Health inspection·September 23, 2024

CFR §483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 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. 22 CCR § 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. H&S §1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 8/21/2024, the California Department of Public Health (CDPH) received a complaint indicating a Certified Nurse Assistant (CNA 1) raised her arm in attempt to hit Resident 1. On 8/27/2024, the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1. Implement its policy and procedure titled, "Abuse Prevention and Prohibition Program" by not reporting an allegation of abuse to the CDPH, after Family Member (FM) 1 reported Certified Nurse Assistant (CNA) 1 raised her arm to hit Resident 1. As a result, there was a potential for the facility to under-reporting abuse incidents, delay in investigation of an abuse allegation, and placed Resident 1 and all residents in the facility at risk for further abuse. Resident 1, was a 79-year-old female, admitted to the facility on 7/13/2023 with diagnoses including hemiplegia (paralysis on one side of the body), intracranial hemorrhage (brain bleed), and syncope (fainting or passing out). A review of Resident 1's Minimum Data Set ([MDS]- a standardized assessment and care screening tool), dated 6/21/2024, indicated Resident 1 was cognitively intact (ability to reason, understand, remember, judge, and learn). A review of Resident 1's Situation, Background, Assessment, and Recommendation form ([SBAR]- a communication tool used by licensed staff after a resident has a change in condition), dated 8/17/24 at 12:02 AM, signed by Licensed Vocational Nurse (LVN) 2 indicated FM 1 reported to LVN 2 that CNA 1 raised their hand to hit Resident 1, but stopped before actually doing so. During a telephone interview on 8/28/24 at 10:30 AM with LVN 2, LVN 2 stated because there was no actual physical contact, the facility did not need to notify the CDPH. During an interview on 8/28/24 at 11:33 AM with the Administrator (ADM), the ADM stated all allegations of abuse must be reported to the state agency (CDPH). The ADM stated all staff were trained to report any allegations of abuse to the appropriate agencies and the staff did not report the abuse allegation on the evening of 8/17/2024. A review of the facility's policy and procedure titled, "Abuse Prevention and Prohibition Program", dated 8/1/2023, indicated the facility will report allegations of abuse immediately but no later than 2 hours after forming the suspicion of abuse. The facility failed to: 1. Implement its policy and procedure titled, "Abuse Prevention and Prohibition Program" by not reporting an allegation of abuse to the CDPH, after Family Member (FM) 1 reported Certified Nurse Assistant (CNA) 1 raised her arm to hit Resident 1. As a result, there was a potential for the facility to under-reporting abuse incidents, delay in investigation of an abuse allegation, and placed Resident 1 and all residents in the facility at risk for further abuse. This violation presented a direct or immediate relationship to the health, safety, or security of Resident 1.