Other·March 20, 2024

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.

F610 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)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §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. 22 CCR § 72521 Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. On 2/8/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident abuse. The facility failed to implement its abuse prevention policy by failing to report an allegation of abuse within 2 hours or in accordance with state or federal law for Residents 3 and 4. As a result, there was a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 3 and Resident 4. a. A review of Admission Record indicated Resident 3 was originally admitted to the facility on 9/26/2022 and readmitted on 12/16/2022, with diagnoses including unspecified asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing), atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart) and muscle weakness. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 12/25/2023, indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 2 required maximal assistance to dependent from staffs for activities of daily living (ADLs - toileting hygiene, shower/bathe, lower and upper body dressing, and personal hygiene). A review of Resident 3's medical record as of 2/8/2024 indicated, there was no progress notes and/or Change of Condition (COC) documented regarding any form of abuse that was reported by Resident 3. b. A review of Admission Record indicated Resident 4 was admitted to the facility on 12/13/2023 with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). A review of the MDS dated 12/20/2023, indicated Resident 4's cognitive skills for daily decisions was moderately impaired. The MDS indicated Resident 4 required maximal assistance to dependent from staffs for ADLs - toileting hygiene, shower/bathe, lower body dressing, and personal hygiene. A review of Resident 4's medical record as of 2/8/2024 indicated, there was no progress notes and/or Change of Condition (COC) documented regarding any form of abuse that was reported by Resident 3. During an interview with Certified Nursing Assistant 5 (CNA 5), on 2/8/2024 at 3:45 p.m., about two weeks ago, the staffing made changes on her assignment because two of the residents (Resident 3 and 4) complained about her. CNA 5 stated, the Registered Nurse 1 (RN 1) supervisor talked to her about it as the Licensed Vocational Nurse 3 (LVN 3) reported to RN 1 that Resident 3 and 4 complained, CNA 5 then asked for a writing description of what Resident 3 and Resident 4 complained about. CNA 5 stated, the management did not follow-up on her request and does not know what Resident 3 and 4 complained about. CNA 5 further stated, they did not put her on leave after the reported incident. During an interview with RN 1 on 2/8/2024 at 3:53 p.m., RN 1 stated, CNA 5's assignment was changed because of Resident 3 and 4's complained of being rough while they were being cleaned and while changing their incontinent briefs. RN 1 stated, Resident 3 and 4 reported to her that CNA 5 was rough and they felt being rushed and disregarded their request to slow down on doing ADL care. RN 1 further stated, they did not monitor Resident 3 and 4 and there was no investigation completed with Resident 3 and 4's allegation and did not monitor after they (Resident 3 and 4) reported the incident. During an interview with Resident 4 on 2/8/2024 at 4:01 p.m., Resident 4 stated, she remembers one of the staff was rough while doing ADL care. Resident 4 was unable to say the exact date but said it was a one-time incident. Resident 4 stated, she felt rushed and abrupt on the staff's care, that staff was not only rough on doing ADL care but also rough on how she talked to the residents. Resident 4 stated, both her and her roommate (Resident 3) reported it to the LVN that was assigned to them that day. Resident 4 was unable to say the exact date of when it happened. During an interview with the Director of Nursing (DON), on 2/8/2024 at 4:19 p.m., DON stated, any form of abuse should be investigated and documented. DON stated, this allegation was not investigated, residents were not monitored and followed through to make sure there were not negative outcome and results. DON further stated this incident was not reported to the state agency, Ombudsman, etc. and all staffs are mandated reporter. A review of the facility's policy and procedures (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating", reviewed 4/19/2023 indicated, "All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management... The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility; the local/state ombudsman; the resident's representative; adult protective services; law enforcement officials; the resident's attending physician; and the facility medical director... Immediately is defined as: within two hours of an allegation involving abuse or result in serious injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury... Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete." The facility failed to implement its abuse prevention policy by failing to report an allegation of abuse within 2 hours or in accordance with state or federal law for Residents 3 and 4. As a result, there was a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 3 and Resident 4. The above violation had a direct relationship to the health, safety, and security of Residents 3 and 4.