Health inspection·October 6, 2023

42 CFR 483.12 (c)(1)(4) (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. (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 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.  W&I 15630(b)(1) (b) (1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days. 22 CCR § 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. On 8/22/2023, the California Department of Public Health (CDPH) received an anonymous complaint alleging Resident 2 physically abused Resident 1. Resident 2 allegedly kicked at Resident 1’s feet and attempted to run a table into Resident 1’s head. On 8/23/2023, the CDPH conducted an unannounced complaint investigation at the facility to investigate the complaint allegation of abuse. The facility failed to implement their policy and procedure on abuse reporting and investigating by not reporting an allegation of physical abuse to CDPH and the Ombudsman (a state agency that investigates, reports on, and assist in settle complaints against facilities). As a result, this failure caused a delay in investigation of a physical abuse allegation, placing Resident 1 at risk for further abuse. Resident 1 was a 73-year-old male, admitted to the facility on 6/26/2023 with diagnoses including malignant neoplasm of brain (a cancer that spreads to other areas of the brain and spine) and cerebrovascular disease (a group of disorders of the heart and blood vessels) with hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body). A review of Resident 1’s Minimum Data Set [(MDS), a standardized assessment and care screening tool], dated 6/30/2023, indicated Resident 1’s cognitive (the ability to understand or to be understood by others) skills for daily decision making were moderately impaired. The MDS indicated, Resident 1 required extensive assistance with two-person physical assistance with bed mobility, eating and personal hygiene. Resident 2 was a 85-year-old male initially admitted to the facility on 11/15/2016 and readmitted on 6/12/2023 with diagnoses including dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), urinary tract infection [(UTI) an infection that in any part of the urinary system that includes kidneys, bladder, or urethra], and anxiety disorder (mental illness characterized by a persistent feelings of dread or worry). A review of Resident’s 2 Minimum Data Set MDS dated 6/15/2023, indicated Resident 2’s cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 2 required limited assistance from staff with one-person physical assistance with locomotion on unit, bed mobility, and transfer. A review of Resident 1’s Licensed Nurses Notes (LNN, dated 7/31/2023, the LNN indicated the Interdisciplinary Team [(IDT), team members from different disciplines who came together to discuss resident care] met to discuss Resident 1’s Family Member (FM 1) grievance regarding Resident 2 (Resident 1’s roommate) being physically aggressive. During an interview on 8/23/2023 at 1:40 p.m., the Social Service Director (SSD), the SSD stated the IDT had a meeting with Resident 1’s FM 1 on 7/27/2023 and discussed the grievance and concerns regarding Resident 2 being aggressive. The SSD stated based on the facility’s investigation, no physical aggression happened between Resident 1 and Resident 2, that was why the SSD did not report this incident to CDPH and Ombudsman. During an interview on 8/23/2023 at 2:15 p.m. the Director of Nurses (DON) stated “if an allegation was unwitnessed then it is reportable to the CDPH, Ombudsman and local enforcement agency.” The DON stated the timeframe for reporting was 2 hours. The DON stated, “it is important to report to CDPH any allegation of abuse so the department can conduct their own investigation.” During a concurrent interview and record review on 8/23/2023 at 3:15 p.m. with the DON, the facility’s policy, and procedure (P&P) titled, “Abuse, Neglect, Exploitation, or Misappropriations-reporting and investigating”, revised September 2022, was reviewed. The P&P indicated, the Administrator or the individual making the allegation immediately reports his or her suspicion to the following person or agencies: A). The state licensing/certification agency (CDPH) responsible for surveying/licensing the facility, B). The local/state Ombudsman… Immediately is defined as A) within two hours of an allegation involving abuse or result in serious bodily injury, or B) within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. During a concurrent interview, the DON stated this was the facility’s policy when it comes to abuse reporting allegation as required by State and Federal law. During an interview on 8/24/2023 at 11:35 a.m. the Administrator (ADM), stated he did investigate the allegation and there was no evidence that abuse occurred. The ADM stated he did not take the incident as an abuse allegation but instead it was more of a customer service issue and that was why he did not report the allegation to CDPH and Ombudsman. The ADM stated for any allegations of abuse such as physical, mental, verbal, or resident to resident altercation, being the abuse coordinator, he needs to report to CDPH immediately within two hours. A review of the facility’s P&P titled, “Resident-to-Resident Altercations,” revised September 2022, the P&P indicated, to investigate and report any allegations within timeframes required by federal requirements. The facility failed to implement their policy and procedure on abuse reporting and investigating by not reporting an allegation of physical abuse to CDPH and the Ombudsman. As a result, this failure caused a delay in investigation of a physical abuse allegation, placing Resident 1 at risk for further abuse. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.