Health inspection·August 8, 2024

§483.10 Resident rights. (j) Grievances. (1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. (2) The resident has the right to, and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. 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: (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 6/13/2024, the California Department of Public Health (CDPH) received a complaint regarding an allegation of resident neglect. On 6/27/2024 at 9:10 a.m., the CDPH conducted an unannounced visit at the facility to investigate the allegations. The facility failed to: 1). Implement its policy and procedure (P&P) titled, "Social Service Policy and Procedure, Grievances," which indicated the facility will actively seek a resolution after the grievance (complaint) was filed and keep Resident 1 informed of its progress. This failure resulted in Resident 1's grievance not investigated and had the potential to result in humiliation and psychosocial harm, affecting Resident 1's quality of life. A review of Resident 1's Admission Record indicated Resident 1 was a 64-year-old female, admitted to the facility on 5/16/2024 with diagnosis of traumatic hemorrhage of left cerebrum (brain bleed). A review of Resident 1's Minimum Data Set (Minimum Data Set [MDS] a standardized assessment and care screening tool), dated 5/21/2024, indicated Resident 1 was cognitively (the ability to think and reason) intact. The MDS indicated Resident 1 was dependent (requiring someone for help) on staff for toileting hygiene. The MDS indicated Resident 1 was dependent with toilet transfer. The MDS indicated Resident 1 was always incontinent (inability to control) of bowel and bladder functions. A review of Resident 1's care plan titled, "Episode of confabulation (gossip) - episode of fabricating (faked) or making up stories," dated 6/12/2024, indicated staff will identify if the resident was in pain, monitor areas of concerns or stories, listen and be supportive, but firm. During an interview on 6/27/2024 at 12:18 p.m. with Resident 1, Resident 1 was unable to recall any incidents with staff on 6/12/2024. During a concurrent interview and record review on 6/27/2024 at 3:49 p.m. with the Director of Nursing (DON), Resident 1's care plan titled, "Episode of confabulation- episode of fabricating or making up stories," dated 6/12/2024 and Resident 1's progress notes dated 6/12/2024 were reviewed. The DON stated she created the care plan without investigating the Resident 1's allegation. The DON stated the progress notes did not indicate Resident 1's complaint of neglect and the facility did not address or investigate the allegation. The DON stated there was no change of condition notes done because there was no documentation in the resident's medical records. The DON stated she could not recall what happened on 6/12/2024 to Resident 1. The DON stated if an investigation was not documented, it meant it was not done. During a concurrent interview and record review on 6/28/2024 at 12:14 p.m., with the Social Services Director (SSD), Resident 1's progress notes dated 6/12/2024 at 5:18 p.m. were reviewed. The SSD stated the progress notes did not indicate an investigation was done regarding Resident 1's complaint that she was left in a soiled diaper. The SSD stated on 6/12/2024, Resident 1 informed her (SSD) that she (Resident 1) was left in a soiled diaper. The SSD stated an investigation was not conducted for the grievance to clarify and resolve Resident 1's concerns. The SSD stated, any verbalized (spoken out loud) complaint was considered a grievance and should have been investigated and documented, when resolved. The SSD stated the lack of documentation, meant no investigation was conducted. A review of facility's P&P titled, "Social Service Policy and Procedure, Grievances," dated 11/2020, indicated the facility should respect resident's right to voice and file grievances without discrimination or retaliation, to receive timely and thoughtful resolutions, and to keep residents apprised (informed) of efforts towards resolution. The P&P indicated a grievance may me filed orally. The P&P indicated all facility grievances will be initiated as soon as practicably possible after the grievance is filed. The P&P indicated the facility will actively seek a resolution and keep the resident appropriately apprised of its progress toward resolution. The P&P indicated corrective action will be taken promptly after filing the report. The facility failed to: 1). Implement its P&P titled, "Social Service Policy and Procedure, Grievances," which indicated the facility should actively seek a resolution after the grievance was filed, and keep the resident informed of its progress. This failure resulted in Resident 1's grievance not investigated and had the potential to result in humiliation and psychosocial harm, affecting Resident 1's quality of life. This violation occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the resident.