Other·March 10, 2022

F609 §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. T22 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. The facility failed to implement its policies and procedures by not reporting to California Department of Public Health (CDPH) within two-hour time frame when Patient 1 verbalized she was allegedly abused by the facility’s staff. This failure had the potential for the patient to develop mental anguish (anxious feeling) during her stay at the facility and placing other patients at risk for being abused. A review of Patient 1’s Admission Record indicated Patient 1, a 79-year-old-female, was initially admitted to the facility on 4/24/21 with the diagnoses that included cerebral infarction (also known as cerebrovascular accident [CVA] or stroke, a damage to tissues in the brain due to a loss of oxygen to the area), abnormal posture and muscle weakness. A review of Patient 1's record titled "Psycho-social Assessment Form", dated 4/24/21, indicated Patient 1 was alert, awake and oriented to person and time. The Psycho-social Assessment Form also indicated, Patient 1 had the capacity to understand and make decision. A review of Patient 1's record titled "Comprehensive Resident Assessment", dated 4/25/21, indicated Patient 1 required one person assist on transfer and ambulation (resident ability to walk). A review of Patient 1's records titled "Initial History and Physical (H & P)", dated 5/4/21, indicated Patient 1 was assessed having the capacity to make decisions. A review of the facility’s facsimile (fax) transmittal confirmation sent to CDPH dated 4/29/21, indicated the report was sent to the department on 4/29/21 (5 days after Patient 1 made an allegation of abuse against CNA 1). A review of the facility’s form regarding Patient 1’s allegation of abuse by CNA 1 on 4/24/21 (night shift), the form indicated the report to the following agencies were faxed on 4/29/21 CDPH and Ombudsman, while the Police Department 1 (PD 1) was called on 4/29/21 at 11:10 AM. A review of the facility's final investigation report dated 5/4/21, indicated the facility started the investigation on 4/29/21 (5 days after the alleged incident) regarding Patient 1's alleged abuse against CNA 1 which happened on 4/24/21. The final investigation report indicated, CNA 1 mishandled Patient 1's care. A review of CNA 1’s undated and unsigned written statement, indicated Licensed Vocational Nurse 1 (LVN 1) was notified regarding what Patient 1 had allegation about CNA 1’s harassment, touching Patient 1 inappropriately and breaking Patient 1's hands and legs. During a telephone interview on 5/5/21 at 11:06 AM, CNA 1 stated while he was assisting Patient 1 to the bathroom on 4/24/21 (unable to recall exact time), Patient 1 had told him "I am going to report you, you touched me and broke my arms and legs". CNA 1 stated he reported Patient 1's allegation to LVN 1 right away. CNA 1 stated he had written down the incident in Patient 1’s ADL notes and had LVN 1 signed it. During an interview on 5/6/21 at 1:26 PM, LVN 1 stated he recalled CNA 1 told him about Patient 1’s abuse allegation against CNA 1 on 4/24/21. LVN 1 stated he could not recall documenting the alleged abuse incident in Patient 1’s nurses note because he was, “very busy” and he did not report it to the Director of Nursing (DON) or Administrator (ADM). A review of the facility's policies and procedures (P & P) titled "Abuse and Neglect Prohibition Policy" dated 4/18, indicated the investigation of incidents and allegations included: "Initiate an investigation within twenty-four (24) hours of an allegation of abuse that focuses on whether an abuse had occurred". The P & P's reporting of incidents, investigations and facility's response to the investigation included: "Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect or exploitation, the Administrator or designee will perform and send a written report within two (2) hours the Licensing and Certification Program District Office and the local Ombudsman's office". The facility failed to ensure a written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved, including but not limited to the facility failed to implement its policies and procedures by not immediately reporting to California Department of Public Health (CDPH) within two-hour time frame when Patient 1 verbalized she was allegedly abused by the facility’s staff. This failure had the potential for the patient to develop mental anguish (anxious feeling) during her stay at the facility placing other patients at risk for being abused. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient.