Other·September 18, 2023

Freedom from Abuse, Neglect, and Exploitation §483.12(c) 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. 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. (b)A failure to comply with the requirements of this section shall be a class "B" violation. The California Department of Public Health (CDPH) received a Complaint on 8/2/23 indicating Resident 1's debit card had been used unlawfully by facility staff. On 8/3/23, the CDPH conducted an unannounced complaint investigation at the facility. The facility failed to: 1. Report an allegation of fiduciary abuse (unauthorized or improper use of monies) by facility staff within two hours to the State Agency (Licensing and Certification), Ombudsman (a person who investigates, reports on, and helps settle complaints) and law enforcement in accordance with State law and Federal Regulations, after Resident 1 reported the allegation to an outside agency. This resulted in the delay of the investigation of the misappropriation of funds and potentially increased the risk for Resident 1 and other residents in the facility to be affected. A review of Resident 1's Admission Record, indicated Resident 1 was 67-year-old admitted to the facility on 1/20/2021 with diagnoses including morbid obesity (condition that results from too much body fat stored in the body), heart failure (occurs when the heart muscle doesn't pump blood as well as it should), and acute bronchitis (occurs when the airways of the lungs swell and produce mucus in the lungs). A review of Resident 1's Minimum Data Set ([MDS], a comprehensive assessment and care planning tool), dated 4/27/2023, the MDS indicated Resident 1 could understand and be understood by others. The MDS also indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for activities of daily living (ADL's) including dressing, toilet use, and personal hygiene. During an interview on 8/3/2023 at 12:55 p.m., Resident 1 stated a facility Activities Coordinator (unnamed) had used his bank card to make unauthorized purchases and withdrawals from his account. Resident 1 also stated he had notified the facility's staff and the Administrator (ADM 2) was made aware of the incident on June 10, 2022. A review of ADM 2's "Narrative" statement, dated 8/4/2023, the statement indicated ADM 2 was informed of Resident 1's allegation of the facility staff's unauthorized use of Resident 1's bank card. During an interview on 8/15/2023 at 11:25 a.m., ADM 2 stated the allegation of misappropriation of Resident 1's funds was not reported to CDPH, Ombudsman and law enforcement agency. ADM 2 also stated failure to report an allegation of misappropriation of resident ' s property and funds could cause further abuse for the residents. A review of the facility's P&P titled, "Abuse Investigation and Reporting," dated 7/2017, the P&P indicated all alleged violation of abuse, neglect, exploitation, or mistreatment, would be reported immediately, but not later than two hours if the alleged violation involved abuse. The facility failed to: 1. Report an allegation of fiduciary abuse by facility staff within two hours to the SA, Ombudsman, and law enforcement in accordance with State law and Federal Regulations, after Resident 1 reported the allegation to an outside agency. Corrected This resulted in the delay of the investigation of the misappropriation of funds and potentially increased the risk for Resident 1 and other residents in the facility to be affected. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, security, or welfare of the residents.