Health inspection·November 15, 2024

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 22 CFR §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. HSC §1418.91 Abuse Reporting (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. WIC §15630 (b)(1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days. On 10/07/2024 at 11:40 a.m., the California Department of Public Health (CDPH) received a complaint regarding an allegation that Resident 1 was physically abused by two Certified Nursing Assistants (CNA 1 and 2). On 10/09/2024, the CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Report an allegation of abuse, to the State Survey Agency (SSA) after Resident 1 informed the Social Services Director (SSD), that someone hit her arm. This failure delayed the investigation by the State Agency and placed Resident 1 and other residents at risk for abuse by CNA 2 and CNA 3. Findings: Resident 1, was a 60-year-old female, admitted to the facility on 12/20/2023 with diagnoses including chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys), urinary tract infection (an infection in any part of the urinary system), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), and Type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of Resident 1’s Minimum Data Set (MDS- an assessment and care screening tool), dated 6/25/2024, indicated Resident’s cognitive skills were intact. The MDS indicated Resident 1 required supervision from for toileting, showering, and upper body dressing. During an interview, on 10/9/2024, at 12:02 p.m., with the SSD, the SSD stated the protocol for reporting abuse was to report it immediately. The SSD stated Resident 1 informed her of someone hitting her arm on 10/3/2024. The SSD stated she had documented what Resident 1 told her and went back to interview Resident 1. The SSD stated she did not inform anybody of Resident 1’s abuse allegations. During an interview, on 10/9/2024, at 12:38 p.m., with the Director of Nursing (DON), the DON stated any allegations of abuse must be reported within 2 hours. The DON stated Resident 1’s allegations should had been reported immediately. During an interview, on 10/9/2024, at 1:04 p.m., with the Administrator (ADM), the ADM stated he was the abuse coordinator. The ADM stated all allegations of abuse should have been reported to him. The ADM stated Resident 1’s abuse allegation was not reported. that time. The ADM stated the risk of not reporting abuse in a timely manner could result in further abuse. A review of the facility’s policy and procedures, revised 4/2019, titled “Abuse: Prevention of and Prohibition Against”, indicated “All allegations of abuse, neglect, misappropriation of resident property, or exploitation are to be reported to the Administrator immediately.” The facility failed to: 1.Report an allegation of abuse, to the State Survey Agency (SSA) after Resident 1 informed the Social Services Director (SSD), that someone hit her arm. This failure delayed the investigation by the State Agency and placed Resident 1 and other residents at risk for abuse by CNA 2 and CNA 3. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.