Health inspection·August 13, 2024

F609 (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) §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. 72523(a) Patient Care Policies and Procedures 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 (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 6/27/2024, the California Department of Public Heath (CDPH) received a complaint alleging a resident (Resident 1) was sexually abused by a male worker in the facility. On 6/28/2024 CDPH conducted an unannounced visit to the facility to investigate the allegation. Upon investigation, CDPH determined on 6/11/2024, Resident 1 accused staff at the facility of putting things in her genitals (a person’s external sexual organs) and in her mouth. The facility failed to: 1. Report an allegation of sexual abuse to CDPH, and the State Long Term Care Ombudsman (an agency that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) within the regulated time frame of two hours. 2. Follow their policy and procedure (P&P) titled, “Abuse, Neglect, and Exploitation,” that indicated the abuse coordinator, the Administrator (ADM), was to report allegations of abuse immediately to other officials in accordance with State law and the State survey and certification agency, and the local Ombudsman. This deficient practice resulted in CDPH’s inability to timely investigate the allegation of sexual abuse and had the potential for other allegations of abuse to go unreported. A review of Resident 1’s Admission Record (Face Sheet) indicated Resident 1, a 76 year old female, was admitted to the facility on 12/9/2023, with diagnoses including bipolar disorder (a mental illness that causes unusual shifts in a person’s mood, energy, activity levels, and concentration), major depressive disorder ([MDD] a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and schizoaffective disorder (a mental health disorder affecting how resident interprets reality). A review of Resident 1's Minimum Data Set ([MDS]), a standardized assessment and care screening tool), dated 6/11/2024, indicated Resident 1’s cognition was intact. A review of Resident 1’s Interdisciplinary Team ([IDT] a group of healthcare professionals who work together to meet resident’s goals) Notes, dated 6/11/2024, indicated Resident 1 accused staff of putting things in her genitals and in her mouth. The IDT Note indicated Resident 1 was alert and oriented times three (to person, place, and time). A review of Resident 1’s Resident Transfer Record, dated 6/11/2024 at 7 a.m., indicated Resident 1 had increased hallucinations (experience involving the apparent perception of something not present), and accused staff of conspiring against her. The Resident Transfer Record indicated Resident 1 was transferred to a General Acute Care Hospital (GACH) for further evaluation. During an interview and record review with the Director of Nursing (DON) on 6/28/2024 at 8:57 a.m., after reviewing Resident 1’s IDT Notes dated 6/11/2024, the DON stated Resident 1 accused staff of going against her and putting something in her genitals. The DON stated Resident 1’s allegation could be considered sexual abuse, and the allegation should have been reported to CDPH and the Ombudsman. The DON stated it was not reported because the resident was transferred to the GACH. During an interview on 6/28/2024 at 9:51 a.m., the ADM stated Resident 1’s allegation that staff put items in her genitals could be considered sexual abuse and should have been reported to CDPH and the Ombudsman. The ADM stated Resident 1’s allegation was not reported because she thought of it more as behavioral symptoms and missed that it was an allegation of sexual abuse. A review of the facility’s undated policy and procedure (P&P) titled, “Abuse, Neglect, and Exploitation,” indicated the abuse coordinator, the ADM, was to report allegations of abuse immediately to other officials in accordance with State law and the State survey and certification agency and the local Ombudsman. The facility failed to: 1. Report an allegation of sexual abuse to CDPH, and the State Long Term Care Ombudsman (an agency that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) within the regulated time frame of two hours. 2. Follow their policy and procedure (P&P) titled, “Abuse, Neglect, and Exploitation,” that indicated the abuse coordinator, the Administrator (ADM), was to report allegations of abuse immediately to other officials in accordance with State law and the State survey and certification agency, and the local Ombudsman. This deficient practice resulted in CDPH’s inability to timely investigate the allegation of sexual abuse and had the potential for other allegations of abuse to go unreported. These violations presented a direct or immediate relationship to the health, safety, security, or welfare of Resident 1.