Health inspection·December 14, 2023

§ 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. F607 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of patients and misappropriation of patient property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under §483.75. §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. On 10/24/2023 at 9:13 AM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint and facility reported incident regarding employee to patient abuse. The facility failed to implement the facility’s policy on “Reporting Alleged Violations of Abuse, Neglect, Exploitation Policy and Procedure” during the provision of care and services for Patient 1, when the facility received an allegation of abuse from the Board of Vocational Nursing and Psychiatric Technicians (BVNPT) on 10/20/2023. The facility failed to: 1. Support an environment in which staff and others freely and without hesitation report situations which may be or are consistent with abuse, neglect, mistreatment, exploitation, or misappropriation of resident property. 2. Conduct a prompt, thorough and complete investigation in response to received report of alleged abuse towards a resident (unknown) during medication administration by Licensed Vocational Nurse (LVN) 1. 3. Depending on the nature of allegation, immediately put effective measures in place to ensure that further potential abuse, neglect, mistreatment. Exploitation or misappropriation of patient property does not occur while the investigation is in process by failing to initiate investigation of alleged abuse report received from the BVNPT. The facility suspended LVN 1 on 10/24/2023 and started the investigation of the abuse allegation, 4 days after the abuse allegation from BVNPT was received (10/20/2023) by the facility. These failures had the potential to result in serious harm, or injury to patients who were cared for by LVN 1. A review of an email received by the California Department of Public Health (CDPH) from the BVNPT on 10/20/2023, indicated the BVNPT was cross reporting the complaint to CDPH. The report indicated a complaint involving LVN 1 working at the facility. The report indicated allegations that on 10/08/2023, LVN 1 was involved in an incident that left a patient traumatized and had “a reputation for verbally abusing the Certified Nursing Assistants (CNA) who work alongside her…” A review of the facility’s census on 10/24/23 at 9 AM indicated there were 151 patients currently residing in the facility. A review of an email provided by the facility and was received from the BVNPT addressed to the facility dated 10/20/2023, timed at 12:02 PM, indicated the subject line “BVNPT Case# …." And “The BVNPT is in receipt of a complaint we received on 10/09/2023, alleging that LVN 1 physically choked the patient during the medication administration process. We will need to discuss this matter, I will need LVN 1’s full name and a copy of the internal investigation.” During an interview on 10/24/2023 at 9:40 AM with the facility Administrator (ADM), the ADM stated she received an email from BVNPT on 10/20/2023, with allegations of abuse towards LVN 1 to an unnamed patient. The ADM stated she did not report to CDPH or begin an abuse investigation because she had attempted to contact BVNPT to ask the name or identity of the unnamed patient who was allegedly abused by LVN 1. The ADM stated she had not received a response from BVNPT. During another interview with the ADM on 10/24/2023 at 11:38 AM, the ADM stated she was the facility’s abuse coordinator and according to the facility policy, she should have immediately suspended LVN 1, reported the abuse allegation to the appropriate agencies, and began investigation on 10/20/2023, upon receipt of the abuse allegation. The ADM stated she forgot to start the abuse investigation immediately. The ADM stated she would start the investigation and abuse investigation immediately by interviewing and suspending LVN 1 that day at 10/24/2023. During an observation and interview on 10/24/2023, at 11:50 AM, LVN 1 was observed in the facility and assigned to work during the 7 AM to 3 PM shift that day. LVN 1 stated she was assigned to Station Rooms 21 to 220 for the day. A review of the facility’s policy and procedure titled “Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment” dated 11, 2017 indicated “In response to allegation of abuse, neglect, exploitation, or mistreatment, the facility will :Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation or resident property are reported immediately but no later than two (2) hours after the allegation is made if the event that cause the allegation involves abuse..the policy further indicated all alleged violations of abuse are reported to :the administrator, the state survey agency, adult protective services. 6 Guidelines for facility compliance: In order to comply with the Facility’s obligations as set forth it will E. Conduct a prompt, thorough and complete investigation in response to reportable allegations of abuse, neglect, mistreatment, exploitation, or misappropriation of resident property. Depending on the nature of the allegation, immediately put effective measures in place to ensure that further potential abuse, neglect, mistreatment, exploitation, or misappropriation of resident property does not occur while the investigation is in process. H. Take corrective action as appropriate given results of the investigation. In violation of the above cited standards, the facility failed to implement the facility’s policy on “Reporting Alleged Violations of Abuse, Neglect, Exploitation Policy and Procedure” during the provision of care and services for Patient 1, when the facility received an allegation of abuse from the Board of Vocational Nursing and Psychiatric Technicians (BVNPT) on 10/20/2023. The facility failed to: 1. Support an environment in which staff and others freely and without hesitation report situations which may be or are consistent with abuse, neglect, mistreatment, exploitation, or misappropriation of resident property. 2. Conduct a prompt, thorough and complete investigation in response to received report of alleged abuse towards a resident (unknown) during medication administration by Licensed Vocational Nurse (LVN) 1. 3. Depending on the nature of allegation, immediately put effective measures in place to ensure that further potential abuse, neglect, mistreatment. Exploitation or misappropriation of patient property does not occur while the investigation is in process by failing to initiate investigation of alleged abuse report received from the BVNPT. The facility suspended LVN 1 on 10/24/2023 and started the investigation of the abuse allegation, 4 days after the abuse allegation from BVNPT was received (10/20/2023) by the facility. These failures had the potential to result in serious harm, or injury to patients who were cared for by LVN 1. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.