Health inspection·July 25, 2024

42 CFR §483.12 Freedom from abuse, neglect, and exploitation. (c) 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. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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. 22 CCR § 72315 Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 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. 22CCR §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. HSC 1418.91 (a) A long-term health care facility shall report all incident of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) Failure to comply with the requirements of this section shall be a class "B" violation. On 6/13/2024, the California Department of Public Health (CDPH) received a complaint indicating a resident to resident (Residents 2 and 3) allegation of physical abuse. On 6/15/2024 at 8:15 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, "Abuse, Neglect, and Exploitation" which indicated the facility should report allegations of abuse immediately, but no later than two hours. As a result, it delayed the investigation by the CDPH. 1). A review of Resident 2's Admission Record indicated Resident 2 was a 31-year-old female, admitted to the facility on 6/26/2023 with diagnoses of schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves). A review of Resident 2's Minimum Data Set (Minimum Data Set [MDS] a standardized assessment and care screening tool), dated 4/5/2024, indicated Resident 2 had moderate (not extreme, within proper limits) cognitive impairment (the ability to think and reason). The MDS indicated Resident 2 was independent with mobility. A review of Resident 2's History and Physical (H&P) dated 9/2/2023 indicated Resident 3 had the fluctuating capacity to understand and make decisions. A review of Resident 2's nurses notes dated 6/11/2024 at 7:30 p.m., indicated 7:10 p.m. on 6/11/2024, Resident 2 was sitting next to another female resident (Resident 3) at a Bible study in the Activity room and were observed by a staff (unidentified) slapping each other. The progress notes indicated a staff intervened and stopped both Residents 2 and 3 from slapping each other. 2). A review of Resident 3's Admission Record indicated Resident 3 was a 47-year-old female, admitted to the facility on 5/16/2024, with a diagnosis of encephalopathy (a brain disorder). A review of Resident 3's MDS dated 5/23/2024, indicated Resident 3 had moderate cognitive impairment. The MDS indicated Resident 3 was independent with mobility. A review of Resident 3's H&P (date not readable) indicated Resident 3 had the fluctuating capacity to understand and make decisions. A review of Resident 3's nurses notes did not indicate documentation about the 6/11/2024 7:10 p.m. incident. A review of the State of California Form 341 ([SOC 341] report of suspected dependent and elder abuse) dated 6/12/2024, faxed by the facility to CDPH on 6/12/2024 at 4:13 p.m., indicated on 6/11/2024 at 7:15 p.m., Residents 2 and 3 were observed exchanging unwanted physical contact. During an interview on 6/17/2024 at 11:59 a.m., with the Administrator (ADMIN), the ADMIN stated on 6/11/2024, Residents 2 and 3 were sitting next to each other in the activity room for a Bible study. The ADMIN stated both residents started arguing and taking swings (hitting) at each other. During a concurrent interview and record review on 6/17/2024 at 11:59 a.m., with the ADMIN, the SOC 341 form dated 6/12/2024 at 4:12 p.m. was reviewed. The ADMIN stated the SOC 341 form was the proof the facility informed CDPH regarding the alleged incident and was not reported to the CDPH within two hours after the incident occurred. The ADMIN stated the resident-to-resident physical abuse should have been reported to the CDPH within two hours. During an interview on 6/25/2024 at 10:07 a.m., with the Director of Nursing (DON), the DON stated a resident who slapped another resident was abuse. The DON stated abuse should be reported to CDPH immediately, within two hours to make sure there was no delay in investigation. A review of facility's undated P&P titled, "Abuse, Neglect and Exploitation," indicated, each resident had the right to be free from abuse. The P&P indicated the facility should report all alleged violations of abuse to the State Survey agency, immediately, but not later than 2 hours, after the allegation was made. The facility failed to: 1). Implement its policy and procedure (P&P) titled, "Abuse, Neglect, and Exploitation" which indicated the facility should report allegations of abuse immediately, but no later than two hours. As a result, it delayed the investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of the residents.