Health inspection·August 28, 2024

§483.12(c) (1) (4) 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 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 8/5/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident neglect and abuse. The facility failed to report alleged abuse to the abuse coordinator and state agency for Resident 1. This deficient practice placed the 61 facility residents at risk for potential alleged abuse. During a review of Resident 1 ' s Admission Record indicated the facility admitted the 67-year-old male on 7/23/2024 with diagnoses including Hemiplegia affecting the left side (weakness of paralysis of the entire left side of the body), dislocation of left shoulder joint, history of falls, essential hypertension (high blood pressure) and polyneuropathy (many nerves in different parts of the body have pain). During a review of Resident 1 ' s Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 8/7/2024, indicated Resident 1 ' s cognition (mental ability to make decisions for daily living) was mildly impaired. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. During an interview on 8/7/2024 at 12:09 p.m., Resident 1 stated on 8/3/2024 the Certified Nursing Assistant (CNA) 1 who delivered Resident 1's breakfast tray tried to hit Resident 1. Resident 1 asked for some butter and CNA 1 allegedly brought the butter and threw the butter onto the tray. Resident 1 was then upset and stated," don't throw it show some respect" to which CNA 1 replied," don't tell me how to do my job" after which Resident 1 stated CNA 1 then reached for Resident 1 as if to hit Resident 1. Resident 1 then stated," don't touch me". Resident 1 then grabbed the cell phone and threatened to call the police. Resident 1 stated CNA 1 did not hit Resident 1 but Resident 1 felt very angry after the incident. Resident 1 stated an unidentified staff member entered the room and asked what was going on because Resident 1 was arguing with CNA 1. Resident 1 explained what happened to the unidentified staff member and the unidentified staff member stated," CNA 1 would not do that". Resident 1 stated," why would I make that up" and told both CNA 1 and the unidentified staff member to exit the room. Resident 1 did not call the police and did not see CNA 1 for the rest of the day. During an interview on 8/7/2024 at 2:10 p.m. with CNA 1, CNA 1 stated on the morning of 8/3/2024, CNA 1 went to Resident 1 ' s room to answer the call light. CNA 1 stated Resident 1 asked for extra butter. CNA 1 went to the kitchen and returned to the room with the butter and placed it on the table and stated," Here is your butter" and exited the room. CNA 1 went to attend to another resident them returned to Resident 1's room to answer the call light again. CNA 1 stated upon entering the room Resident 1 began to yell stating, "why would you do that and treat me like a dog". CNA 1 stated Resident 1 was accusing CNA 1 of throwing butter at Resident 1 and hitting Resident 1. CNA 1 denied this happened and went to get the Licensed Vocational Nurse (LVN) 1 in charge to come to Resident 1 ' s room. During an interview on 8/7/2024 at 3:53 p.m., the Assistant Director of Nursing (ADON) stated alleged abuse had to be reported immediately to the supervisor on shift and the Administrator (Adm). The ADON further added the ADON had been covering for the DON since 8/5/2024 and was not informed by LVN 1 nor CNA 1 about the alleged incident between CNA 1 and Resident 1 on 8/3/2024. During an interview on 8/7/2024 at 4:22 p.m. with LVN 1, LVN 1 stated on 8/3/2024 CNA 1 asked LVN 1 to go into Resident 1 ' s room because there was a problem; Resident 1 was accusing CNA 1 of things that did not happen. Resident 1 told LVN 1 that CNA 1 threw food at and hit Resident 1. LVN 1 then removed the cover from the breakfast tray and noticed all the food there was untouched. LVN 1 said to Resident 1, maybe Resident 1 was offended by the tone of CNA 1 ' s speech at times but LVN 1 did not believe CNA 1 threw food and hit Resident 1. LVN 1 apologized to Resident 1 for the misunderstanding and reassigned CNA 1. LVN 1 did not interview CNA 1 ' s other residents to inquire about potential abuse. LVN 1 did not report the incident to the abuse coordinator nor to the ADON. LVN 1 stated the incident should have been reported because Resident 1 alleged physical abuse, and the abuse allegation should have been investigated. During an interview on 8/7/2024 at 4:22 p.m. with the Administrator (ADM), The ADM stated the ADM was the abuse coordinator and allegations of abuse had to be reported to the ADM immediately. The ADM stated neither LVN 1 nor CNA 1 reported the incident between CNA 1 and Resident 1 on 8/3/2024 until the interview on 8/7/2024. The ADM stated LVN 1 absolutely should have reported the incident to the ADM immediately, so the ADM could then report the incident to the ombudsman and police; investigated and submitted the five (5) days conclusion to CDPH. During a review of the facility policy and procedure titled," Abuse Prevention and Prohibition Program" dated 10/2022 indicated, "IX. Reporting/Response A. Facility Staff are Mandatory Reporters i. Facility owners, operc1tors, employees, managers, agents, and contractors are obligated by the Elder Justice Act and the California Elder Abuse and Dependent Adult Civil Protection Act to report known or suspected instances of abuse of elder or dependent adults. ii. The Facility will not impede or inhibit a Facility Staff member's reporting duties, nor will Facility Staff be reprimanded or disciplined for reporting abuse. iii. The Facility has a strict non-retaliation policy for good faith reporting in compliance with the Elder Justice Act and the Elder Abuse and Dependent Adult Civil Protection Act. iv. Failure to report suspected or known abuse may result in legal action against the individual(s) withholding such information. Administrator, or his/her designee, as Abuse Coordinator i. In order to facilitate reporting, ensure confidentiality, and promote order at the Facility, the Administrator, or his/her designee, shall be the individual who reports known or suspected instances of abuse of residents at the Facility to the proper authorities. ii. Facility Staff will report known or suspected instances of abuse to the Administrator, or his/her designee. iii. Facility/staff members shall be notified that the Administrator, or his/her designee, has this responsibility, and that inquiries concerning resident abuse and reporting requirements should be referred to the Administrator, or his/her designee." The facility failed to report alleged abuse to the abuse coordinator and state agency for Resident 1. This deficient practice placed the 61 facility residents at risk for potential alleged abuse. The above violation had a direct relationship to the health, safety, and security of the residents in the facility.