Health inspection·June 16, 2023

T22 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. 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. An unannounced visit to the facility was conducted on 4/28/2023 at 1:40 pm to investigate an allegation of abuse for Patient 1. A facility reported incident was received by the Department of Public Health on 4/20/2023, indicated an allegation of verbal abuse that occurred on 4/11/2023 (9 days after the abuse allegation). The facility failed to report an allegation of abuse to the Department of Public Health (CDPH) and other officials immediately, but not later than two hours for Patient 1 in accordance with the facility’s policy on “Abuse Reporting and Investigation.” This deficient practice had the potential for under reporting allegations of abuse, which could lead to failure to investigate alleged abuse in a timely manner. A review of Patient 1’s Face Sheet indicated Patient 1, a female, 61 year old patient with facility admission date of 11/6/2019 with diagnoses that included Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar [glucose] where the body either doesn’t produce enough insulin) with hyperglycemia (high blood sugar), generalized osteoarthritis (the cartilage in several joints is slowly breaking down), and schizoaffective disorder (a mental health condition that includes features of both schizophrenia (disorder that affects a person’s ability to think, feel, and behave clearly) and mood disorder) bipolar type (associated with episodes of mood swings ranging from depressive lows to manic highs). A review of Patient 1’s History and Physical Examination dated 11/30/2022, indicated Patient 1 did not have the capacity to understand and make decisions. A review of Patient 1’s Minimum Data Set (MDS, an assessment and screen tool) dated 2/3/2023 indicated Patient 1 had intact cognition and required supervision (oversight, encouragement or cueing) with bed mobility and transfer. During an interview with the Administrator (ADM) on 4/28/2023 at 1:44 PM, the ADM stated the allegation was that the Director of Nursing (DON) called Patient 1 the “N” word. The ADM stated it was reported by Certified Nursing Assistant (CNA 1) and that the incident was in the past. The ADM stated once the allegation was reported to him on 4/20/2023, he immediately reported it to the necessary authorities. The ADM stated he did not know the exact date the DON allegedly said the “N” word to Patient 1. The ADM stated the staff should have told him right away. The ADM stated he wrote up CNA 1 and CNA 2 because they did not report it right away. The ADM stated the abuse allegation was escalated to the corporate level and Human Resources (HR) were at the facility conducting confidential interviews with staff. During an interview with CNA 3 on 4/28/2023 at 2:20 PM, CNA 3 stated on 4/12/2023, he was told by CNA 1 and CNA 2 about the alleged verbal abuse that happened on 4/11/2023. CNA 3 stated he made the report to Human Resources. During an interview with Patient 1 on 4/28/2023 at 3:14 PM, Patient 1 could not recall if the DON or any other staff yelled or mistreated her. During a telephone interview with CNA 1 on 4/28/2023 at 3:54 PM, CNA 1 stated she knows she should have reported the verbal abuse allegation right away but did not report at the time. CNA 1 stated she and CNA 2 discussed the allegation and instead reported it to CNA 3 the next day, who then reported the allegation to Human Resources. CNA 1 stated it should have been reported to the ADM, CDPH, Ombudsman, and the local authorities within 2 hours or immediately. During a telephone interview with CNA 2 on 4/28/2023 at 4:09 PM, CNA 2 stated she did not report the incident right away, she told CNA 3 who reported it to Human Resources. CNA 2 stated she knew she was supposed to report to the ADM right away or immediately. CNA 2 stated she told CNA 3 about the alleged verbal abuse on 04/12/23. A review of facility’s policy and procedure titled “Abuse Reporting and Investigation,” dated 11/2018 indicated the facility will report all allegations of abuse as required by law and regulations to the appropriate agencies within 2 hours. The facility failed to report an allegation of abuse to the Department of Public Health (CDPH) and other officials immediately, but not later than two hours for Patient 1 in accordance with the facility’s policy on “Abuse Reporting and Investigation.” This deficient practice had the potential for under reporting allegations of abuse, which could lead to failure to investigate alleged abuse in a timely manner. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.