Other·June 14, 2024

42 CFR §483.12 (c) Freedom from Abuse, Neglect, and Exploitation. 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 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. H&S § 1418.91 (a) A long-term health care facility shall report all incidents of alleged 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 2/8/2024 the California Department of Public Health (CDPH) received a complaint indicating Resident 1 was not receiving physical therapy and medications as ordered by the physician. On 5/8/2024, the CDPH conducted an unannounced visit at the facility and discovered there was an alleged incident on 3/14/2024 where in Resident 1 threw water at Resident 2. The facility failed to: 1.Implement its abuse policy and procedure (P&P) titled, “Abuse Reporting and Investigation” which indicated all allegations of abuse would be reported to the CDPH within two hours. As a result, there was a delay in the investigation by the CDPH. Resident 1 was an 85-year-old male, admitted to the facility on 12/4/2023 with diagnoses including respiratory failure (condition that makes it difficult to breathe), hemiplegia (paralysis that affects one side of the body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (condition that occurs when blood flow to the brain is disrupted causing parts of the brain to die). A review of Resident 1’s History and Physical (H&P) dated 12/6/2023, indicated Resident 1 had the capacity to make decisions. A review of Resident 1’s Minimum Data Set ([MDS], a standardized care assessment and care screening tool), dated 3/12/2024, indicated Resident 1 could understand and be understood by others. The MDS indicated Resident 1 required partial to moderate assistance (helper did less than half of the effort) for Activities of Daily Living (ADLs) such as bed mobility (how the resident moved in bed), transfer (how the resident moved from bed, chair, and wheelchair), upper body dressing, and required substantial/maximal assistance (staff did more than half the effort) for toilet use, showering lower body dressing and putting on/taking off footwear. A review of Resident 1’s Care Plan focused on Resident 1’s potential to be physically aggressive r/t (related to) throwing water at roommate (Resident 2) dated 3/13/2024, indicated Resident 1’s goal was not to harm self or others and would verbalize understanding to control physical aggressive behavior. A review of Resident 1’s Change in Condition (COC) dated 3/14/2024 indicated Resident 1 threw water at Resident 2. The COC indicated Resident 1 informed the Certified Nursing Assistant ([CNA] unnamed) that he threw water at Resident 2. During an interview on 5/9/2024 at 9:45 a.m. Resident 1 stated, he threw water towards Resident 2 a few months ago because Resident 2 was opening and closing the curtain. Resident 2 was a 93-year-old male, originally admitted to the facility on 11/13/2022 and readmitted on 12/25/2022 with diagnoses including traumatic subdural hemorrhage (brain bleed), muscle weakness and other abnormalities of gait and mobility (unable to walk in a typical way). A review of Resident 2’s MDS dated 2/20/2024 indicated Resident 2 could not understand and be understood by others. The MDS indicated Resident 2 required substantial/maximal assistance from staff for ADLs such as dressing, personal hygiene, bed mobility, transfer, and walking. During an interview on 5/9/2024 at 12:50 p.m., CNA 1 stated, (On 3/14/2024), she walked in Resident 1 and 2’s room and observed the floor and Resident 4’s bed were wet. CNA 1 stated, Resident 1 informed her, he was upset and threw water at Resident 2 because he kept touching and making noises with the curtains. During an interview on 5/9/2024 at 6:20 p.m. Licensed Vocational Nurse (LVN) 1 stated, (on 3/14/2024), CNA 1 reported to her the allegation that Resident 1 threw water at Resident 2. LVN 1 stated she did not report the incident because she thought it was not physical abuse and the water barely touched Resident 2. During an interview on 5/10/2024 at 12:40 p.m., the Director of Nursing (DON) stated she was not aware of the incident between Resident 1 and Resident 2 until the morning of 5/10/2024. The DON stated, it was not acceptable for Resident 1 to throw water towards Resident 2 and any kind of abuse needed to be reported to the CDPH within two hours, however, was not done. The DON stated it was important to report abuse and allegations of abuse to the CDPH to ensure the incident was investigated and to prevent future abuse. A review of the facility’s P&P titled, “Abuse Reporting and Investigation” dated 1/10/2024, indicated all alleged violations involving abuse including but not limited to neglect exploitation or mistreatment shall be reported by the Abuse Prevention Coordinator (APC) or Designee to the local CDPH, LTC Ombudsman and Local Enforcement either by telephone, email or in writing (SOC 341) immediately: within 2 hours after the allegation was made or reported if alleged violation involved abuse with or without serious bodily injury. The facility failed to: 1.Implement its abuse policy and procedure (P&P) titled, “Abuse Reporting and Investigation” which indicated all allegations of abuse would be reported to the CDPH within two hours. As a result, there was a delay in the investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of residents.