Other·January 10, 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. 22 CCR § 72527. Patient’s 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: (10) To be free from mental and physical abuse. 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 12/11/2023 the California Department of Public Health (CDPH) received a Complaint indicating Resident 2 struck Resident 1 across the face. On 12/26/23, CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1. Follow its policy and procedure (P&P) titled “Abuse Prohibition and Prevention Program” by not reporting an alleged abuse incident involving Resident 1 (Victim) and 2, to the CDPH within 2 hours. 2. Implement their P&P "Abuse Prohibition and Prevention Program" which indicated the facility shall ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriations of property, were reported immediately, but not later than 2 hours after the allegation was made. This violation delayed the investigation by the State agency and placed Resident 1 and other residents at risk of abuse from Resident 2. Resident 1 was a 69-year-old male, admitted to the facility on 12/1/23, with diagnoses including congestive heart failure ([CHF] when the heart does not pump blood as well as it should), cardiomyopathy (enlargement of heart), and chronic kidney disease (a condition in which the kidneys cannot filter blood as well as they should). A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/7/2023, indicated Resident 1's cognitive (the ability to understand or to be understood by others) skills for daily decision making was intact. The MDS indicated, Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene, and upper body dressing (the ability to dress and undress above the waist). Resident 2 was a 66- year-old male, admitted to the facility on 11/7/2023, with diagnoses including CHF, atrial fibrillation (irregular and abnormal heartbeat), and chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 2's MDS dated 11/14/2023, indicated Resident 2 was able to understand and be understood by others. The MDS indicated, Resident 2 required setup or clean-up assistance with eating and oral hygiene. A review of Resident 2's Situation, Background, Assessment, and Recommendation form ([SBAR] a communication tool used by licensed staff after a resident has a change of condition), dated 12/10/2023, electronically signed by Registered Nurse (RN 1) indicated Resident 2 slapped another resident (Resident 1) in the face. On 12/26/2023 at 12:15 p.m., during an interview with the Director of Staff Development (DSD), the DSD stated he was fully aware of the incident that happened between Resident 1 and Resident 2 as it was mentioned in the huddle and stand-up meeting. The DSD stated he did not report the allegation to the licensing agency since he assumed the Administrator (ADM), Director of Nursing (DON), and the Social Services Director (SSD) already did the reporting because they conducted the investigation. The DSD stated any allegation of abuse should be reported to the CDPH immediately so they can conduct their own investigation. The DSD stated the facility did not follow the process of abuse reporting to the regulatory agency and the risk of not reporting abuse in a timely manner could result in jail and monetary fine. On 12/26/2023 at 1:23 p.m., during a concurrent interview and record review with the Administrator (ADM), the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) provided by the facility, was reviewed. The ADM stated, the SOC 341 was completed on 12/10/2023 by RN 1 and RN 1 made a telephone report to Adult Protective Services (APS), Law Enforcement Agency and Ombudsman. The ADM sated he had no evidence that RN 1 called the CDPH or faxed the SOC 341 to CDPH or Local District Office. The ADM stated the process for abuse reporting was to call in, fax the SOC 341, and submit the initial report to CDPH. The ADM stated it was an oversight on his part, that the abuse was reported to a different government agency, not to CDPH. The ADM stated for all allegations of abuse such as physical, verbal, misappropriation of property, seclusion, neglect, resident to resident altercation, being the abuse Coordinator, he had to report to the CDPH within 2 hours. A review of the facility's policy and procedure (P&P), titled "Abuse Prohibition and Prevention Program", revised October 2022, indicated the facility shall ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriations of resident property, were reported immediately, but not later than 2 hours after the allegation was made. The facility failed to: 1. Report an allegation of abuse between Resident 2 and Resident 1 no later than two hours. 2. Implement their abuse prohibition and prevention program policy and procedure. As a result, there was a delay in the investigation by the State agency. This violation presented a direct or immediate relationship to the health, safety, security, or welfare of Resident 2.