Health inspection·November 6, 2024

F609 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual’s obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a Patient of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. §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 Patient 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. § 72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. On 10/2/20204, at 10:28 AM the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding patient abuse. The facility failed to report an allegation abuse to the California Department of Public Health (CDPH) Licensing and Certification, according to the facility’s policy and procedure by not promptly and thoroughly investigating an allegation of abuse by Patient 1. This failure resulted in the facility under reporting an allegation of abuse. A review of Patient 1 ' s Admission Record (AR), indicated the facility admitted 65 year old female patient on 11/14/2022, with a diagnosis of major depressive disorder (a persistent feeling of sadness and loss of Interest) and paraplegia (loss of muscle function that affects the legs). A review of Patient 1 ' s History and Physical Examination (HPE, a comprehensive physician ' s note regarding the assessment of the Patient's health status) dated 9/25/2024, indicated Patient 1 had the capacity to understand and make decisions. A review of Patient 1 ' s Minimum Data Set (MDS, a federally mandated assessment tool) dated 9/12/2024, indicated the Patient 1' s cognition (thought process) was intact. A review of Patient 1 ' s Situation, Background, Assessment, Recommendation (SBAR) Communication Form and Narrative Note dated 9/4/2024 at 10:52PM, indicated two police officers (PO) came to the facility and stated that Patient 1 reported that she was mistreated by certified nurse assistant (CNA) 1. The SBAR indicated the PO reported to the facility that CNA 1 pointed his fingers, like a gun to Patient 1, and that Patient 1 stated feeling threatened. The SBAR indicated PO spoke to Family Member (FM) 1 and the facility notified the Medical Director (MD) 1. There was no indication on the SBAR that the facility reported the incident to CDPH. A review of Patient 1's Investigation Summary (IS) dated 9/5/2024, indicated that Patient 1 called for transportation and went to the police department (PD) on 9/4/2024. The IS indicated that Patient 1 reported to the PD that she did not feel safe because Patient 1 alleged CNA 1 was carrying a gun in the facility. A review of Patient 1 ' s Interdisciplinary Team (IDT) Conference Record dated 9/6/2024, indicated that Patient 1 ' s FM 1 asked the facility if any report was made to the California Department of Public Health (CDPH) regarding Patient 1’s allegation to the PD regarding CNA1. The IDT record indicated that the Administrator (ADM) informed FM 1 that no report was made to CDPH because Patient 1 was alert and oriented and she had never complained of any staff or reported any unusual occurrence, or allegation of abuse. The IDT indicated ADM asked Patient 1 if she had experienced any issues while in the facility and the Record indicated Patient 1 felt mistreated by CNA 1. The record indicated that Patient 1 felt rushed by CNA1 during a bed transfer, and that juice spilled all over Patient 1. The IDT indicated Patient 1 made false allegations against CNA1, however, the Record did not indicate why Patient 1 made the false allegations. A review of Patient 1 ' s Psychology Intake Note (PIN) dated 9/6/2024, indicated Patient 1 was evaluated since Patient 1 reported to the police department regarding CNA 1 carrying a gun while in the facility. The PIN indicated Patient 1 was feeling down and was sad and felt lonely. During an interview on 10/2/2024 at 9:31AM with Patient 1, Patient 1 stated CNA 1 had mistreated her "by cursing at me and not giving me care." Patient 1 stated she had called the police and that the police "did nothing to punish" CNA 1. Patient 1 stated the mistreatment from CNA 1 began in February, but she did not want to report it in fear of retaliation, so Patient 1 waited until 9/4/24, when she spoke with the police. Patient 1 stated that the staff would gossip about her stating that she had feelings for CNA 1 and that she was jealous because CNA 1 gave more attention to other female patients and not enough to Patient 1. Patient 1 stated that CNA 1 had feelings for her since CNA 1 gave a valentine ' s day chocolate on Valentine ' s Day which indicated "I LUV YOU". Patient 1 stated that after she had called the police on CNA 1, the ADM changed her room and only allowed female CNAs to care for Patient 1. Patient 1 stated feeling discriminated against that only female CNA’s can care for Patient 1. During an interview on 10/2/2024 at 11:48AM with SSD, SSD stated that Patient 1 requested transportation on 9/4/2024 and went to the police station. SSD stated two PO came to the facility on 9/5/24 to investigate Patient 1' s allegation that CNA 1 had a gun in his possession while working at the facility. SSD stated an IDT was conducted on 9/5/2024 with FM 1. SSD stated that Patient 1 had withdrew the false allegation she made with the police regarding CNA 1 carrying a gun while at work. SSD stated since Patient 1' s allegation, the IDT' s intervention included for Patient 1 to be only taken care of by female CNA' s. SSD stated the incident of Patient 1 going to the police department and reporting CNA 1 was in possession of a gun, and then retracting her statement was not reported to California Department of Public Health. During an interview on 10/2/2024 at 12:09PM with the Director of Nurses (DON), DON stated that Patient 1 filed a report to the PD to punish CNA 1. The DON stated Patient 1 reporting the false allegation to the PD, and the PO coming to the facility was an unusual occurrence. The DON stated the facility had not reported the incident of unusual occurrence and allegation of abuse to CDPH. During a phone interview on 10/2/2024 at 3:36PM with FM 1, FM 1 stated Patient 1 had complained about CNA1 being rough. FM 1 stated that the facility should have reported the incident of Patient 1 making false allegations to the PD about CNA 1 to CDPH and that the facility should have "done a better job" on investigating the incident between Patient 1 and CNA 1. During a review of the facility's P&P titled "Abuse Investigation & Reporting" dated 4/22/2024, the P&P indicated all allegations of Patient abuse, neglect, exploitation, misappropriation of Patient property, mistreatment and/or injuries of unknown source ("Abuse") shall be promptly reported to the appropriate local, state and/or federal agencies (as defined by current regulations) and thoroughly investigated by Company management. Findings of abuse investigations will also be reported to local law enforcement and the Office of Ombudsman. The P&P indicated if an incident or suspected incident of Patient abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate Individual. The P&P indicated all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the company administrator. The facility failed to report an allegation abuse to the California Department of Public Health (CDPH) Licensing and Certification, according to the facility’s policy and procedure by not promptly and thoroughly investigating an allegation of abuse by Patient 1. This failure resulted in the facility under reporting allegations of abuse. The above violations cause or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patient 1.