Other·September 12, 2023

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00851736. Representing the Department, HFEN # 44891 State Citation (B) was written. F609 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. 22 CR § 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 8/3/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident-to-resident abuse. The facility failed to implement its policy titled "Abuse Investigation and Reporting," by failing to: 1. Report a physical abuse no later than 24 hours the allegation of abuse to law enforcement, the State Agency (SA) and the Ombudsman, 2. Report the results of the investigations within five (5) working days, and 3. Provide proof that appropriate corrective action was taken by the facility regarding the alleged abuse for Resident 1. As result, there was a delay of an onsite investigation by the law enforcement and CDPH to ensure the rights and safety of the residents involved. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on 3/3/2023 with diagnosis including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), rheumatoid arthritis (a disorder affecting joints of the body including hands and feet), and hypothyroidism (or underactive thyroid, happens when your thyroid gland doesn't make enough thyroid hormones to meet your body's needs). A review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 6/9/2023, indicated Resident 1 was moderately cognitive impaired (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). MDS indicated Resident 1 required extensive assistance with bed mobility, transfer, toilet use, and personal hygiene. During a concurrent interview and record review on 8/3/2023 at 10:52 AM with Social Services Director (SSD), an untitled grievance log document, dated 7/2023, was reviewed. The undated grievance log indicated, on 7/20/2023, social services department received a grievance regarding Resident 1. The grievance log indicated resolved date for the grievance was 7/20/2023. SSD stated Resident 1's son had filed a grievance on 7/20/2023 stating Resident 1 was "attacked" by Resident 2 on 7/17/2023. SSD stated she had notified the Director of Nursing (DON), Resident 1's conservator, and the psychiatrist on 7/20/2023 of the alleged abuse between Resident 1 and 2. SSD stated she had interviewed Resident 1 and 2, and both denied of alleged abuse. SSD stated she did not report the abuse to the State (Department Public of Health), law enforcement, the Ombudsman, or the Abuse Coordinator. SSD stated she only reported it to the DON because Resident 1 and 2 both denied of the alleged abuse. SSD stated it is the facility policy to report allegations of abuse to the Abuse Coordinator, which is also the Facility Administrator (FA). SSD stated if both residents deny allegations of abuse, the abuse will not be reported to the FA and other officials. During an interview on 8/3/2023 at 11:40 AM, FA stated SSD had notified her about the abuse allegations today (8/3/2023) regarding Residents 1 and 2. FA stated "we (the facility) know you (the State) would like for us to report abuse allegations." FA further stated facility did not report the abuse because both parties, Residents 1 and 2, had denied the abuse allegations. During an interview with Registered Nurse Supervisor (RNS), on 8/3/2023 at 12:00 PM, RNS stated if there is an abuse allegation, it needs to be reported to the FA within two hours. RNS stated if both parties deny, regardless of the mental status, abuse allegations, it is still mandated to report the abuse to the State, Ombudsman, Abuse Coordinator, and law enforcement. During an interview with Director of Staff Development (DSD), on 8/3/2023 at 2:16 PM, DSD stated allegations of abuse needs to be reported to the Ombudsman, law enforcement, and the State within two hours. DSD stated if both residents and parties deny of allegation of abuse, it is still mandated to report the abuse. DSD stated if the facility failed to report the abuse in a timely manner, the facility will fail to keep residents safe from abuse. During a review of Resident 1's "Progress Notes," dated 7/19/2023, the "Progress Notes" indicated, on 7/20/2023 Resident 1's son called stating Resident 1 was "allegedly physically assaulted" on 7/17/2023 by the other resident (Resident 2) and had demanded a room change. During a review of Director of Nursing (DON) "Job Description," dated 10/2010, the "Job Description," indicated the DON's duties and responsibilities is to report allegations of resident abuse. During a review of Social Services Director (SSD) "Job Description," dated 10/2010, the "Job Description," indicated the SSD's duties and responsibilities is to report allegations of resident abuse. A review of the facility's policy and procedures (P&P), titled "Abuse and Neglect-Clinical Protocol," dated 3/2018, indicated the nurse will assess the individual and document related findings. Assessment data will include injury assessment (bleeding, bruising, deformity, swelling), pain assessment, current behavior, vital signs, behavior over the last 24 hours, and any recent labs. The nurse will report findings to the physician. In addition, P&P indicated, "The facility management and staff...will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations." A review of the facility's P&P, titled "Abuse Investigation and Reporting," dated 7/2017, indicated, "All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ("abuse") shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management." In addition, P&P indicated "An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but no later than two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury or 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury." The facility failed to implement its policy titled "Abuse Investigation and Reporting," by failing to: 1. Report a physical abuse no later than 24 hours the allegation of abuse to law enforcement, the State Agency (SA) and the Ombudsman, 2. Report the results of the investigations within five (5) working days, and 3. Provide proof that appropriate corrective action was taken by the facility regarding the alleged abuse for Resident 1. As result, there was a delay of an onsite investigation by the law enforcement and CDPH to ensure the rights and safety of the residents involved. The above violation had a direct relationship to the health, safety, and security of the residents in the facility.