Other·May 31, 2024

Title 22 California Code of Regulations, Title 22, Section 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 Code of Federal Regulations, Title 42, Section 483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual’s obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. On 4/16/2024 an unannounced visit was conducted by California Department of Public Health (CDPH, the Department) to investigate a compliant regarding an alleged abuse. As a result of the investigation, the facility failed to ensure all allegations of abuse are reported immediately but no later than two hours if the alleged violation involves abuse, to the local, state, and federal agencies, in accordance with the facility's policy and procedure on "Abuse Investigation and Reporting" for Patient 1. Speech Therapist (ST) 1 found Patient 1 tied by a white sheet around the wheelchair by Certified Nursing Assistant (CNA) 1 on 4/11/24 at 6 PM. The facility abuse coordinator was made aware of the incident on 4/12/24 at 9 AM and the facility reported the incident to the CDPH on 4/12/24 at 11:41 AM (18 hours). This deficient practice violated Resident 1’s right and had the potential for Patient 1 to suffer further abuse, and the potential for other patients assigned to CNA 1 to suffer abuse from CNA 1. A review of Patient 1's Admission Record dated 4/12/2024 indicated the facility admitted Patient 1, a 80 years old female to the facility on 3/22/2024, with diagnoses that included pneumonia (an infection of one or both lungs), anxiety (feeling of fear, dread, and uneasiness), depression (mood disorder that causes a persistent feeling of sadness) and bipolar disorder (mental illness that causes unusual shifts in mood from extreme happiness to extreme sadness and vice-versa). A review of Patient 1's History and Physical (H&P), dated 3/22/2024, indicated the patient did not have the capacity to make decisions. A review of Patient 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 3/28/24, indicated the patient has severe cognitive (thought process) impairment. The MDS indicated the patient was independent (able to complete task by themselves) in walking with the use of a walker. The MDS indicated the patient required maximal assistance (helper does more than half the effort) on tasks such as lower body dressing, bathing, and toileting, moderate assistance (helper does less than half the effort) on tasks such as upper body dressing, and supervision on tasks such as sit to stand and bed mobility. A review of the facility's Nursing Assignment dated 4/11/2024, for the 3 PM to 11 PM shift, indicated CNA 1 was assigned to 10 patients, including Patient 1 and Patient 2. A review of CNA 1's timesheet for the week of 4/11/2024 indicated CNA 1 clocked in to the facility at 3:22 PM and locked out from the facility on 4/11/2024, at 11 PM. A review Patient 1's Progress Notes New, authored by the Director of Nursing (DON) dated 4/12/24, timed at 9:30 AM, indicated the DON received a report from the Director of Rehabilitation (DOR) "regarding an alleged incident of abuse; Patient 1 was tied with white single sheet around the waist in the wheelchair on 4/11/2024 during 3 to 11 shift..." The progress notes indicated CNA 1 admitted tying Patient 1 in the wheelchair to prevent the patient from falling while CNA 1 was attending to other patients. The progress notes indicated the DON reached out to Speech Therapist (ST1) who saw Patient 1 in the patient's room on 4/11/2024 (at 6 PM). The progress notes indicated Patient 1 informed ST 1 that there was a sheet around Patient 1's waist and ST 1 immediately informed the charge nurse (LVN 1). The progress notes indicated Patient 1 was "slightly upset/frustrated about the incident..." and stated that someone tied her with a bed sheet around her waist in the wheelchair. A review of the facility’s record titled, "Care Plan Conference Summary," dated 4/12/2024, authored by Social Service Designee (SSD)1, indicated that Patient 1 stated/reported that (on 4/11/2024) during the evening shift CNA tied her (Patient 1) with a bedsheet around her waist while sitting in the wheelchair. The record indicated Patient 1 stated that she could not get up and became frustrated and informed ST 1 that she was tied to the wheelchair. During an interview on 4/12/2024 at 2:42 PM, Patient 1 stated she remembered being "tied up yesterday (4/11/2024)" by a staff that works at the facility. Patient 1 stated "when the new nurse (CNA 1) came in" the nurse tied Patient 1 using a bed sheet around the waist to the wheelchair "for hours." Patient 1 stated she kept screaming while she was being tied up. Patient 1 stated while she was screaming "She heard two people walking by and nothing happened." Patient 1 stated being tied up made her "cried," “feel upset and humiliated." Resident 1 stated being tied up made her "feel like a person that got caught in a nightmare." Patient 1 further stated that being tied up made her feel "like a kid" who had no control and that her "life was over because someone had the power to make her a bad person." Patient 1 stated she could not remove the bedsheet. Patient 1 stated she would "feel scared" if she ever sees CNA 1 again. Patient 1 stated CNA 1 took her freedom away. During an interview on 4/12/2024 at 4:13 PM with the DOR, the DOR stated she received a text message from ST 1 (on 4/11/2024) at around 6 PM, stating that "a patient" was tied to the wheelchair. The DOR stated the text message also indicated that ST 1 informed "a nurse" about the incident. The DOR stated ST 1 did not mention talking to the facility's abuse coordinator. The DOR stated she did not report to the abuse coordinator what happened to Patient 1, until 4/12/2024 at around 9 AM. The DOR stated the incident is a case of abuse and should have been reported immediately or within 2 hours of finding out about the abuse. The DOR further stated if abuse allegations are not reported within 2 hours, the affected patient and other patients could suffer further abuse. During an interview on 4/12/2024 at 4:22 PM with CNA 1, CNA 1 stated she was assigned to Patient 1 and Patient 2 in the same room, on 4/11/2024 for the 3 PM to 11 PM shift. CNA 1 stated when she was doing her initial rounds for her assigned patients, Patient 2 asked for assistance go to the bathroom. CNA 1 stated she was helping Patient 2 in the bathroom when Patient 1 started getting up from the bed. CNA 1 stated she did not call other staff for help because when she looked outside the patients’ (Patient 1 and 2’s) room, no one was in the hallway. CNA 1 stated she put Patient 1 in the wheelchair and tied her (Patient 1) to the wheelchair using a bed sheet. CNA 1 stated she tied Patient 1 to prevent the patient from falling because Patient 1 kept trying to get up from the wheelchair. CNA 1 stated she started her initial rounds within 30 minutes of her arrival into the facility during the 3 PM to 11 PM shift. CNA 1 stated she finished the evening shift and had Patient 1 in her assignment throughout the shift, on 4/11/2024. CNA 1 stated that she informed LVN 2 on 4/11/2024, that she tied Patient 1 to the wheelchair. During an interview on 4/12/2024 at 4:36 PM with ST 1, ST 1 stated (on 4/11/2024) he went to Patient 1's room at around 5:45 PM to 6 PM and when he opened the door, he heard a patient yelling for help. ST 1 stated when Patient 1 saw ST 1, Patient 1 called ST 1 by his first name, asking for "help to get her out." ST 1 stated he walked closer to Patient 1's bedside and he saw that Patient 1 was sitting on a wheelchair with a bed sheet wrapped around the waist and the wheelchair. ST 1 stated Patient 1 had a bedside table in front of her. ST 1 stated that during that same time, CNA 1 was inside the room, feeding another patient (Patient 3). ST 1 stated he reported what he saw to LVN 1 and the DOR (on 4/11/2024). During an interview on 4/12/2024 at 5:33 PM with LVN 1, LVN 1 stated (on 4/11/2024) ST 1 reported to her that there was "something blocking Patient 1," and she went to see (check on) Patient 1. LVN 1 stated that when she was closed to Patient 1's room, she saw Patient 1 was already walking outside of Patient 1’s room with CNA 1 and LVN 2, so LVN 1 did not bother to go closer to Patient 1. During an interview on 4/12/2024 at 6 PM with LVN 2, LVN 2 stated CNA 1 did not inform him on 4/11/2024 that she tied Patient 1 to the wheelchair. LVN 2 stated he did not report the incident to the abuse coordinator. During an interview on 4/12/2024 at 8:24 PM with the DON, the DON stated ST 1 should have reported the incident to the facility's abuse coordinator (the Administrator [ADM]). The DON stated CNA 1 should have been suspended and sent home immediately on 4/11/2024, until the investigation was finished to protect Patient 1 and other patients. The DON stated because the incident was not reported timely, Patient 1 could have suffered more psychological harm and other patients could have become victims of abuse. During an interview on 4/15/2024 at 3:10 PM, with the ADM, the ADM stated the improper use of restraints on Patient 1 with or without consent, could be classified as a form of physical, emotional, and psychological abuse. The ADM stated he was notified of the incident on 4/12/2024 at 9 AM. The ADM stated ST 1 should have reported the incident to him on 4/11/2024 so that the facility could have acted sooner such as sending CNA 1 home and not let CNA 1 finish her shift. During a follow up interview on 4/16/24 at 3:44 PM with ST 1, ST 1 stated Patient 1 suffered a form of abuse when Patient 1 was tied to the wheelchair by CNA 1. ST 1 stated he should have reported the incident to the abuse coordinator or to the state agency. ST 1 stated he is a mandated reporter and "there was no excuse for [him] to not report it." ST 1 further stated cases of abuse should be reported immediately or within 2 hours to protect the affected patient and other patients from suffering abuse. A review of the facility's policy and procedure (P&P) titled, "Abuse Investigation and Reporting", revised 7/17, indicated all reports of abuse "shall be promptly reported to local, state, and federal agencies." The P&P also indicated an alleged violation of abuse "will be reported immediately," but no later than "two hours if the alleged violation involves abuse." The facility failed to ensure that all allegations of abuse are reported immediately but no later than two hours if the alleged violation involves abuse, to the local, state, and federal agencies, in accordance with the facility's policy and procedure on "Abuse Investigation and Reporting" for Patient 1. ST 1 found Patient 1 tied by a white sheet around the wheelchair by CNA 1 on 4/11/24 at 6 PM. The facility abuse coordinator was made aware of the incident on 4/12/24 at 9 AM and the facility reported to the CDPH on 4/12/24 at 11:41 AM. This deficient practice violated Patient 1’s right and had the potential for Patient 1 to suffer further abuse, and the potential for other patients assigned to CNA 1 to suffer abuse from CNA 1. The above violation had a direct or immediate relationship to the health, safety or security of Patient 1.