Health inspection·September 6, 2024

California Code, Health and Safety Code - HSC § 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. On 7/25/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident about abuse during a relicensing survey. The facility failed to report a patient-to-patient physical abuse (unwanted contact with resulting physical harm or mental suffering) to CDPH, local law enforcement, and ombudsman within 24 hours for Patient 7. This deficient practice resulted in unidentified abuse in the facility and failure to protect Patient 7 from abuse. A review of Patient 7’s Admission Record indicated the facility admitted the patient on 11/21/2018 with a primary diagnosis of schizoaffective disorder (a mental health condition marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression). The Admission Record further indicated Patient 7 had a public guardian (a representative responsible for the care of an individual who is no longer able to make decisions). A review of Patient 7’s History and Physical (H&P), dated 8/31/2023, indicated Patient 7 has poor decision-making capacity. A review of Patient 7’s nurses note, dated 6/1/2024, indicated Registered Nurse (RN) 2 documented Patient 7 was struck in the face three times with a closed fist by another patient (Patient 11) while they were waiting for breakfast on 6/1/2024 at 7:50 a.m. The nurses note indicated Patient 7 refused a physical assessment but was noted to have sustained a superficial laceration to the lower lip. The nurses note did not indicate the incident was reported to CDPH, law enforcement, or the ombudsman. During an interview on 7/23/2024 at 9:22 a.m. with Patient 7, Patient 7 stated another patient hit him in the head last month. Patient 7 stated he does not know why he hit him, and that staff moved the patient that hit him away from him immediately after. During an interview on 7/23/2024 at 4:45 p.m. with the Director of Nursing (DON), the DON stated the incident involving Patient 7 being hit by another patient was not reported to the state survey agency, local law enforcement, or ombudsman. The DON stated it should have been reported to keep the patients safe. A review of the facility's policy and procedure (P&P) titled "Abuse Reporting – Dependent Adults," last reviewed 12/6/2023, indicated reportable events which do not result in serious bodily injury should be reported within 24 hours to CDPH, local law enforcement, and the ombudsman. The facility failed to report a patient-to-patient physical abuse to CDPH, local law enforcement, and ombudsman within 24 hours for Patient 7. This deficient practice resulted in unidentified abuse in the facility and failure to protect Patient 7 from abuse. The above violations had a direct relationship to the health, safety, or security of Patient 7.