Health inspection·December 6, 2023

F609 Freedom from Abuse, Neglect, and Exploitation §483.12(c) (1)-(4)

F609 Freedom from Abuse, Neglect, and Exploitation §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. §483.12(c)(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. § 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. On 10/31/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding allegation of sexual abuse. The facility failed to report the alleged sexual abuse incident to CDPH and implement its abuse prevention policy and procedures (P &P), when Resident 1's son reported to the Administrator that his mom told him that a male nurse touched her inappropriately in her private area on 05/13/2022. As a result, there was a delay in the investigation of the allegation of sexual abuse putting Resident 1 and other residents at the facility at risk for further sexual abuse to occur. A review of Resident 1's Admission Record indicated Resident 1, was originally admitted to the facility on 5/13/2022, with diagnoses including closed fracture repair of the lower end of the femur (fracture of the leg) difficulty walking, lack of coordination and generalized muscle weakness. A review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 5/16/2022, indicated Resident 1 was alert and oriented with clear speech able to understand and be understood. Requiring set-up or one-person assistance with extensive assistance to total dependence with staff on activities of daily living (ADLs-bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene). During an interview and a concurrent record review with the Director of Nursing (DON), on 10/31/2023 at 12 p.m. and 1 p.m., the DON stated, “I do not remember any abuse allegation incidents with Resident 1, she was only admitted to the facility for three days”. During a concurrent interview and record review with the administrator (ADM), on 10/31/2023 at 1:40 p.m., the ADM stated I do remember Resident 1 requested not to have any male certified nurse’s assistants (CNA) provide care to her, so we assigned female CNA's, she also requested to transfer to another SNF which was done. The ADM stated a Grievance Form was filed on 5/16/2023; an investigation was conducted on 5/18/2023 (investigation requested). Review of the investigation disclosed there was no interviews with the male CNAs on duty that night. The ADM stated they were not assigned to Resident 1. When asked was the allegation of abuse reported to the State Agency (SA), police or the Ombudsman he stated no because Resident 1's son told him everything was okay, so it was not reported to the SA nor other authorities. When asked both ADM and DON agreed they should have reported the alleged abuse to the proper authorities. During an interview with Resident 1 on 10/31/2023 at 3:28pm. Resident 1 stated that on 05/13/2022 at 12 midnight, a male nurse came into her room, woke her up to change her adult brief, Resident 1 stated, she said no, however, the male nurse proceeded to change her and touched her private area inappropriately. Resident 1 further stated, she has no bowel movement and also did not wet her adult brief. A review of the facility 's policy and procedures (P&P), titled, "Abuse Prevention," revised 2/1/2023, indicated the facility will ensure that all alleged violations by anyone are reported immediately to the administrator of the facility. The administrator as the abuse coordinator will investigate each alleged violation thoroughly and report the results to the appropriate agencies and personnel. The administrator, or his / her designee, will report each alleged abuse to the Ombudsman's office and the Department of Public Health immediately or within 2 hours per Section 1418.91 of the Health and Safety Code. The facility failed to report the alleged sexual abuse incident to CDPH and implement its abuse prevention P &P, when Resident 1's son reported to the Administrator that his mom told him that a male nurse touched her inappropriately in her private area on 05/13/2022. As a result, there was a delay in the investigation of the allegation of sexual abuse putting Resident 1 and other residents at the facility at risk for further sexual abuse to occur. The above violation had a direct relationship to the health, safety, and security of the residents in the facility.