Other·January 26, 2024

§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. 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 12/11/2023 the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) was raped at the facility by someone she referred to as "mister" "my neighbor" on 12/10/2023 during the evening shift (3 p.m. - 11 p.m.). On 12/12/2023, at 10:45 a.m., CDPH conducted an unannounced visit to the facility to investigate the allegation of rape. Upon investigation, the CDPH determined the facility's Social Services Director (SSD) was made aware of Resident 1's allegation of rape on 12/11/2023 at 11:37 a.m., but did not report the allegation of rape to the CDPH until 12/12/2023 at 12:35 p.m. The facility failed to: 1. Ensure an allegation rape was reported to the CDPH, the State Long Term Care Ombudsman (an agency that provides support for residents of nursing homes, board and care homes and assisted living facilities) and the local police department within the regulated time frame of two hours. 2. Ensure staff followed the facility's policy and procedure (P/P), titled, "Abuse-Reporting and Investigations," that indicated the facility will report all allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies. As a result of these deficient practices, there was a delay in the CDPH's investigation and a potential for important information to be lost, the perpetrator to go missing and/or sexual abuse to continue. Findings: A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1, a 69-year-old female, was admitted to the facility on 10/24/2023 with diagnosis including Parkinsonism (a brain condition which causes slowed movements, rigidity [stiffness] and tremors), dementia (impaired ability to remember, think, or make decisions), schizophrenia (a mental health condition which causes hallucinations [when a person hears, sees, smells, tastes or feels things which appear to be real but only exist in the mind], delusions [a belief which is clearly false and which indicates an abnormality in the affected person's content of thought), and disorganized speech (speech that is filled with run-on sentences, jumbled or incoherent words, words or concepts that do not go together, or awkward phrasing). A review of Resident 1's History and Physical (H&P) dated 10/28/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 10/29/2023, indicated Resident 1's cognitive skills for daily decision-making were severely impaired. A review of Resident 1's Social Service Notes, dated 12/11/2023 and timed at 11:37 a.m., indicated Resident 1's Responsible Party (RP) reported that Resident 1 informed the staff at the dialysis center (a clinic where people with kidney issues receive care) that she (Resident 1) was raped on 12/10/2023 at the facility. During an interview on 12/12/2023 at 12:40 p.m., while at the facility, Resident 1's RP stated she reported (2/12/2023) the allegation of abuse to the SSD at the facility after she (the RP) was informed by staff at the dialysis center of Resident 1's report of abuse (12/12/2023) During an interview and concurrent record review on 12/12/2023 at 1:37 p.m., with the SSD, Resident 1's Social Service Notes dated 12/11/2023 and timed at 2:30 p.m., were reviewed. The Social Services Notes indicated Resident 1 reported she was raped by an African American male nurse on 12/6/2023. The SSD stated she did not report the allegation of abuse immediately to the Administrator (ADM) or the CDPH because Resident 1 did not sustain any bodily injury, so she wanted to further investigate the allegation. During an interview on 12/12/2023 at 2:11 p.m., the Director of Nursing (DON) stated all allegations of abuse should be reported immediately to the CDPH, the Ombudsman, and the local police department. During an interview on 12/12/2023 at 2:35 p.m., the ADM stated she was made aware of the allegation of abuse on 12/11/2023 but stated she made an honest mistake and overlooked reporting the allegation of abuse to the CDPH, the Ombudsman, or the police department and she should have reported the allegation of abuse on 12/11/2023 within two hours after being made aware of the allegation. A review of the facility's P/P titled, "Abuse-Reporting and Investigations," dated 8/18/2023, indicated the facility will report all allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies. The purpose of the policy is to protect the health, safety, and welfare of the facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source and suspicion of a crime are promptly reported and thoroughly investigated. The facility failed to ensure: 1. Ensure an allegation rape was reported to the CDPH, the State Long Term Care Ombudsman (an agency that provides support for residents of nursing homes, board and care homes and assisted living facilities) and the local police department within the regulated time frame of two hours. 2. Ensure staff followed the facility's policy and procedure (P/P), titled, "Abuse-Reporting and Investigations," that indicated the facility will report all allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies. As a result of these deficient practices, there was a delay in the CDPH's investigation and a potential for important information to be lost, the perpetrator to go missing and/or sexual abuse to continue. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.