Other·December 6, 2023

42 CFR §483.12 Freedom from abuse, neglect, and exploitation. (a) The facility must— (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. (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. 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. 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. The California Department of Public Health (CDPH) received a complaint on 10/30/2023 regarding Resident 1’s allegations of physical abuse. On 10/30/2023 at 2 p.m., an unannounced visit was conducted at the facility to investigate the allegation of physical abuse. The facility failed to: 1. Follow its policy and procedure (P&P) titled “Abuse Investigation and Reporting” by not reporting an alleged abuse incident involving Resident 1, to the CDPH immediately but not later than 24 hours. As a result of not reporting, there was a delay in the investigation by the CDPH and placed Resident 1 and other residents at risk for continuous abuse. A review of Resident 1’s admission record indicated Resident 1, was a 66-year-old female resident, admitted to the facility on 8/14/2023 with diagnosis of pathological hip fracture (a break in the bone that is caused by an underlying disease), muscle weakness and paranoid schizophrenia (a mental disorder where a person feels distrustful and suspicious of others). A review of Resident 1’s Minimum Data Set (MDS-an assessment and care planning tool) dated 8/24/2023 indicated Resident 1 had clear speech, had the ability to express ideas and wants, and was able to understand others. The MDS indicated Resident 1 required extensive assistance (physical help for weight-bearing support or full performance of the activity) from staff with bed mobility (how a resident moves to and from a lying position, turns side to side, and positions body while in bed or in an alternative sleep furniture), dressing and personal hygiene. A review of the notes provided by the Director of Nursing (DON) from his personal note pad, dated 8/24/2023 indicated Resident 1 reported a Certified Nurse Assistant (CNA) threw a bed remote control and hit the left side of her face. The notes indicated Resident 1 stated she had issues with the CNA in the past, in which the CNA wanted to hit her with her hand, and she (Resident 1) stopped the CNA. The notes also indicated, “everything happened yesterday, 8/23/2023 at 11 to 12 p.m.” The notes indicated CNA 1 told the DON on 8/24/2023, during an interview that Resident 1 notified CNA 1 that her a nurse threw something at her, at an unknown time. A review of the Interdisciplinary Team Conference Note (group of healthcare professionals working together to provide residents with needed care), dated 8/24/2023, indicated the DON spoke with Resident 1’s family member (FM 1) about Resident 1’s fabricated stories of not getting care and of a remote control touching her face. The notes indicated when the DON asked Resident 1 how it occurred, Resident 1 pointed at the call light stating the call light landed on the left side of her cheek. During an interview the Director of Nursing (DON) on 10/30/2023 at 2:15 p.m., the DON stated there was no report of abuse made to the CDPH, Ombudsman, or local police because it was determined to be a customer care issue. The DON stated Resident 1 had concerns about staff providing assistance with activities of daily living ([ADLs], activities related to personal care). The DON stated the remote control, was a call light that swung up and hit Resident 1 on the shoulder. During an interview on 10/30/2023 at 2:30 p.m. Resident 1 stated a CNA used scalding (extremely) hot water to clean her up last week (date unknown). Resident 1 started crying, stating staff talked to her loudly and screamed at her. Resident 1 stated about 2 months ago a nurse threw a remote control on her left cheek and “almost put out her left eye.” Resident 1 stated the DON was made aware of both incidents. During an interview on 10/30/2023 at 4:45 p.m., the DON stated he was informed about the hot water and remoted control incidents. The DON stated Resident 1 had a history of making up stories. The DON also stated after investigating both allegations, they were determined, to be customer service issues, not abuse and therefore not reportable to CDPH. A review of Resident 1’s Change of Condition (COC) report, dated 10/27/2023 indicated Resident 1 had a moisture associated skin damage on 10/27/2023 at 2:20 p.m. A review of the facility’s P&P titled “Abuse Investigation and Reporting,” dated July 2017, indicated all reports of resident abuse, neglect, mistreatment and/or injuries of unknown source shall be promptly reported to the local, state, and federal agencies and thoroughly investigated by facility management. The P&P indicated, an alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately, but not later than two hours (2) if the alleged violation involved abuse or resulted in serious bodily injury; or twenty-four (24) hours if the alleged violation did not involve abuse and did not result in serious bodily injury. The facility failed to: 1. Follow its policy and procedure (P&P) titled “Abuse Investigation and Reporting” by not reporting an alleged abuse incident involving Resident 1, to the CDPH immediately but not later than 24 hours. As a result of not reporting, there was a delay in the investigation by the CDPH and placed Resident 1 and other residents at risk for continuous abuse. These violations had a direct or immediate relationship to the health, safety, security of Resident 1.