Other·September 9, 2022

§483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under §483.75. [§483.12(b)(4) will be implemented beginning November 28, 2019 (Phase 3)] 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 7/25/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint and a facility reported incident about resident-to-resident abuse. The facility failed to implement its abuse prevention and reporting policy by failing to investigate and immediately report but no later than two hours, an allegation of sexual abuse to the State Survey Agency, Ombudsman, and law enforcement agency for Resident 1. As a result, Resident 1 was placed at risk for unidentified abuse in the facility and had the potential for Resident 1 to experience further abuse. A review of Resident 1's Admission Record indicated the facility admitted the 35-year-old male resident on 2/16/2021, with diagnoses including paranoid schizophrenia (mental disorder in which people interpret reality abnormally and may result in some combination of hallucinations, delusions and disordered thinking and behavior that impairs daily functioning), cannabis (plants with psychoactive properties) dependence, and other stimulant abuse. A review of Resident 1's Minimum Data Set (MDS, resident assessment and care-screening tool), dated 5/27/2022, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated the resident was independent in most areas of activities of daily living. A review of Resident 1's History and Physical, dated 6/18/2022, indicated the resident had poor decision-making capacity. During a phone interview on 7/25/2022 at 10:40 a.m., family member 1 (FM 1) stated she reported to Social Services designee 1 (SSD 1) on 7/15/2022 to report that Resident 1's roommates were sexually and physically threatening Resident 1. During an interview on 7/25/2022 at 2:07 p.m., SSD 1 stated that about two weeks ago, FM 1 called her to report that Resident 1's roommates were threatening the resident sexually. SSD 1 stated she reported the allegation to the Floor Supervisor 1 (FS 1). SSD 1 stated she did not document, nor did she report the allegation to the Administrator (ADM) and the Director of Nursing (DON). SSD 1 stated she was not aware if the allegation was investigated. During an interview on 7/25/2022 at 2:20 p.m., with Floor Supervisor 1 (FS 1), FS 1 stated he does not recall SSD 1 reported to him Resident 1's roommates were sexually threatening the resident. FS 1 stated SSD 1 reported concerns of roommate incompatibility and Resident 1's roommates were moved to another room. During an interview on 7/25/2022 at 2:44 p.m., the Administrator (ADM) stated he was not aware of the allegations reported by Resident 1's family member to SSD 1. The ADM stated all allegations of abuse must be investigated and reported no later than two hours to the Department, the Ombudsman, and the local law enforcement agency. A review of the facility’s policy titled, "Abuse Reporting-Dependent Adults," revised on 12/6/2021, indicated a telephone report shall be made to the local law enforcement agency immediately and no later than two hours of the observation, knowledge or suspicion of the physical abuse. In addition, a written report shall be made to the local Ombudsman, the California Department of Public Health, and the local law enforcement agency within two hours of the observation, knowledge, or suspicion of the physical abuse. Incidents will be investigated by any of the following: Incident Report Coordinator (IRC), DON, Administrator, Program Director, or Charge Nurse. The facility failed to implement its abuse prevention and reporting policy by failing to investigate and immediately report but no later than two hours, an allegation of sexual abuse to the State Survey Agency, Ombudsman, and law enforcement agency for Resident 1. As a result, Resident 1 was placed at risk for unidentified abuse in the facility and had the potential for Resident 1 to experience further abuse. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.