Other·November 27, 2023

42 CFR § 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. CCR § 72319 - Nursing Service - Restraints and Postural Supports (b) Restraints shall only be used with a written order of a licensed healthcare practitioner acting within the scope of his or her professional licensure. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients. In accordance with Section 72317, there shall be no standing orders and in accordance with Section 72319(i)(2)(A), there shall be no P.R.N. orders for physical restraints. 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 9/30/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about resident abuse. The facility failed to implement its Abuse Prohibition Policy by not to reporting to CDPH an allegation of physical abuse (any intentional act causing injury, trauma, bodily harm or other physical suffering to another resident by way of bodily contact) on 9/25/2023 at when Certified Nurse Assistant 1 (CNA 1) used a bed sheet as a physical restraint (any manual method, physical or mechanical device, equipment attached to a resident's body restricting the resident's freedom of movement) on Resident 1. As a result, Resident 1 was placed at an increased risk for further physical abuse from CNA 1 and had the potential to result in unidentified abuse in the facility. A review of Resident 1’s Admission Record indicated the facility admitted Resident 1 on 9/17/2023 with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and history of falling. A review of Resident 1’s History and Physical dated 9/19/2023 indicated Resident 1 did not have the capacity to understand and make decisions due to dementia. A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated 9/24/2023, indicated Resident 1 was able to communicate, make needs known, make decisions, and remember. The MDS further indicated that Resident 1 needed extensive assistance from two staff with bed mobility, transfer, and dressing. A review of Resident 1's Concern Record Form dated 9/25/2023 indicated CNA 1 and CNA 2 were arguing by using profanities. A review of the investigation of the incident between CNA 1 and CNA 2, included an Interview Record form dated 9/25/2023, timed at 6:00 a.m., that indicated CNA 2 alleged CNA 1 was using a bed sheet as a safety belt (a belt fastening a person to an object to prevent falling or injury, it is a form of physical restraint) on Resident 1 while in the wheelchair for Resident 1’s safety. The Interview Record form further indicated CNA 2 believed the bed sheet was used as a form of physical restraint while Resident 1 was sitting on the wheelchair. During a concurrent interview and record review with Registered Nurse 2 (RN 2) on 10/11/2023 at 8:02 a.m., RN 2 reviewed Resident 1 Physician’s Orders from 9/17/2023 to 10/11/2023. RN 2 stated there was no physician’s order for the use of physical restraints for Resident 1. During an interview with the Director of Nursing (DON) on 10/11/2023 at 10:37 a.m., DON stated that on 9/25/2023, when the facility was first made aware of the abuse allegation of a staff tying the resident to a wheelchair without a physician’s order, they should have reported the incident immediately to CDPH, the Ombudsman Program (advocates for residents' rights and quality care in nursing homes) local office, and the Local Law Enforcement (LLE) in a timely manner. During a concurrent interview and record review with the Administrator (ADM) on 10/11/2023 at 1:30 p.m., ADM reviewed the Interview Record form dated 9/25/2023. ADM stated if any staff used a physical restraint without a physician’s order, that would be considered a potential abuse, and it is the facility’s responsibility to report the possible abuse to the required authorities. When the ADM was asked how come the incident wherein CNA 1 allegedly tied Resident 1 to a wheelchair was not reported to the SSA, Ombudsman Office, and Local Law Enforcement, the ADM stated that she should have reported the incident within two (2) hours of being made aware. A review of the facility’s policy and procedure titled, "Abuse Allegation Reporting", reviewed on 7/27/2023, indicated that all employees who identified suspected abuse committed against an individual who is a resident must report the incident and provide a written report to the local Ombudsman, the SSA, and Local Law Enforcement. The facility failed to implement its Abuse Prohibition Policy by not to reporting to CDPH an allegation of physical abuse on 9/25/2023 when CNA 1 used a bed sheet as a physical restraint on Resident 1. As a result, Resident 1 was placed at an increased risk for further physical abuse from CNA 1 and had the potential to result in unidentified abuse in the facility. The above violations had a direct relationship to the health, safety, or security of Resident 1.