Other·May 18, 2018

F000 INITIAL COMMENTS

F000 DEFICIENCY) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of a complaint and a Facility Reported Incident (FRI). Complaint Number: CA00571815 FRI Number: CA00571829 Representing the Department of Public Health: Health Facilities Evaluator Nurse: 38487 The inspection was limited to the specific complaint and FRI incident investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for complaint CA00571815 and FRIs CA00571829.

F600 SS=D Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; 555061 04/27/2018 GOOD SHEPHERD HEALTH CARE CENTER OF SANTA MONICA 1131 Arizona Ave Santa Monica, CA 90401 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from sexual abuse. This deficient practice violated Resident 1's right to be free any type of sexual abuse. Findings: On 2/1/18, an unannounced visit was made to the facility to investigate an alleged incident of sexual abuse. Certified Nurse Assistant 2 (CNA 2) had witnessed CNA 1 on top of Resident 1. A review of the Record of Admission, dated 4/11/17, indicated Resident 1 was admitted on 10/13/16 with diagnoses that included altered mental status and generalized muscle weakness. A review of the Minimum Data Set, an assessment tool, dated 1/18/18, indicated Resident 1 had a brief interview for mental status score of 14, indicating intact cognition. On 2/1/18, at 10:07 a.m., during an interview with CNA 2, CNA 2 stated on 1/31/18, at approximately 8:20 a.m., he went from roomto-room to pick up breakfast trays. CNA 2 stated she went to Resident 1's room, he noticed the curtain was completely drawn, a practice out of the ordinary. CNA 2 stated she knocked on the closet without a response. CNA 2 "peeked" around the curtain and noticed CNA 1 with his pants down with his "bottom" exposed on top of Resident 1. CNA 2 stated and demonstrated that he saw Resident 1's legs folded upward, to the side of CNA 1. After CNA 1 noticed CNA 2 peeking around the 555061 04/27/2018 GOOD SHEPHERD HEALTH CARE CENTER OF SANTA MONICA 1131 Arizona Ave Santa Monica, CA 90401 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE curtain, he stopped, jumped up out of the bed, while verbalizing, "Woo!" CNA 1 gathered "his stuff" and left the room. CNA 2 immediately reported the alleged incident to the charge nurse after ensuring Resident 1's safety. On 2/1/18, at 10:37 a.m., licensed vocational nurse (LVN) 1 was interviewed. LVN 1 confirmed CNA 2 had reported the alleged incident of sexual abuse. LVN 1 admitted she did not notify the physician and the responsible party of the alleged sexual abuse. She admitted she did not know whether the nurse consultant notified the physician and the resident's responsible party, as stated she would. LVN 1 stated Resident 1 had refused his medication for the first time today (2/1/18), after the incident (1/31/18). LVN 1 stated CNA 2 had no reason to lie about the alleged incident of sexual abuse. On 2/1/18, at 11:25 a.m., Resident 1 was interviewed. He repeatedly denied the alleged incident of sexual abuse by verbalizing, "Nothing happened." On 1/31/18, at 1:32 p.m., CNA 1's employee filed was reviewed with the Director of Staff Development (DSD). The DSD admitted there is no documented evidence CNA 1 had a background or reference check nor a verification of findings in the State nurse aide registry, but should have; she had no explanation. On 2/1/18, at 12:16 a.m., the Interim Director of Nursing (IDON) was interviewed. The IDON stated the process for abuse prevention and investigation after an alleged incident includes: immediately ensure resident safety and being investigation; immediately notify physician and responsible party; have interdisciplinary team meeting (IDT) with the family; and form care 555061 04/27/2018 GOOD SHEPHERD HEALTH CARE CENTER OF SANTA MONICA 1131 Arizona Ave Santa Monica, CA 90401 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE plans after meeting with the IDT. During a concurrent review of Resident 1's medical record, the IDON admitted the physician and responsible party were not notified. The responsible party was not involved in the IDT meeting. A care plan was not initiated. The IDON admitted the staff would not know what interventions were appropriate for Resident 1, as there was no care plan initiated. The Social Worker (SW) was providing emotional support, but there is no documented evidence. The IDON admitted the abuse prevention process was not implemented, but should have; there was, "No time. Nothing was done for the resident." A review of the undated policy, titled Abuse and Prevention, indicated, in order to abide with the state and federal regulations governing abuse, the facility shall establish general procedures covering specific fundamental of the regulatory requirement, as such, screening, training, prevention, identification, investigation, protection and reporting. The facility shall make reasonable efforts to protect the residents from harm during an investigation process. Charge Nurse and/or RN (Registered Nurse) Supervisor shall notify attending physician of said incident for necessary interventions. Charge Nurse and/or RN Supervisor shall likewise inform and notify family members and/or legal agents of the incident. Assure the responsible party or family member that an immediate investigation has already been initiated and that appropriate actions will be taken as necessary. If resident is not hospitalized, observe resident for the next 72 hours with an hourly monitoring to identify trauma or manifestation of negative effect related to the incident. Return to normal routine care when no signs and symptoms or residual effect of the incident has been observed. Document all finds in the resident's 555061 04/27/2018 GOOD SHEPHERD HEALTH CARE CENTER OF SANTA MONICA 1131 Arizona Ave Santa Monica, CA 90401 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE medical record.

F607 SS=D Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement the facility's Abuse Prevention policy and procedure by not performing employment screenings for potential history of abuse for one of one sampled Certified Nursing Assistant 1 (CNA 1). This deficient practice had the potential for resident abuse. Cross-reference F600 Findings: On 2/1/18, an unannounced visit was made to the facility to investigate an alleged incident of sexual abuse. Certified Nurse Assistant (CNA) 2 had witnessed CNA 1 on top of Resident 1. 555061 04/27/2018 GOOD SHEPHERD HEALTH CARE CENTER OF SANTA MONICA 1131 Arizona Ave Santa Monica, CA 90401 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE On 1/31/18, at 1:32 p.m., CNA 1's employee filed was reviewed with the Director of Staff Development (DSD). The DSD admitted there is no documented evidence CNA 1 had a background or reference check nor a verification of findings in the State nurse aide registry, but should have; she had no explanation. A review of the undated policy, titled Abuse and Prevention, indicated, prior to hiring of an employee, the facility shall ensure provisions covering employment screenings for potential history of abuse. This includes, but is not limited to, obtaining information from previous and current employers, making appropriate inquiries to applicable licensing boards and registries, criminal background check for those offered a position in direct patient care and others. Licenses and certifications shall be verified before hiring by the Director of Nurses and Director of Staff Development, respectively. Appropriate licensing boards and registries and other agencies, including but not limited to, the State Nurse Aide Registry and/or the Office of the Ombudsman shall also be checked for possible abuse records.

F610 SS=D Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 §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. 555061 04/27/2018 GOOD SHEPHERD HEALTH CARE CENTER OF SANTA MONICA 1131 Arizona Ave Santa Monica, CA 90401 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE §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. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a thorough investigation was conducted and the resident was protected after a witness sexual abuse of one of two sampled residents (Resident 1), including: - Immediately notify the resident's physician and the responsible party after a witness resident sexual abuse; - Forming an interdisciplinary team (IDT) meeting that involved the resident responsible party; - Assess and develop a resident-centered care plan, This deficient practice had the potential for ongoing abuse and psychological harm. Findings: On 2/1/18, an unannounced visit was made to the facility to investigate an alleged incident of sexual abuse. Certified Nurse Assistant 2 (CNA 2) had witnessed CNA 1 on top of Resident 1. A review of the Record of Admission, dated 4/11/17, indicated Resident 1 was admitted on 10/13/16 with diagnoses that included altered mental status and generalized muscle weakness. 555061 04/27/2018 GOOD SHEPHERD HEALTH CARE CENTER OF SANTA MONICA 1131 Arizona Ave Santa Monica, CA 90401 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A review of the Minimum Data Set, an assessment tool, dated 1/18/18, indicated Resident 1 had a brief interview for mental status score of 14, indicating intact cognition. On 2/1/18, at 10:07 a.m., during an interview with CNA 2, CNA 2 stated on 1/31/18, at approximately 8:20 a.m., he went from roomto-room to pick up breakfast trays. CNA 2 stated she went to Resident 1's room, he noticed the curtain was completely drawn, a practice out of the ordinary. CNA 2 stated she knocked on the closet without a response. CNA 2 "peeked" around the curtain and noticed CNA 1 with his pants down with his "bottom" exposed on top of Resident 1. CNA 2 stated and demonstrated that he saw Resident 1's legs folded upward, to the side of CNA 1. After CNA 1 noticed CNA 2 peeking around the curtain, he stopped, jumped up out of the bed, while verbalizing, "Woo!" CNA 1 gathered "his stuff" and left the room. CNA 2 immediately reported the alleged incident to the charge nurse after ensuring Resident 1's safety. On 2/1/18, at 10:37 a.m., licensed vocational nurse (LVN) 1 was interviewed. LVN 1 confirmed CNA 2 had reported the alleged incident of sexual abuse. LVN 1 admitted she did not notify the physician and the responsible party of the alleged sexual abuse. She admitted she did not know whether the nurse consultant notified the physician and the resident's responsible party, as stated she would. LVN 1 stated Resident 1 had refused his medication for the first time today (2/1/18), after the incident (1/31/18). LVN 1 stated CNA 2 had no reason to lie about the alleged incident of sexual abuse. On 2/1/18, at 11:25 a.m., Resident 1 was interviewed. He repeatedly denied the alleged incident of sexual abuse by verbalizing, 555061 04/27/2018 GOOD SHEPHERD HEALTH CARE CENTER OF SANTA MONICA 1131 Arizona Ave Santa Monica, CA 90401 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE "Nothing happened." On 2/1/18, at 12:16 a.m., the Interim Director of Nursing (IDON) was interviewed. The IDON stated the process for abuse prevention and investigation after an alleged incident includes: immediately ensure resident safety and being investigation; immediately notify physician and responsible party; have interdisciplinary team meeting (IDT) with the family; and form care plans after meeting with the IDT. During a concurrent review of Resident 1's medical record, the IDON admitted the physician and responsible party were not notified. The responsible party was not involved in the IDT meeting. A care plan was not initiated. The IDON admitted the staff would not know what interventions were appropriate for Resident 1, as there was no care plan initiated. The Social Worker (SW) was providing emotional support, but there is no documented evidence. The IDON admitted the abuse prevention process was not implemented, but should have; there was, "No time. Nothing was done for the resident." A review of the undated policy, titled Abuse and Prevention, indicated, in order to abide with the state and federal regulations governing abuse, the facility shall establish general procedures covering specific fundamental of the regulatory requirement, as such, screening, training, prevention, identification, investigation, protection and reporting. The facility shall make reasonable efforts to protect the residents from harm during an investigation process. Charge Nurse and/or RN (Registered Nurse) Supervisor shall notify attending physician of said incident for necessary interventions. Charge Nurse and/or RN Supervisor shall likewise inform and notify family members and/or legal agents of the incident. Assure the responsible party or family 555061 04/27/2018 GOOD SHEPHERD HEALTH CARE CENTER OF SANTA MONICA 1131 Arizona Ave Santa Monica, CA 90401 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE member that an immediate investigation has already been initiated and that appropriate actions will be taken as necessary. If resident is not hospitalized, observe resident for the next 72 hours with an hourly monitoring to identify trauma or manifestation of negative effect related to the incident. Return to normal routine care when no signs and symptoms or residual effect of A review of the policy, titled Care Management, revised August 2009, indicated resident care management should be consistent with the medical Plan of Care. All resident care is designed to meet a resident's individual needs and is directed toward conservation and restoration of an optimal physical and emotional state. The RN performs a functional nursing assessment to obtain information for planning resident care. Nurses on all shifts are expected to participate in gathering information. The interdisciplinary Plan of Care is generated from the assessment process. The goal of the care planning process is to select the path that provides the greatest benefit to a resident and is most consistent with a resident's ability to control his or her own existence.