Health inspection·June 11, 2024

42 CFR §483.12 Freedom from abuse, neglect, and exploitation. (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property (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. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. 22CCR §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 (a) A long-term health care facility shall report all incident of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) Failure to comply with the requirements of this section shall be a class “B” violation. The California Department of Public Health (CDPH) received a complaint on 5/10/2024 regarding Resident 2 allegations of theft of more than $5,000.00, negligence (carelessness/ lack of care) and lack of communication between facility staff and the resident’s family. On 5/13/2024 at 9 a.m., an unannounced visit was conducted at the facility to investigate the allegations. The facility failed to: 1) Implement its policy and procedure (P&P) titled, “Investigating Incidents of Theft and/ or Misappropriation of Resident Property,” which indicated all reports of theft or misappropriation (unauthorized use) of resident property should be promptly and thoroughly investigated. 2) Implement its P&P titled, “Abuse Reporting and Investigation”, which indicated misappropriation of funds should be reported to the State Licensing Agency (SA) within two hours. These violations delayed the investigation by the CDPH. A review of Resident 2’s Admission Record indicated Resident 2 was admitted to the facility on 1/11/2024, with diagnoses that included fracture of the left femur (a break in the left thigh bone), hypertension (high blood pressure) and history of falling. A review of Resident 2’s History and Physical (H&P) dated 1/12/2024, the H&P indicated Resident 2 had the capacity to understand and make medical decisions. A review of Resident 2’s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 2/28/2024, indicated Resident 2’s cognitive skills (thought process) was intact. The MDS indicated Resident 2 required partial to moderate assistance (helper does less than half the effort) with activities such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). The MDS indicated Resident 2 was always incontinent of bowel and bladder. A review of Resident 2’s credit card statement dated 2/8/2024-2/21/2024, indicated a total of $1,358.39 was withdrawn from the card, unauthorized by Resident 1. A review of an Ombudsman’s (patient advocate) electronic mail (email) to the facility’s Business Officer Manager dated 4/23/2024, indicated Resident 2’s wallet was missing, and the resident’s credit cards had incurred thousands of dollars (unspecified amounts) in fraudulent (unauthorized) charges. The email indicated an inquiry if the facility had investigated this incident. The email indicated the facility’s Business Office Manager included the Social Worker (SW) and the Administrator (ADM) to the response email for further investigation. During an interview on 5/13/2024 at 8:30 a.m. with family member (FM 1), FM 1 stated (she) FM 1 notified the facility’s ADM about the missing credit cards and cash. FM 1 stated the ADM told FM 1 he would investigate the incident. FM 1 stated she did not hear a response from the ADM or the SW. During an interview on 5/14/2024 at 12:37 p.m. with the Director of Social Services (DSS), the DSS confirmed she (DSS) received the email from the Ombudsman indicating Resident 2’s missing wallet and fraudulent bank account charges made. The DSS stated she did not report the fraudulent charges to the CDPH and did not investigate the incident because the report was from the Ombudsman and the Ombudsman did not provide more information regarding the missing wallet or fraudulent charges. The DSS stated she did not attempt to reach out to Resident 2 or his family because the allegations were from the Ombudsman, and not from the family member or Resident 2. During an interview on 5/14/2024 at 1:30 p.m. with the Director of Nursing (DON), the DON stated the theft and loss reports were not opened, the allegations of missing belongings and fraudulent charges not investigated or reported to the CDPH when the ADM and the DSS were notified of Resident 2’s missing belongings and fraudulent charges. A review of the facility’s policy and procedure (P&P) titled, “Investigating Incidents of Theft and/ or misappropriation of Resident Property,” dated 12/2006, indicated all reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated. A review of the facility’s P&P titled “Abuse Reporting and Investigation”, dated 1/10/2024, indicated all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, should be reported to the CDPH, Ombudsman, and local law enforcement either by telephone, email, or in writing immediately or within two (2) hours after the allegations was made or reported, if the alleged violation involved abuse with or without serious bodily injury.” The facility failed to: 1) Implement its P&P titled, “Investigating Incidents of Theft and/ or Misappropriation of Resident Property,” dated 12/2006, which indicated all reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated. 2) Implement its P&P titled, “Abuse Reporting and Investigation”, which indicated misappropriation of funds should be reported to the State Licensing Agency within two hours. This delayed the investigation by the CDPH. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of the residents.