Health inspection·April 5, 2024

F609 Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 42 CFR §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. 42 CFR §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. Title 22 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. § HSC 1418.91 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. The California Department of Public Health (CDPH) received a facility reported incident on 2/28/2024 indicating a resident (Resident 1) alleged she was hit on the right arm by another resident (Resident 2). On 3/13/2024, an unannounced visit was conducted at the facility. The facility failed to: 1. Follow its policy and procedure (P&P) titled "Policy on Patient Abuse and Mistreatment," updated 10/2022 which indicated the facility shall report by notifying CDPH, LTC Ombudsman, and the local police department of such an incident within the required timeframes (i.e., 2/24 hours) via telephonic and/or the required SOC-341 form. As a result, it delayed the investigation by the CDPH and placed Resident 1 and other residents at risk of further abuse, and neglect. A review of Resident 1's Admission Record indicated Resident 1 was a 76-year-old female admitted to the facility on 8/10/2018 and re-admitted on 8/9/2021. Resident 1's admitting diagnoses included unspecified abnormalities of gait and mobility and generalized weakness. A review of Resident 1's History and Physical (H&P), dated 2/12/2024, indicated Resident 1 had 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 3/12/2024, indicated Resident 1 had no cognitive impairments (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 required a wheelchair and required supervision or touching assistance to walk distances of 10 to 150 feet. A review of Resident 1's medical record titled "IDT ([Interdisciplinary Team] group of different disciplines working together towards a common goal of a resident) Care Conference Meeting Revised", dated 2/28/2024, indicated Resident 1 had been hit on the arm by Resident 2 and this incident was witnessed by "activity staff". A review of Resident 2's Admission Record indicated Resident 2 was a 55-year-old female admitted to the facility on 1/25/2019, re-admitted on 2/24/2024. Resident 2's admitting diagnoses included hemiplegia (inability to move one side of the body) and hemiparesis (weakness to one side of the body) following a stroke (damage to the brain from interruption of its blood supply), paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly), and anxiety disorder (Intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 2's H&P, dated 2/26/24, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's MDS, dated 2/1/2024, indicated Resident 2 had mild cognitive impairments. The MDS indicated Resident 2 also had hallucinations (the perception of seeing, hearing, touching, tasting, or smelling something that wasn't actually there) and delusions (a false belief or judgment about external reality). The MDS further indicated Resident 2 exhibited verbal behavioral symptoms that were directed toward others, and other behavioral symptoms not directed at others (e.g., physical symptoms such as hitting or scratching self, pacing, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS indicated these behaviors occurred four to six days a week. A review of Resident 2's care plans, dated 2/24/2024, indicated Resident 2 had "risk for aggression with other residents" due to "paranoid delusion..." and "cursing or verbal aggressiveness". A review of Resident 2's medical record titled "IDT Care Conference Meeting Revised", dated 2/28/2024, indicated staff met with Resident 2 to discuss the resident-to-resident altercation that occurred between her and Resident 1. The record indicated Resident 2 stated she hit Resident 1's arm, and when asked why, Resident 2 stated because "[Resident 1] did this to me". The record further indicated that during the staff's interview of Resident 2 demonstrated aggression such as kicking and hitting the floor, stating "they did this to me". During an interview on 3/13/2024 at 11:30 AM, with the Director of Social Services (DSS), the DSS stated Resident 2 had not been physically aggressive with other residents before but had verbally expressed paranoia (an unrealistic distrust of others or a feeling of being persecuted). The DSS stated Resident 2 stated that she meant to hit Resident 1 and that it was not an accident. The DSS stated resident-to-resident altercations were considered an allegation of abuse and stated it needed to be reported within two hours. The DSS stated it was important to report within the two-hour timeframe because late reporting was important in decreasing the risk of harm to other facility residents. During an interview on 3/13/2024 at 12:02 PM, with the Activities Assistant (AA), the AA stated she was the staff member who witness the resident-to-resident altercation between Resident 1 and Resident 2. The AA stated the altercation occurred on 2/27/2024. The AA stated she was provided with the facility Administrator's (ADM) phone number to notify him because he was the abuse coordinator. The AA stated she did not call him because she "didn't want to bother him". The AA stated that allegations of abuse, including resident-to-resident altercations, were supposed to be reported as soon as possible and stated she did not report it to the necessary agencies. During a concurrent interview and record review, on 3/13/2024 at 12:16 PM, with the DSS, the document titled, "Report of Suspected Dependent Adult/Elder Abuse", 2/28/2024 was reviewed. The DSS stated the document indicated the altercation between Resident 1 and Resident 2 occurred on 2/27/2024 at 6:30 PM, and that she faxed the form on 2/28/2024. The DSS stated the altercation should have been reported on 2/27/24 by 8:30 PM. The DSS stated all staff were responsible for reporting and stated there should not have been a delay. During an interview on 3/13/2024 at 12:28 PM, with the Director of Nursing (DON), the DON stated resident-to-resident altercations were considered a type of abuse and stated that all allegations of abuse were supposed to be reported within two hours. The DON stated it was important to report within the required timeframe to have prompt intervention and investigation from outside agencies. The DON stated the purpose was to keep the facility staff and residents safe. The DON stated that all facility staff were mandated reporters, and the altercation should have been reported by 8:30 PM the day that it occurred. A review of the facility policy and procedure (P&P) titled, "Policy on Patient Abuse and Mistreatment", dated 10/2022, indicated "residents shall not be subjected to abuse by anyone, including but not limited to...other resident...". The P&P indicated "When an incident has been determined to have satisfied the definition of abuse or suspected abuse: Facility staff shall report the incident by notifying the CDPH of such an incident within the required timeframes (i.e., 2/24 hours)". The facility failed to: 1. Follow its P&P titled "Policy on Patient Abuse and Mistreatment," which indicated the facility shall report by notifying CDPH, LTC Ombudsman, and the local police department of such an incident within the required timeframes (i.e., 2/24 hours) via telephonic and/or the required SOC-341 form. As a result, it delayed the investigation by the CDPH and placed Resident 1 and other residents at risk of further abuse, and neglect. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.