Health inspection·August 25, 2022

42CFR §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. 42CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §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. 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. On 4/19/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a facility reported incident about misappropriation of property. The facility failed to report a missing wallet in a timely manner for Resident 1. Also, the facility failed to report the five-day final investigation summary in a timely manner for Resident 1. Resident 1 reported his wallet was missing on 3/22/2022 and the facility reported it on 4/7/2022. As a result, Resident 1 was placed at risk for unidentified abuse in the facility. A review of Residents 1's Admission Record indicated the facility admitted the 63-year old resident on 1/28/21 with diagnoses including cognitive communication deficit (impairment that can lead to difficulty with attention, memory, organizing, problem solving and reasoning, processing speed, and language), anxiety disorder (excessive fear and worried thoughts), and schizoaffective disorder (mental health disorder with a combination of symptoms such as depression, mania, hallucinations, and delusions). The Admission Record indicated Resident 1 was self-responsible (able to make one's own decisions). A review of Resident 1's History and Physical, dated 1/30/22, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's progress notes, dated 3/24/22, indicated Resident 1 was alert and oriented to person, place, time, and situation. On 4/19/22 at 2:32 p.m., during an interview, Resident 1 stated that he brought his wallet to the General Acute Care Hospital 1 (GACH 1) emergency room, but he did not receive it when he came to the facility. Resident 1 stated he was regretting it, why he did not ask for the receipt upon depositing his wallet with GACH 1. On 4/19/22 at 4:15 p.m., during an interview, the Social Services Director (SSD) stated the Social Services Department was in charge of residents' inventory checking upon admission which needed to be completed within 24 hours or 48 hours from admission. The SSD stated she was not sure of the exact time frame and needed to review the facility's policy and procedure. The SSD referred the surveyor to the Administrator when asked who was responsible for missing items and the inventory list was not done upon a resident's arrival/admission. The SSD stated that she had started the investigation immediately and figured that Resident 1 did not bring the wallet to the facility since it was not on the inventory list, when asked why the facility did not report that Resident 1 reported his wallet missing on 3/22/22. The SSD stated it took several days to confirm with GACH 1 when asked how the facility knew that Resident 1 did not bring his wallet to the facility if the Residents 1's inventory list was not done till the fifth day after admission. The SSD stated the missing wallet did not occur at the facility and the facility reported to CDPH, Ombudsman, and the local law department when the facility received the bank statement and the Resident 1 discovered that someone used his money. On 4/19/22 at 5:30 p.m., during an interview, the Administrator stated the facility did not submit the 5-day investigation summary report because Resident 1's wallet did not get lost in the facility. On 4/19/22 at 5:35 p.m., during an interview and concurrent record review of the facility's investigation report, the Administrator stated Resident 1 reported his wallet, debit card, driver's license, social security card, among others as missing on 3/22/22. The SSD figured out that Resident 1 did not bring the missing items to the facility per documentation of the inventory list for the resident. The Administrator stated the inventory list was done four days after the facility admitted Resident 1. The Administrator stated he received a report from the social services director on 4/2/22 that Resident 1 reported missing items. The Administrator was not able to give an answer when asked how the facility was sure Resident 1 did not bring in any belongings. The Administrator stated that on 4/7/22 Resident 1 received a bank statement that indicated that someone had used the resident's money. The Administrator stated local law enforcement went to the facility to investigate Resident 1's missing items. The Administrator stated the facility was still investigating it (not finished with the investigation) that was why the Administrator did not report the investigation summary to CDPH, yet, at that time. A review of the facility's document titled, "Seven Components of Abuse prohibition program," refers to the seven steps. The seven steps included screening, training, reporting/response, identification, investigation, prevention, and protection. The document indicated that "The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse including injuries of unknow source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with state law." A review of the facility's policy and procedures titled, "Mandated Reported Elder Abuse and Dependent Adult Civil Protection Act," revised on 1/2018, indicated that: 1. All persons employed in a health care facility are mandated reporters. 2. The facility Abuse Coordinator must be notified of any suspected abuse allegation immediately and an investigation will be initiated. Identified employee may be subjected to a change in assignment or removal from the schedule during the investigation process. 3. Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury ( an injury involving extreme physical pain, substantial risk of death, or protracted loss of impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention that may include hospitalization, surgery or physical rehabilitation). · Report the alleged violation immediately to the Administrator or Designee and no later than 2 hours · Report the incident immediately and no later than two hours by telephone to local law enforcement, and/or · Send a written report within two hours to the local law enforcement agency, the L&C Program, and the Ombudsman. A review of the facility's P&P titled, "Elder Justice Act," dated 1/18, indicated the Administrator, Director of Nursing, or any other designated individual will report (within required time frames) any reasonable suspicion of a crime against a resident to the State Survey Agency and local law enforcement agency. The timing of reporting will be based on the events that cause suspicion. It shows that the events involve abuse or bodily injury, the suspicion will be reported immediately, but no later than 2 hours after forming the suspicion. If the event does not involve abuse or bodily injury, the suspicion will be reported no later than 24 hours after forming the suspicion. The facility failed to report a missing wallet in a timely manner for Resident 1. Also, the facility failed to report the five-day final investigation summary in a timely manner for Resident 1. Resident 1 reported his wallet was missing on 3/22/2022 and the facility reported it on 4/7/2022. As a result, Resident 1 was placed at risk for unidentified abuse in the facility. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.