300 and $440 respectively. Resident 1 asked Family 1 to check the postal mail stamp date on the envelope, Family 1 indicated it was dated 9/18/2023. Resident 1 stated she immediately reported the incident to the former Administrator (ADM1) and was instructed to call the police because she did not have definitive proof of the perpetrator and there was nothing the facility could do to help her. During an interview on 1/23/2024 at 12:57 p.m. the current Administrator (ADM2) stated during and interdisciplinary team meeting on an unrelated incident, Resident 1 alleged that CNA4 had previously stolen money out of her EBT card. Upon further investigation, ADM2 stated he was not unable to find any records indicating the EBT missing funds incident was ever reported to the Department of Public Health (DPH) by the ADM2 and immediately reported the incident as required by state regulations. During an interview on 1/24/2024 at 2:55 p.m. CNA4 denied knowledge about an EBT card and stated she (CNA4) was on vacation during the time Resident alleges she (CNA4) took and used her (Resident 1 ' s) EBT card. CNA4 stated she started vacation on 9/9/2023 and returned to work 9/15/2023. CNA4 stated the previous facility Administrator interviewed her (CNA4) while she was on vacation. CNA4 stated she was unaware of anything regarding an EBT card and denied receiving an envelope from Resident 1 to place in outgoing mail. A review of facility ' s monthly schedule from 09/1/2023-9/30/2023 indicated CNA4 was scheduled for work on 9/15,16,17/2023 and was off on 9/18 - 19/2023. A review of facility nursing staffing assignment and sign-in sheet dated 9/15/2023 indicated CNA4 worked the 7am-3pm shift. A review of facility policy and procedure titled "Abuse and Crime Reporting" dated 10/11/2023 indicated, it is the policy of the facility to report and investigate, in accordance with local, state and/or federal laws and regulations, to the appropriate agency, any allegations of and/or suspected conditions of abuse ....., Policy further states, any employee, or covered individual who has a reasonable suspicion that a crime has been committed against any resident must report the incident within 2 hrs. to DPHS (Department of Public Health Services) and to the local law enforcement agency. The facility failed to implement its abuse prevention policy by failing to report an alleged abuse related missing funds to the state agency within 2hrs after the allegation was reported by Resident 1. This failure resulted in a delay of an onsite inspection by the Department of Public Health and had potential to place all 77 residents in the facility at risk of elder abuse through misappropriation of funds. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1.