Health inspection·September 26, 2024

42 CFR §483.12 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. §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §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. 22CCR§ 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. 22 CCR§ 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. 22 CCR § 72523 (a) 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 (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 On 8/12/2024 the California Department of Public Health (CDPH) received a complaint alleging the Assistant Director of Nursing (ADON) was verbally abusive to Resident 1 by stating he (Resident 1) would find peace, when he was six feet (ft. a unit of measurement of length) under (ground). On 8/13/2024, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation, CDPH determined the facility failed to implement their policy titled, “Abuse, neglect, exploitation or misappropriation – Reporting and investigation” by failing to ensure: 1. Resident 1’s Family Member (FM 2)’s allegation of verbal abuse toward Resident 1 was reported to CDPH, the State Long Term Care Ombudsman (an agency that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences), and the local police within the regulated time frame of two hours. 3. The licensed nurses immediately assessed Resident 1’s physical and psychosocial (effect of social interactions on behavior and feelings) status after the allegation of abuse was made and evaluated whether the alleged victim felt safe. 4. Immediately notify Resident 1’s physician. 5 There were measures taken to prevent the ADON from the contact with Resident 1 and other residents, after the allegation of verbal abuse was reported on 7/19/2024. 6. FM2’s allegation of verbal abuse by the ADON toward Resident 1 were investigated. 7. Provide the Five-Day investigation conclusion report to CDPH. These deficient practices resulted in CDPH inability to investigate FM 2’s allegation of the ADON verbal abuse in a timely manner and failure to protect Resident 1 and other residents from potential verbal abuse by ADON. These deficient practices also resulted in Resident 1 feeling sad and depressed after the alleged verbal abuse incident. A review of Resident 1’s Admission Record indicated Resident 1, a 58-year-old male, was originally admitted to the facility on 8/19/2022 with diagnoses including acute and chronic respiratory failure (a condition where there's not enough oxygen [element that supports life] or too much carbon dioxide [important part of air] in your body) and schizoaffective disorder (a mental health disorder affecting how resident interprets reality). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/29/2024, indicated Resident 1’s cognition was moderately impaired. A review of Resident 1’s History and physical (H&P), dated 6/5/2024, indicated Resident 1 was alert and oriented and had the capacity to make decisions. A review of Resident 1’s Resident Grievance/ Complaint Form, dated 7/19/2024, indicated FM 2 filed a report that the ADON responded to Resident 1’s request for peace in his room by replying, “You will find peace six feet under!” During an interview on 8/13/2024 at 11:42 a.m., Resident 1 stated on the day (unsure of date) of the incident the ADON said Resident 1 “If you want to find peace you will find it six feet underground.” Resident 1 stated he was shocked; the comment was bothersome and that was why FM 2 filed the complaint. Resident 1 stated it made him feel depressed and sad and he felt it was verbally abusive because “you don’t say those things to other people.” During an interview with Social Services Designee (SSD 1) on 8/13/2024 at 12:34 p.m., SSD 1 stated that she was present during the incident of alleged verbal abuse. SSD 1 stated Resident 1 verbalized "l want to have peace and quiet in my room," and the ADON then stated, "l don't think you want to be there because “ I (ADON) don't want to be there either and you know where that is?" Resident stated, "Where?" and the ADON then stated, "Has to be six feet below the ground and you don't want to be there, and l don't want to be there." SSD1 stated the ADON did not make the comment towards Resident 1. SSD 1 stated that it was a general statement that there is quiet once one is dead. During an interview and record review on 8/14/2024 at 10:26 a.m., of Resident 1’s medical record with Registered Nurse (RN 1), RN 1 found that there was no documentation indicating the licensed nurses assessed Resident 1’s psychosocial wellbeing after FM 2 reported an allegation that the ADON verbally abused Resident 1 on 7/19/2024. RN 1 stated that Resident 1’s medical record did not have a detailed report of the incident, Resident 1’s physical and psychosocial assessment after alleged abuse, notification of Resident 1’s physician, nursing progress notes of the alleged incident, updated care plans to address FM 2’s allegation of abuse, interdisciplinary team meeting notes addressing the abuse allegation, and 72-hour post incident psychosocial follow up. During an interview on 8/14/2024 at 1:43 p.m., the Director of Nursing (DON) stated “you will find peace when you are six feet under the ground”, was very inappropriate statement and Resident 1 was upset. The DON stated he coached and counseled the ADON on 7/22/2024, that it was not considered a good joke in a health care setting. The DON stated other cultures may use that term as a joke, but it was not appropriate phrase in a health care setting. The DON stated the ADON apologized to Resident 1. During an interview and record review on 8/14/2024 at 1:45 p.m., of Resident 1’s Resident Grievance/ Complaint Form, the DON stated for allegations of verbal abuse he (the DON) would implement the facility’s Abuse Policy, which included reporting the allegation of abuse to the CDPH, the police, and the ombudsman, and suspending the alleged abuser (if staff) spending investigation of the abuse allegation. The DON stated that upon conclusion of the investigation a Five-Day Report of abuse allegation investigation results should have been submitted to CDPH. The DON stated Resident 1 should have been assessed and Resident 1’s physician should have been notified. The DON stated an abuse allegation should have also triggered a psychosocial visit to Resident 1 by the Social Service for 72 hours, and a psychological (affecting the mind, related to the mental and emotional state of a person) evaluation by a mental health professional as needed. The DON stated Resident 1’s care plan should have also been updated. During an interview on 8/14/2024 at 3:06 p.m., the Administrator (ADMIN) stated that on 7/30/2024 he read everything on Resident 1’s Grievance form. The ADMIN stated he did not report this allegation of verbal abuse because he did not think it was an abuse. The ADMIN stated he now realized it should have been reported and investigated. The ADMIN stated all allegations of abuse were reportable. The ADMIN stated he did not submit a Five-Day investigation report to CDPH and Ombudsman. A review of the facility’s policy and procedure (P&P) titled, “Resident Rights” revised 2/2021, indicated the employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all the residents of the facility and that include the resident’s right to a dignified existence and to be treated with respect, kindness, and dignity and to be free of abuse. A review of the facility’s policy and procedure (P&P) titled, “Abuse, Neglect, and Exploitation or Misappropriation- Reporting and Investigating,” revised 9/2022, indicated: 1. The administrator or the individual making the allegation immediately within two hours reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. b. The local/state ombudsman. c. The resident's representative. d. Adult protective services (where state law provides jurisdiction in long-term care). e. Law enforcement officials. f. The resident' s attending physician; and g. The facility medical director. 2. Upon receiving any allegations of abuse, the administrator was responsible for determining what actions (if any) are needed for the protection of residents. 3. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. 4. The investigator notifies the ombudsman that an abuse investigation is being conducted. The ombudsman is invited to participate in the review process. If the ombudsman declines the invitation to participate in the investigation, that information is noted in the investigation record. 5. The ombudsman is notified of the results of the investigation as well as any corrective measures taken. 6.Within five business days of the incident, the administrator will provide a follow-up investigation report. 7. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. 8. The follow-up investigation report wil1 provide as much information as possible at the time of submission of the report. 9. The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. The facility failed to ensure: 1. Resident 1’s Family Member (FM 2) allegation of verbal abuse toward Resident 1 was reported to CDPH, the State Long Term Care Ombudsman (an agency that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences), and the local police within the regulated time frame of two hours. 3. The licensed nurses immediately assessed Resident 1’s physical and psychosocial (effect of social interactions on behavior and feelings) status after the allegation of abuse was made and evaluated whether the alleged victim felt safe. 4. Immediately notify Resident 1’s physician. 5 There were measures taken to prevent the ADON from the contact with Resident 1 and other residents, after the allegation of verbal abuse was reported on 7/19/2024. 6. FM2’s allegation of verbal abuse by the ADON toward Resident 1 were investigated. 7. Provide the Five-Day investigation conclusion report to CDPH. These deficient practices resulted in CDPH inability to investigate FM 2’s allegation of the ADON verbal abuse in a timely manner and failure to protect Resident 1 and other residents from potential verbal abuse by ADON. These deficient practices also resulted in Resident 1 feeling sad and depressed after the alleged verbal abuse incident. These violations had a direct or immediate relationship to the health, safety, or security of Resident 1.