Other·February 21, 2024

F609 (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) §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. 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 1/2/2024 during annual recertification survey, the California Department of Public Health (CDPH) received a complaint from Resident 70 alleging verbal and mental abuse from Resident 9 including racial slurs (words or phrases that refer to members of racial and ethnic groups in a derogatory manner), calling him names (insult someone verbally) and being yelled at. Upon investigation, CDPH has determined the facility failed to report Resident 9 verbal and mental abuse to Resident 70. The facility failed to: 1. Ensure an allegation of verbal and mental abuse involving Resident 70 and Resident 9 was reported to CDPH, the State Long Term Care Ombudsman (an agency that provides support for residents of nursing homes, board and care homes and assisted living facilities) and the local police department within the regulated time frame of two hours. 2. Ensure staff followed the facility's policy and procedure (P&P) titled, "Abuse-Reporting and Investigations," to report the allegation of abuse to the appropriate agencies including CDPH, the State Long Term Care Ombudsman, and the local police department. As a result of these deficient practices Resident 70 was placed at risk for possible continuous abuse, for allegations of abuse to go unreported, delay in the CDPH's investigation and the potential for important information to be lost. A review of Resident 70's Face Sheet indicated Resident 70, a 56 year old male was admitted to the facility on 3/24/23, with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), epilepsy (sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), and neuropathy (nerve damage leads to pain, weakness, numbness or tingling in one or more parts of your body). A review of Resident 70's History and Physical (H&P), dated 6/9/23, indicated, Resident 70 had the capacity to understand and make decisions. A review of Resident 70's Minimum Data Set [(MDS), a standardized assessment and care screening tool), dated 10/5/23, indicated Resident 70 had impairment on both sides of the lower extremities. A review of Resident 9's Face Sheet indicated Resident 9, a 75-year-old male admitted to the facility on 3/24/23, with diagnoses including chronic obstructive pulmonary disease ([COPD] a progressive disease that makes it hard to breath) and hypertensive heart disease (problems with the heart that can develop if you have high blood pressure). A review of Resident 9's MDS dated 10/10/2023 indicated Resident 9 had moderate cognitive (ability to learn, understand, and make decisions) skills for daily decision making. During an interview on 1/2/24 at 11:22 a.m. with Resident 70 in the north hallway, Resident 70 stated for four months he had experienced Resident 9 (his roommate) calling him racial slurs. Resident 70 stated Resident 9 have called him a (f-----g Mexican) and continued to use derogatory (showing a critical or disrespectful attitude) words towards him. Resident 70 stated that he requested the License Vocational Nurse LVN 1 in December (a month ago) to have a room change. Resident 70 stated LVN 1 and a Certified Nursing Assistant (CNA 1) had witnessed Resident 9 calling him (Resident 70) names (insult someone verbally). Resident 70 stated the verbal abuse made him feel stressed out and raised his blood pressure. Resident 70 stated he felt afraid to stay in the facility. During an interview on 1/3/24 9:46 a.m. CNA 1 stated Resident 70 and Resident 9 were not getting along. CNA 1 stated he witnessed verbal altercation between Resident 70 and Resident 9 about four months ago. CNA 1 stated Resident 9 was verbally aggressive, using derogatory language towards Resident 70 and called him names. CNA 1 stated calling Resident 70 racial slurs and named was considered a verbal and mental abuse. CNA 1 stated Resident 70 could experience sadness and depression due to verbal abuse from Resident 9. CNA 1 stated he reported the verbal abuse to LVN 1 but does not know what happened after he reported it. During an interview on 1/4/24 at 9:47 a.m. LVN 1 stated Resident 70 asked her to be moved to another room a month ago because Resident 9 was yelling at Resident 70. LVN 1 stated Resident 70 stated Resident 9 was too noisy and yelling racial slurs to him. LVN 1 stated she never informed anyone of Resident 70's request and she failed to report it to the Administrator. LVN 1 stated racial slurs would be considered a verbal abuse and should be reported immediately. LVN 1 stated Resident 70 could feel bad and upset from being called racial slurs. During an interview on 1/4/24 at 11:19 a.m. the Administrator (ADM) stated she was not aware of verbal abuse allegation involving Resident 70. The ADM stated abuse should be reported immediately to her. The ADM stated any allegations of abuse should be reported immediately to CDPH, Ombudsman and local Police Department. The ADM stated she was responsible for ensuring the safety and quality of care for the residents (in general) in the facility. A review of facility's P&P, titled "Abuse, Neglect and Exploitation" revised 2020, the P&P indicated the facility will consider factors indicating possible abuse including but not limited to verbal abuse of a resident overheard and anyone in the facility can report suspected abuse. The P&P indicated alleged violations involving abuse are reported immediately but not later than two hours, or not later than 24 hours if the advents that cause the allegations do not involve abuse and do not result in serious bodily injury to the administrator, and to other official including State Survey Agency and Adult Protected Services. The facility failed to: 1. Ensure an allegation of verbal and mental abuse involving Resident 70 and Resident 9 was reported to CDPH, the State Long Term Care Ombudsman and the local police department within the regulated time frame of two hours. 2. Ensure staff followed the facility's P&P titled, "Abuse-Reporting and Investigations," to report the allegation of abuse to the appropriate agencies including CDPH, the State Long Term Care Ombudsman, and the local police department. As a result of these deficient practices Resident 70 was placed at risk for possible continuous abuse, for allegations of abuse to go unreported, delay in the CDPH's investigation and the potential for important information to be lost. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.