Other·February 16, 2023

42 CCR §483.12(c) Freedom from Abuse, Neglect, and Exploitation (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. (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 § 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 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. The California Department of Public Health (CDPH) received a complaint on 01/20/2023 indicating Resident 1 had a bruise on her face and alleged a staff member hit her on 1/18/2023. On 01/20/2023, the CDPH conducted an unannounced visit at the facility to investigate the allegations. The facility failed to follow its policy and procedures (P&P) titled "Reporting" by not reporting an incident of an alleged abuse to the California Department of Public Health (CDPH) within 2 hours after Resident alleged a staff member hit her on the left side of the face. As a result of not reporting to the CDPH there was a delay in the investigation by the State agency. Resident 1 was a 94-year-old-female admitted to facility on 12/16/2022, 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), muscle weakness, and type 2 diabetes ([DM] abnormal blood sugar). During a review of Resident 1's History and Physical (H&P) dated 12/17/22, indicated Resident 1 was able to make decisions for activities of daily living. During a review of Resident 1's Minimum Data Set ([MDS], a comprehensive standardized assessment and care screening tool) dated 12/23/2022, the MDS indicated Resident 1 was sometimes able to understand and be understood by others. The MDS indicated Resident 1 required a one-person physical assist for bed mobility, dressing, toilet use, eating and personal hygiene. The MDS indicated Resident required a two-person physical assist transferring to or from a bed, chair, wheelchair, and a standing position. During a review of Resident 1's Progress Notes dated 1/20/2022 at 3:30 p.m., the Licensed Vocational Nurse (LVN) 1 indicated on 1/19/2023 at 2:45 p.m., the Social Worker (SW) informed LVN 1 that Resident 1's family member (FM) 1 wanted resident to be discharged home on 1/20/2023. The progress notes indicated FM 1 stated Resident 1 had a bruise on her face and that FM 1 was afraid about the type of care Resident 1 was receiving at the facility. The progress notes indicated the Assistant Director of Nursing (ADON) was made aware, and Resident 1's physician agreed for Resident 1 to be discharged home on 1/20/2023, per family's request. During an interview on 1/20/2023 at 10:55 a.m., FM 1, stated on 1/19/2023, she notified the facility's SW on that Resident 1, was hit on the left eye by a staff member. FM 1 stated the SW told FM 1 the facility investigated the alleged abuse. FM 1 also stated the incident happened between 1/18/2023 2:00 p.m., and 1/19/2023 10:00 a.m. During an interview on 1/20/2023 at 2:39 p.m., LVN 1 stated Resident 1's family alleged the resident was abused on 1/19/2023. LVN 1 stated she reported it to the ADON and the ADON provided Resident 1's doctor's number to LVN 1 to notify the doctor for discharge orders per Resident 1's family's request. LVN 1 stated the SW told her FM 1 did not feel the facility was safe for the resident after the alleged abuse incident. The LVN 1 further stated the SW asked her to call the doctor per resident family's request due to bruising to Resident 1's face and safety. During an interview on 1/20/2023 at 2:51 p.m., the SW stated on 1/19/2023 she was in Resident 1's room with FM 1. The SW stated Resident 1 told FM 1 that she had a bruise under her eye, but the SW did not see any bruise on the resident's face. The SW stated FM 1 did not raised her voice or insinuated any abuse or concern of safety regarding the bruise the family allegedly saw. During an interview on 1/20/2023 at 3:20 p.m., the ADON stated Resident 1's family wanted to take the resident home for financial reasons. The ADON stated on 1/19/2023, Resident 1's family did not complain of any bruising to the resident's face. The ADON stated on the morning of 1/20/2023 the SW notified the ADON that FM 1 alleged a bruise to Resident 1's left eye. The ADON stated she did not notify the Administrator (ADM). The ADON further stated the importance to report abuse and alleged abuse was to keep resident's safe. During an interview on 1/20/2023, at 4:07 p.m., the ADM stated all abuse or alleged abuse incidents were reported within two hours to the CDPH. The ADM stated all staff members were mandated reporters. The ADM also stated he was not aware of Resident 1's allegation of abuse and therefore did not report to the CDPH per the facility's P&P on abuse reporting. During a review of the facility's undated P&P titled, "Reporting," the P&P indicated the facility's Administrator and/or designee were responsible for reporting any reasonable suspicion of a crime against a resident and or all alleged and substantiated violations to the state agency and all other agencies as required. The P&P indicated the facility shall report the incident by notifying the CDPH and local enforcement entities no later than two (2) hours of the knowledge of the allegation, if the events that caused the allegation involved abuse or resulted in serious bodily injury and no later than 24 hours if no serious bodily injury. The facility failed to follow its policy and procedures (P&P) titled "Reporting" by not reporting an incident of an alleged abuse to the CDPH within 2 hours after Resident alleged a staff member hit her on the left side of the face. As a result of not reporting to the CDPH there was a delay in the investigation by the State agency. This violation presented a direct or immediate relationship to the health, safety, security, or welfare of Residents 1