Health inspection·July 13, 2022

F609 §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. Title 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. Title 22 CCR 72527. Patients’ 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: (4) To consent to or to refuse any treatment or procedure or participation in experimental research. (5) To receive all information that is material to an individual patient's decision concerning whether to accept or refuse any proposed treatment or procedure. The disclosure of material information for administration of psychotherapeutic drugs or physical restraints or the prolonged use of a device that may lead to the inability to regain use of a normal bodily function shall include the disclosure of information listed in Section 72528(b). (1) How the facility will verify that informed consent was obtained, or a treatment or procedure was refused pertaining to the administration of psychotherapeutic drugs or physical restraints or the prolonged use of a device that may lead to the inability of the patient to regain the use of a normal bodily function. (10) To be free from mental and physical abuse. Title 22 CCR 72528: Informed Consent Requirements. (a) It is the responsibility of the attending licensed healthcare practitioner acting within the scope of his or her professional licensure to determine what information a reasonable person in the patient's condition and circumstances would consider material to a decision to accept or refuse a proposed treatment or procedure. Information that is commonly appreciated need not be disclosed. The disclosure of the material information and obtaining informed consent shall be the responsibility of the licensed healthcare practitioner who, acting within the scope of his or her professional licensure, performs or orders the procedure or treatment for which informed consent is required. (b) The information material to a decision concerning the administration of a psychotherapeutic drug or physical restraint, or the prolonged use of a device that may lead to the inability of the patient to regain use of a normal bodily function shall include at least the following: (1) The reason for the treatment and the nature and seriousness of the patient's illness. (2) The nature of the procedures to be used in the proposed treatment including their probable frequency and duration. (3) The probable degree and duration (temporary or permanent) of improvement or remission, expected with or without such treatment. (4) The nature, degree, duration and probability of the side effects and significant risks, commonly known by the health professions. (5) The reasonable alternative treatments and risks, and why the health professional is recommending this particular treatment. (6) That the patient has the right to accept or refuse the proposed treatment, and if he or she consents, has the right to revoke his or her consent for any reason at any time. (c) Before initiating the administration of psychotherapeutic drugs, or physical restraints, or the prolonged use of a device that may lead to the inability to regain use of a normal bodily function, facility staff shall verify that the patient's health record contains documentation that the patient has given informed consent to the proposed treatment or procedure. Title 22 CCR 72311. Nursing Service. (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or (C) An unusual occurrence, as provided in Section 72541, involving a patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety, or security of the patient. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). Title 22 CCR 72315. Patient Care. (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. On 5/3/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about resident abuse. The facility failed to: 1. Report an allegation of sexual abuse to the California Department of Public Health (CDPH), the Long Term-Ombudsman Program (representatives assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences), and to the local law enforcement no later than two hours after the allegation was made by one of three sampled residents (Resident 1). On 4/22/2022 at around 2:30 pm, Resident 1 alleged Certified Nursing Assistant 1 (CNA 1) touched her breasts. The facility failed to ensure Receptionist 1, CNA 2, and Licensed Vocational Nurse 1 (LVN 1) immediately reported Resident 1’s allegation CNA 1 touched her breast. 2. Ensure Receptionist 1, CNA 2, and LVN 1 immediately reported Resident 1’s allegation CNA 1 touched her breasts. 3. Ensure Registered Nurse 1 (RN 1) consulted with Medical Doctor 1 (MD 1) to determine the need to increase the dose of Abilify (medication used to treat certain mental/mood disorders) Abilify (medication to treat mental illness) for Resident 1. 4. Notify Medical Doctor 1’s (MD 1) of allegation of sexual abuse for Resident 1. 5. Ensure RN 1 did not assume Resident 1 was confused and was hallucinating (perception of a nonexistence), and increased Abilify without adequate indication for use for Resident 1. As a result: 1. Resident 1 felt nervous, afraid, scared, depressed, upset, became isolated, did not want CNA 1 to come near her (Resident 1), and thought CNA 1 would touch the resident (Resident 1) again. 2. RN 1 increased Abilify dose was increased from 5 mg (milligram-unit of measurement) to 10 mg for Resident 1. 3. Resident 1 received Abilify on 10mg 4/29/2022 and 4/30/2022, and 5/12022 to 5/30/2022. 4. RN 1 used MD 1’s name to increase Abilify from 5 mg (milligrams- unit of measurement) to 10 mg. 5. Resident 1 received Abilify 10 mg on 4/29/2022 and 4/30/2022, and from 5/1/2022 to 5/30/2022.  6. An investigation of the abuse allegation was delayed. A review of Resident 1's Admission Record indicated the facility admitted Resident 1, a 68 year old female, on 3/19/2021, with diagnoses including major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), auditory hallucinations (perception of hearing something that was not actually there), hypertension (a condition in which the force of the blood against the artery walls is too high), hemiplegia (is a severe or complete loss of strength or paralysis on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (a mild or partial weakness or loss of strength on one side of the body). A review of Resident 1 's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/6/2022, indicated Resident 1’s had no memory problems, could make decisions, and was able to communicate needs. Resident 1 used a wheelchair for mobility. A review of Resident 1’s Nursing Progress notes, dated 4/18/2022, indicated Resident 1 was alert and orientated to person, place, and time, was able to make needs known and independent decision making, and decisions are consistent and reasonable. A review of Resident 1’s Care Plan developed on 4/25/2022 for the resident’s risk for psychosocial impact secondary to alleging a CNA touched her breast on 4/22/2022 at around 2:30 pm in the hallway by the Administrator’s office. Resident 1 claimed she reported to a family member but not to any facility staff. The care plan goal included Resident 1 not having signs and symptoms of negative psychosocial impact such as crying, isolation, depression, and anxiety for 72 hours. The interventions included anticipating resident’s needs and monitoring the resident for signs and symptoms of negative psychosocial impact such as depression, anxiety, isolation, and crying every shift; notifying the physician for psychology evaluation and follow up as needed; and reporting the alleged incident to the Police, Ombudsman, and Department of Health (CDPH). A review of the Resident 1’s Informed Consent (permission for something to happen or agreement to do something) of Psychotropic medication, titled, “Abilify ordered to increase to 10 mg QHS (every night),” was signed by the facility on 4/29/22. The consent also indicated MD 2 both signed and faxed the document on 5/23/2022. The consent also indicated FM2 was notified of the increase in medication and signed the document via telephone on 4/29/22. A review of Resident 1's MAR dated 4/2022, indicated Resident received Abilify 10 mg on 4/29/2022 and 4/30/2022. A review of Resident 1's MAR dated 5/2022, indicated Resident received Abilify 10 mg from 5/1/2022 to 5/30/2022. During an interview with Resident 1 on 5/3/2022 at 10:02 am, Resident 1 stated, on 4/22/2022, CNA 1 grabbed her breasts from behind. Resident 1 stated she told CNA to stop and not to touch her again. Resident 1 stated CNA 1 told her, "Do not give these to anyone else and that they were hers (CNA 1).” Resident 1 stated CNA 1 grabbed her breasts again, “for three minutes.” Resident 1 stated, she felt very nervous, afraid, scared, and upset that CNA 1 “was going to do this again.” Resident 1 stated, she called a family member (FM 1) and told her about the incident on the same day. Resident 1 stated FM 1called the facility and spoke with the staff at the front desk and told the front desk staff to not allow CNA 1 take care of her (Resident 1) because CNA 1 had grabbed Resident 1’s breasts. Resident 1 stated, she told CNA 2 on 4/23/2022 that a CNA had touched her breasts on 4/22/2022. During an interview with the Administrator (Admin), on 5/3/2022 at 10:46 AM, the Admin stated he did not know about the incident until Monday, 4/25/2022 and the report of the alleged sexual abuse to the required agencies was not made within two hours. During an interview with CNA 2 on 5/3/2022 at 10:55 AM, CNA 2 stated Resident 1 reported to her on 4/23/2022 that CNA 1 touched the resident’s “breasts and ribs.” CNA 1 stated Resident 1 told her CNA 1 said “your clothes are very pretty.” CNA 2 stated she reported the incident to LVN 1 on the same day, 4/23/2022. CNA 2 stated CNA 1's behavior was not appropriate. During an interview with Receptionist (RECP) on 5/3/2022 at 11:25 PM, the RECP stated she remembered speaking with FM 1 sometime during the morning on 4/22/2022 and confirmed FM 1 told her she did not want CNA 1 near Resident 1. Receptionist 1 stated she told FM 1 that she did not want to hear any more about the incident and transferred the call to the Assistant Director of Nursing (ADON). During an interview with the ADON on 5/3/2022 at 11:40 AM, the ADON denied speaking with FM 1 on 4/22/2022 and the abuse allegation was not reported to her on 4/22/2022. During an interview with the AD on 5/3/2022 at 11:45 AM, the AD stated she did not know about Resident 1’s abuse incident. The AD stated on 4/24/2022, she went to see Resident 1 because she noticed Resident 1 did not come out of her room. The AD stated Resident 1 told her she did not feel good and was thinking of the nurse that rubbed her stomach. The AD further stated she documented on her notes that Resident 1 “was not feeling well and wrote a note to the Administrator.” During an interview with LVN 1 on 5/3/2022, at 12:30 PM, LVN 1 stated no one reported the abuse allegation to her. LVN 1 stated she became aware of the incident from the change of condition documented in Resident 1’s “chart from either Friday or Saturday.” During an interview with the ADMIN on 5/3/2022, at 12:50 PM, the Admin stated any abuse allegation should be reported within two hours of the incident and reported right away to the State (CDPH). During a telephone interview with FM 1 on 5/3/2022 at 1:55 PM, FM 1 stated she received a call from Resident 1 on 4/22/2022 who stated CNA 1 touched the resident’s breasts. FM 1 stated Resident 1 sounded very upset and “she did not want this nurse to come near her.” FM 1 stated she called the facility and spoke with Receptionist 1 and told her that CNA 1 touched Resident 1’s breast and she did not want “this nurse near” the resident. FM 1 stated she told Receptionist 1 she wanted to speak to a supervisor, but that “the supervisor was too busy to come to the phone.” During a telephone interview on 5/4/2022 at 11:07 am, CNA 1 stated on Friday 4/22/22 at 2:00 pm, Resident 1 was “pushing” herself towards the dining room. CNA 1 helped pushing Resident 1’s wheelchair into the dining room. CNA 1 denied touching the resident’s breasts or making any comment about the resident’s breasts. CNA 1stated she gave Resident 1 a hug and said, “see you later.” CNA 1 stated she had never provided care to Resident 1 before. CNA 1 stated she was trained about residents and physical contact, and that the facility had instructed staff not to touch the residents because they might interpret physical contact differently. During a telephone interview with the AD on 5/23/2022 at 10:31 AM, the AD stated she interviewed Resident 1 on 4/24/2022 and Resident 1 told her that CNA 1 had rubbed her (Resident 1’s) stomach. The AD stated this concerned h