Health inspection·May 16, 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. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 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. 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 4/22/2024, the California Department of Public Health (CDPH) received an anonymous complaint regarding an allegation of resident-to-resident physical abuse between Resident 1 and Resident 2. On 4/23/2024 at 8:17 a.m., CDPH conducted an unannounced visit at the facility. During the investigation, it was observed that Resident 2 allegedly hit Resident 1 on 4/1/2024 and 4/23/2024. The facility failed to: 1. Implement its policy and procedure (P&P) titled, "Abuse & Mistreatment of Residents," which indicated, the facility will investigate and report all abuse allegations to the California Department of Public Health (CDPH) within two hours of the knowledge of such incident; followed by a letter explaining the circumstances surrounding the incident by failing to: a. Report to the CDPH the alleged abuse reported on 4/1/2024 and 4/23/2024 within two hours. b. Investigate a resident-to-resident altercation on 4/1/2024 and 4/23/2024 between Resident 1 and Resident 2. These violations delayed the investigation by the CDPH and subjected Resident 1 to a repeated physical abuse. It also placed other residents at risk for abuse. a). A review of Resident 1's Admission record, indicated Resident 1 was a 59-year-old male, originally admitted to the facility on 11/16/2016 and readmitted on 4/10/2023 with diagnosis of essential primary hypertension (high blood pressure) type 2 diabetes mellitus (abnormal blood sugar) and muscle weakness. A review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 1/5/2024, indicated Resident 1 had an intact cognition (mental capacity). The MDS indicated Resident 1 required supervision (oversight help) with toileting and showers and was independent with personal hygiene and mobility (resident completes the activity with no assistance). A review of Resident 1's History and Physical (H&P), dated 1/30/2024, indicated Resident 1 had the capacity to understand and make decisions. b). A review of Resident 2's Admission record, indicated Resident 2 was a 66-year-old male, admitted to the facility on 7/20/2023, with diagnoses of schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves) with striking out behavior, hypertensive heart disease (high blood pressure that affects the heart). A review of Resident 2's MDS, dated 7/27/2023, indicated Resident 2 had intact cognition and was independent with mobility. The MDS indicated Resident 2 had schizophrenia and was on antipsychotic medication (medication to manage schizophrenia). A review of Resident 2's H&P, dated 7/21/2023 indicated Resident 1 had the capacity to understand and make decisions. A review of LVN 1's progress notes dated 4/1/2024 at 0152 (1:52 a.m.), indicated the LVN 1 responded to a loud, slammed door at Resident 2's room. The progress notes indicated when LVN 1 asked Resident 2 what happened, Resident 2 stated he slammed the door because the "M..F.." kept opening the door (referring to Resident 1). During a concurrent observation and interview on 4/23/2024 at 8:17 a.m., Resident 1 and Resident 2 were in the same room (Room B). Resident 1 stated Resident 2 hit him on the face on 4/1/2024, and on 4/23/2024 early morning. Resident 1 was observed with a red bruise and a swollen right eye lid. Resident 1 stated Resident 2 hit him on the face (pointing to both eyes and bridge of the nose). Resident 1 stated he told the licensed nurses, and CNA that Resident 2 kept hitting him. During an interview on 4/23/2024 at 11:15 a.m. with the DON, the DON stated he did not report the allegation of abuse to CDPH on 4/1/2024 because he was not aware of the incident. The DON stated it was important to investigate all alleged abuse allegations to ensure the safety of the residents and to prevent continued abuse. During an interview on 4/24/2024 at 12:14 p.m. with the Director of Staff Development (DSD), the DSD stated according to her in-service for abuse and abuse reporting, all alleged abuse should be reported withing two hours to keep residents safe and ensure the abuse allegations are properly investigated. A review of the facility ' s undated P&P titled "Abuse & Mistreatment of Residents," indicated the charge nurse and/or nursing supervisor should conduct an immediate resident assessment to identify any injuries or extent of injuries, if any, notify the attending physician of incident for necessary interventions. The P&P indicated the facility would investigate all allegations involving abuse of any type and would report all allegations involving abuse, by notifying CDPH within two hours of the knowledge of such incident; followed by a letter explaining the circumstances surrounding the incident. The facility failed to: 1. Implement its P&P titled, "Abuse & Mistreatment of Residents," which indicated, the facility will investigate and report all abuse allegations to the CDPH within two hours of the knowledge of such incident; followed by a letter explaining the circumstances surrounding the incident, by failing to: a. Report to the CDPH the alleged abuse reported on 4/1/2024 and 4/23/2024 within two hours. b. Investigate a resident-to-resident altercation on 4/1/2024 and 4/23/2024 between Resident 1 and Resident 2. These violations delayed the investigation by the CDPH and resulted in Resident 1 being subjected to a repeated physical abuse. It also placed other residents at risk for abuse. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1 and Resident 2.