Health inspection·October 25, 2024

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (c) Freedom from Abuse, Neglect, and Exploitation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. 22 CCR § 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. H&S § 1418.91 (a) A long-term health care facility shall report all incidents of alleged or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 10/1/2024, the California Department of Public Health (CDPH) received a Facility Reported Incident indicating Resident 2 was physically abused by a facility staff on 9/23/2024. On 10/3/2024 at 11:45 a.m., the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1. Implement its policy and procedure (P&P) titled, "Reporting Abuse," which indicated the facility must report all allegations of abuse to the Department of Health Services within two (2) hours. This violation delayed the investigation by the CDPH. Resident 2 was a 34 - year -old male, admitted to the facility on 7/17/2024, with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), nicotine dependence (compulsive craving to use a drug), and homelessness (unhoused or unsheltered). A review of Resident 2's Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 7/30/2024, indicated Resident 2 had the capacity to make self-understood and the ability to understand others. The MDS indicated Resident 2 was independent with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). A review of Resident 2's progress notes dated 9/23/2024 did not indicate Resident 2's alleged physical abuse was reported to the CDPH. A review of Resident 2's Final Investigation Report dated 9/23/2024. indicated on 9/23/2024, at approximately 3:40 p.m., Resident 2 reported to have been hit, kicked, and kneed by a staff (unidentified) when he had lost his temper. During an interview on 10/4/2024 at 9:20 a.m. with the Registered Nurse (RN), the RN stated, any reported abuse allegations should have been reported to the CDPH within 2 hours of knowing the abuse allegations. During an interview and concurrent record review on 10/4/2024 at 12:53 p.m. with the Director of Nursing (DON), the fax transmission report dated 9/23/2024 at 6:34 p.m. was reviewed. The DON stated based on the fax confirmation report sent by the facility on 9/23/24 at 6: 34 p.m., the report incomplete. The DON stated the abuse allegation was therefore not reported to CDPH. The DON stated any alleged abuse must be reported to the CDPH within 2 hours. A review of the facility's P&P titled "Reporting Abuse," dated 2023, indicated the facility must report all allegations of abuse to the Department of Health Services within 2 hours. A review of the All Facilities Letter ([AFL] a letter from the Center for Health Care Quality (CHCQ), Licensing and Certification (L&C) Program to health facilities that are licensed or certified by L&C with information that include changes in requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the health facility) 21-26, dated 7/26/2021, indicated a reminder to facilities regarding mandated reporting requirements of abuse, neglect, exploitation, and/or mistreatment of residents, particularly elders or dependent adults. The AFL indicated facilities must file a written or electronic report to the District Office (DO), within two hours. The facility failed to: 1. Implement its P&P titled, "Reporting Abuse," which indicated the facility must report all allegations of abuse to the Department of Health Services within 2 hours. This violation delayed the investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of Resident 2.