Health inspection·April 17, 2024

§483.12(c) Reporting of Alleged Violations. 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. 22CCR §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. HSC 1418.91 (a) Abuse Reporting (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 3/20/24 at 4:20 p.m., the California Department of Public Health (CDPH) received a facility reported incident (FRI) indicating Resident 12 was physically abused by a Certified Nursing Assistant (CNA 10). On 3/21/2024, the CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Report an allegation of physical abuse for Resident 12 to the CDPH on 3/2/2024. This violation delayed the investigation by the State Agency and placed Resident 12 and other residents at risk for continuous abuse. A review of Resident 12’s Admission Record (face sheet) indicated the resident was a 61-year-old male, admitted to the facility on 5/23/2023 and readmitted on 3/19/2024. Resident 12’s diagnoses included metabolic encephalopathy (a chemical imbalance in the brain caused by an illness or organs), epilepsy (a brain disorder characterized by recurrent brief episodes of involuntary movement that may involve a part of or the entire body) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident’s 12’s Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 1/29/2024, indicated Resident 12 was cognitively impaired with daily decision making. Resident 12 required supervision with toileting, bathing, and lower body dressing. During an interview on 3/21/24 at 8:45 a.m., with Registered Nurse 1 (RN 1), RN 1 stated (CNA 9) reported the incident regarding CNA 10 and Resident 12 to the DON on 3/20/24, (18 days) after then incident occurred. . RN 1 stated the protocol for any staff to resident abuse was to report it immediately when the incident occurred. RN 1 stated the risk of not reporting abuse could result in a potential for further abuse, a resident could be intimidated or scared of staff, or a resident could isolate or hurt him/herself. During a phone interview on 3/21/24 at 9:37 AM with CNA 9, CNA 9 stated the incident happened 2 or 3 weeks ago. CNA 9 stated he observed Resident 12 verbally abuse staff and punching his tablet in the hallway. CNA 9 stated Resident 12 walked towards CNA 10, in the hallway and CNA10 stood up from his chair and pushed Resident 12. CNA 9 stated CNA 10 then went behind Resident 12, pushed the resident to the floor, put his knee on Resident 12’s back while holding Resident 12 on the floor. CNA 9 stated “what is there to report if all of the staff members who were there saw what happened?” During an interview on 3/21/24 at 11:30 a.m., with the Director of Nursing (DON), the DON stated the facility’s protocol for any abuse allegation was to be reported to the law enforcement, ombudsman and CDPH, within two hours. The DON stated “Sometimes reporting can be delayed due to waiting for law enforcement to arrive so we wait. Sometimes, the 2 hours can go by fast.” During an interview on 3/21/24 at 11:30 AM with the Administrator (Admin), Admin stated she is the abuse coordinator of the facility, and all abuse is to be reported immediately or at least within 2 hours. Admin stated the risk of not reporting in a timely manner could result in “the safety of other residents, could continue to happen, and we wouldn’t be stopping it.” A review of the facility’s policy and procedures, titled “Abuse-Reporting and Investigations”, revised on 12/21/2023 and effective as of 1/4/2024, indicated, “The Administrator or designated representative will notify law enforcement by telephone immediately or as soon as practicably possible but no longer than two (2) hours.” The facility failed to: 1. Report an allegation of physical abuse for Resident 12 to the CDPH on 3/2/2024. This violation delayed the investigation by the State Agency and placed Resident 12 and other residents at risk for continuous abuse. This violation, jointly, separately, or in any combination, presented a direct or immediate relationship to the health, safety, security, or welfare of Resident 12.