Other·February 7, 2024

F609 §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. (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. Title 22 § 72523. Patient Care Policies and Procedures. (b) All policies and procedures required or these regulations shall be in writing. Made available upon request to physicians and other involved health professionals. patients or their representatives. employees and the public shall be carried out as written. Policies and procedures shall be re­viewed at least annually. revised as needed and approved in writing by the patient care policy committee. An unannounced visit was conducted by California Department of Public Health (CDPH) on 12/18/2023, 8:30 am to investigate a complaint regarding an allegation of Misappropriation of Property, for Patient 1. The facility failed to implement its policy and procedures titled, "Theft and Loss Policy and Procedures" and "Abuse Prevention and Prohibition Program" by not thoroughly investigating an alleged misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, permanent use of a resident's belongings or money without the resident's consent) and report to California Department of Public Health, Ombudsman (stated agency that advocates for the patients and the Police Department) within 24 hours when patient 1 reported missing $1500 on 12/11/23 to the Administrator (ADM-the Abuse Coordinator) and the ADM Designee (ADMD). This deficient practice resulted in Patient 1's verbalizing feeling sad for not being able to share money to his family during Christmas time. This deficiency could also result in other potential patients to be a subject for theft or loss that could lead to a psychosocial decline and mistrust with the facility staff. Findings: A review of Patient 1’s admission record indicated the patient was originally admitted to the facility on 1/14/2023 and readmitted on 11/10/2023 with diagnoses that included respiratory failure (a condition in which the lungs have a hard time loading the blood with oxygen and result in difficulty breathing), kidney failure (failure of the kidney to remove toxins and excess fluid in the body) and heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Patient 1’s History and Physical Examination, dated 11/7/2023, indicated the patient has the capacity to understand and make decisions. A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), date 11/17/2023, indicated Patient 1’s cognitive skills (ability to make daily decisions) was intact. The MDS indicated Patient 1 required partial/moderate assistance (helper does less than half the effort) with eating, required substantial/maximal assist (helper does more than half the effort) wit oral hygiene, dressing, and dependent (helper does all the effort) with toileting, bathing, roll left and right, and sit to lying, lying to sitting on side of bed. A review of facility document titled "CONCERN RECORD -Theft/Loss and Grievance Report, dated 12/11/2023, indicated Patient 1 reported he was missing money in the amount of $1500 to ADMD. During a concurrent observation and interview on 12/18/2023 at 9:55 AM with Patient 1 in the patient’s room, Patient 1 was observed sitting in his wheelchair frowning (expression of disapproval, displeasure). Patient 1 stated, last week he reported to the Administrator (ADM) and the ADM Assistant (ADMD) that he was missing $1500, but no one had investigated his claim. Patient 1 stated, he was sad because it was almost Christmas and he wanted to share his money with his family (FAM 1). During an interview on 12/18/2023 at 1:31 PM with ADM, the ADM stated, she knew about Patient 1's allegation regarding missing money since last week. The ADM stated, she informed the Administrator Designee (ADMD) to investigate Patient 1's allegation of missing money. The ADM stated, she did not report Patient 1's allegation of missing money to CDPH (California Department of Public Health), the police or any other agency because she was not sure if Patient 1 had the money or not. ADM further stated she informed the Administrator Designee (ADMD) to investigate Patient 1's allegation of missing money and a grievance report was initiated. During an interview on 12/20/2023 at 8:49 AM, Patient 1 stated, he gets money from the pension plan and directly deposited to his bank. Patient 1 stated, he authorized FAM 2 to take money from his account monthly, and he keeps around $300 a month and puts it in his wallet and keeps it in his side table drawer. Patient 1 stated he reported that he was missing $1500 to ADMD on 12/11/2023. Patient 1 stated, the facility staff did not believe he was missing $1500. Patient 1 stated, "I feel terrible, and it is almost Christmas and he wanted to give money to the FAM 1." During an interview on 12/20/2023 at 9:04 AM, FAM 2 stated, it was possible for Patient 1 to have $1500 in his possession, because she gives the patient $500 to $600 a month from the patient’s bank account. FAM 2 stated, the day after the patient went to the hospital on 10/29/2023, and she picked up the patient’s empty wallet from his room in the facility. FAM 2 stated that was when Patient 1 told her that his money in the amount of $1500 was missing. FAM 2 stated, she and Patient 1 reported to the facility that the patient’s money was missing on 12/11/2023 (Patient 1 was hospitalized on 10/29/2023 and readmitted to the facility on 11/10/2023). During an interview on 12/20/2023 at 11:36 AM, the ADM stated, the ADM stated, the ADMD (assigned to do the investigation) did not thoroughly investigate Patient 1's alleged missing money because the ADMD only interviewed the patient and FAM 2 on 12/11/23. The ADM stated, the patient’s allegation of missing money should have been thoroughly investigated by the ADMD per facility policy and procedure. The ADM stated, "It was a human error.". During a concurrent interview and record review on 12/20/2023, at 11:40 AM, with ADMD, Patient 1s electronic medical records (EMR) was reviewed from 11/10/2023 to 12/20/23, the ADMD stated there were no interdisciplinary team (IDT-a group of health care professionals with various areas of expertise who work together toward the goals of the patients) notes, nurses notes, social service notes, care plans documented to indicate the allegation of the patient’s missing money was thoroughly investigated. The ADMD stated, he only interviewed Patient 1 and FAM 2 when he investigated the alleged missing money. The ADMD stated, "It should have been investigated thoroughly." During a record review of Patient 1's on 12/20/2023, there was documented evidence that the facility and/or nursing staff diligently look for reported lost or stolen items throughout the facility on 12/11/23 when the patient reported he was missing $1500. A review of the facility's policy and procedure (P&P) titled "Theft and Loss Policy and Procedures", (undated), indicated, the social service designee and/or nursing staff will diligently look for reported lost or stolen items throughout the facility. The P&P indicated a report will be filed with the local law enforcement agency within 36 hours when the administrator has reason to believe the patient's stolen property is worth $100 or more. A review of the facility's policy and procedure (P&P) titled "Abuse Prevention and Prohibition Program", (undated), indicated, each patient has the right to be free from misappropriation of property. The P&P indicated, facility should promptly and thoroughly investigate reports of patient abuse, mistreatment or criminal acts. The facility failed to implement its policy and procedures titled, "Theft and Loss Policy and Procedures" and "Abuse Prevention and Prohibition Program" by not thoroughly investigating an alleged misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, permanent use of a resident's belongings or money without the resident's consent) and report to California Department of Public Health, Ombudsman (stated agency that advocates for the patients and the Police Department) within 24 hours when Patient 1 reported missing $1500 on 12/11/23 to the Administrator (ADM-the Abuse Coordinator) and the ADM Designee (ADMD). This deficient practice resulted in Patient 1 verbalizing feeling sad for not being able to share money to his family during Christmas time. This deficiency could also result in other potential residents to be a subject for theft or loss that could lead to a psychosocial decline and mistrust with the facility staff. The above violation had a direct or immediate relationship to the health, safety or security of Patient 1.