Health inspection·October 27, 2023

§ 72315. Nursing Service - 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. § 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: (10) To be free from mental and physical abuse. F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms. §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. On 9/7/23 at 10:50 PM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding sexual abuse (non-nonconsensual touching of one person for the sexual gratification of another) The facility failed to ensure Patient 1, a 70 year old female, who was alert, oriented to name, place, time and person, and able to make needs known, was free from sexual abuse by failing to ensure: 1. Laundry Staff (LS) did not sexually abuse Patient 1 from 8/30/23 to 9/1/23. 2. Patient 1 was protected from sexual abuse from the LS. The Licensed Vocational Nurse (LVN 1) and the Director of Nursing (DON) were aware of Patient 1's allegation of sexual abuse when Patient 1 reported it on 9/2/23. The LS continued to work in the facility and had continued contact with Patient 1 until 9/5/23. These deficient practices resulted in Patient 1 experiencing sexual abuse, verbalized feeling unhappy, uncomfortable, disgusted, shocked, and violated (failing to respect someone ' s peace or privacy) from the action and sexual abuse of the LS. This deficient practice also had the potential to affect other vulnerable patients in the facility to experience sexual abuse. A review of an Admission Record indicated Patient 1 was admitted the facility on 12/11/18 with diagnoses that included unspecified epilepsy (neurological disorder in which a person has two or more unprovoked seizures that occur more than 24 hours apart), myocardial infarction (partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle) and, muscle weakness (when full effort doesn't produce a normal muscle contraction or movement). A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 8/17/23, indicated Patient 1 had the capacity to make needs known and understand others, and with moderate cognitive impairment (ability to understand and make decisions) that required extensive assistance (patient involved in activity, staff provide weight bearing support) with one-person physical assistance on bed mobility and transfer. During an interview on 9/7/23 at 11:20 AM, the DON stated LVN 1 informed her on 9/3/23 (Sunday) at around 2:30 PM, Patient 1 alleged that she was sexual abused by the LS. The DON stated Patient 1's allegation of abuse was not considered a sexual abuse since Patient 1 has dementia (progressive or persistent loss of intellectual functioning). The DON stated she told LVN 1 she will come back tomorrow (9/4/23) to assess the sexual allegation. The DON stated Patient 1 informed her about the allegation of sexual abuse on 9/4/23 at around 6:35 PM. The DON stated she did not report Patient 1’s allegation of sexual abuse to the Adult Protective Services (agency that advocates for the elderly), the state survey agency, ombudsman, and the local law enforcement. The DON also stated she did not investigate Patient 1’s the allegation of sexual abuse because Patient 1 has dementia. The DON stated the facility' s policy on “Abuse” indicated the facility's abuse coordinator was the ADM who should report any allegation of abuse to the Department of Public Health, ombudsman, and local law enforcement within two hours. The DON admitted it was her "fault" that she did not inform the ADM and suspend the LS when she was informed by LVN 1 about the sexual abuse allegation on 9/3/23. The DON denied that she was informed of the sexual abuse allegation on 9/2/23 that was reported by Patient 1 to the law enforcement and the surveyor. During an interview on 9/7/23 at 11:50 AM, the ADM stated he was not informed on 9/2/2023 of Patient 1’s alleged sexual abused by the LS. The ADM stated he was notified of Patient 1’s alleged sexual abuse on 9/5/23 at around 9 AM. The ADM stated, the DON and LVN 1 did not report Patient 1 ' s allegation of sexual abuse to the adult protective services, the state survey agency, ombudsman, and the local law enforcement. The ADM stated the facility's Abuse policy indicated the facility should report any allegation of abuse to the Department of Health, ombudsman, and local law enforcement within two hours of alleged abuse. During an observation and interview with on 9/7/23 at 12:30 PM, Patient 1 was observed sitting on the bed. In an interview Patient 1 was alert and oriented to name, place, time, and date. Patient 1 stated on 8/30/23 while she was sitting on the bed, the LS stood in front of her and said something to her that she could not understand. The LS then grabbed her left hand and put her hand under the buckle of his belt and had her rub his penis five to six times back and forth. Patient 1 stated the LS was smiling and kept looking behind him to see if there was anyone watching. Patient 1 stated before the LS left her room, he said he was coming back. Patient 1 stated, the next day on 8/31/23, the LS went in her room between 10 AM to 11 AM, and again grabbed her hand and rubbed her hand on penis about five to six times and he kept watching the door to see if someone was coming. Patient 1 stated on 9/1/23, the LS came into her room again, grabbed and rubbed her hand against his penis. Patient 1 stated she pulled back her left hand and told the LS "Do not do that ever again." Patient 1 stated she felt unhappy, uncomfortable, disgusted, and shocked with the incident. Patient 1 stated she did not know what to do and who to tell. Patient 1 stated she talked to Family 1 (FAM1) about the sexual abuse and FAM 1 informed the Licensed Vocational Nurse (LVN 1) about the sexual abuse by the LS on 9/2/23. Patient 1 stated on 9/5/23 before 9 am, the LS went to her room and begged her not to tell anyone because he has a sick daughter in college. A review of Police Report (PR) from Police Department report dated 9/5/23, timed at 11:52 AM, indicate an interview with Patient 1 that was conducted by PD1. The report indicated the following: 1. Patient 1 stated on 8/30/23 around 1 PM, LS went into her room and approached her bedside. Patient 1 was in a sitting position on her bed and LS stood on left side of her bed, grabbed her left hand, and pulled towards the bottom portion of his belt buckle. Patient 1 stated the LS rubbed the back of her hand approximately five to six times back and forth between his belt-buckle and his penis. LS placed her hand over his paints and not under his clothes. LS was looking back toward the bedroom door to see if anyone was approaching her bedroom. Patient 1 said LS looked at her, touched her face with his other hand. LS released her left hand and put his finger to his mouth and said "Shh, shh shh, I'll be back." 2. Patient 1 stated on 8/31/23 between 10 AM to 11 AM, the LS went into her room and approached her on the left side of bed. Patient 1 was in a sitting position on her bed and LS stood on the left side. The LS grabbed her left hand and pulled it toward his groin area. Patient 1 stated the LS grabbed her hand that was in a fist position. Patient 1 said the LS rubbed the back of her hand below his belt buckle over his pants approximately six times back and forth between his belt-buckle and his penis. The LS was looking back toward the bedroom door to see if anyone was approaching her bedroom. LS released her left hand and put his finger to his mouth and said "Shh ... shh..shh, I'll be back." 3. Patient 1 stated on 9/1/23 between 10 AM to 11 AM, the LS went into her room and approached her left side of bed. Patient 1 was in a sitting position on her bed and LS stood on the left side. LS grabbed her left hand and pulled it toward his groin area. Patient 1 stated the LS grabbed her hand that was in a fist position. Patient 1 said LS rubbed the back of her hand below his belt buckle over his pants two times. Resident said she was in “shock" the other two times that the LS assaulted her and now she was angry and pulled her hand away. Patient 1 recalled saying "No don’t ever do that again," the LS walked away and never returned. 4. Patient 1 stated she notified LVN 1 on 9/2/23. 5. Patient 1 stated on 9/5/23 at around 9 AM the LS walked in her room and said, "Momma, momma, momma, please don't. I have a sick daughter in college. Please momma, please don't get me fired. I won' t be able to get work." 6. The report indicated the Patient 1 was coherent (able to speak clearly and logically) and provided detailed statements of the answer to the question and the allegation appeared credible (able to be believed). During an interview on 9/12/23 at 10:35 AM, LVN 1 stated Patient 1's Family called him around noon on 9/3/23 and informed him that the LS sexually abused Patient 1 on 8/30/23, 8/31/23 and 9/1/23. LVN 1 stated he went to Patient 1's room to gather information from Patient 1. LVN 1 stated at the beginning, on 9/3/23 Patient 1 she was in shocked and hesitated to tell the whole story. LVN 1 stated Patient 1 reported feeling anxious and afraid to go to nursing station to look for him. LVN 1 stated Patient 1 was able to give detailed information of the sexual abuse incident clearly and was not confused. LVN 1 stated he reported Patient 1 ' s allegation of sexual abuse to DON around 2 PM on 9/3/23. LVN 1 denied that he received Patient 1 ' s allegation of sexual abuse on 9/2/23 as reported by Patient 1 to the police the surveyor. During an interview on 9/12/23 at 12:10 PM with Maintenance and Laundry Supervisor (MLS), stated he was informed by LVN 1 on 9/3/23 that Patient 1's alleged sexual abuse by the LS. The MLS stated the LS was off on 9/3/23 and 9/4/23. MLS stated LS returned to work on 9/5/23. During an interview on 9/13/23 at 3:20 PM, the DON stated that she talked to the LS on 9/5/23 not to go to Patient 1's room. The DON stated she did not suspend the LS on 9/3/23 when LVN 1 reported to her the alleged sexual abuse of Patient 1 by the LS. A review of Patient 1 ' s progress note titled "Psych evaluation following an alleged sexual abuse", dated 9/8/23, indicated Patient 1 was sexually violated by a facility staff on 8/30/23, 8/31/23 and 9/1/23. The evaluation indicated, on 8/30/23 the LS came into to her room and stoked her face with his hand; on 8/31/23 Patient 1 stated the LS came to her room and stoked her arms; Patient 1 stated she felt "uncomfortable" and "unhappy" by the action of the LS, and on 9/1/23 Patient 1 stated the LS came to her room and held her left hand to rub his groin below his belt. Patient 1 reported she felt "violated" and "disgusted" by the action of the LS. Patient 1 reported that on 9/2/23 she informed LVN 1 who informed the DON about the allegation of sexual abuse by the LS. A review of the facility ' s policy and procedure, titled "Abuse Prevention and Prohibition Program" revised on 10/24/22, indicated the patients had the right to be free from abuse and the facility had "zero-tolerance" for abuse, neglect, and mistreatment of each resident. The policy indicated the facility was committed to protecting patients from abuse by anyone, including from the facility staff; shall thoroughly investigate; and report resident allegation of abuse no later than two hours after forming the allegation to the ombudsman, law enforcement: adult protective services and state survey agency; protect resident from any harm that could result from investigation; and the facility staff member accused of committing abuse against a resident is suspended until the investigation is complete, and the findings had been reviewed by the Administrator. The facility failed to ensure Patient 1 was a 70 years old female, who was alert, oriented to name, place, time and person, and able to make needs known was free from sexual abuse by failing to ensure: 1. Patient 1 was not sexually abused by the LS from 8/30/23 to 9/1/23. 2. Patient 1 was protected from sexual abuse from the LS. The Licensed Vocational Nurse (LVN 1) and the Director of Nursing (DON) was aware of Patient 1's allegation of sexual abuse when it was reported by Patient 1 on 9/2/23. The LS continued to work in the facility and had continued contact with Patient 1 until 9/5/23. These deficient practices resulted in Patient 1 experiencing sexual abuse, verbalized feeling unhappy, uncomfortable, disgusted, shocked, and violated from the action and sexual abuse of the LS. This deficient practice also had the potential to affect other vulnerable patients in the facility to experience sexual abuse. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious physical harm would result.