Health inspection·December 12, 2023

22 CFR § 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. § 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. Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 42 CFR §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. 42 CFR §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. The California Department of Public Health (CDPH) received a facility reported incident (FRI) on 11/1/2023 regarding a resident-to-resident physical altercation. The FRI alleges a resident (Resident 1) was found by a staff member standing next to his roommate’s (Resident 2) bed. Resident 2 had a minor bruise on his face and verbalized someone was trying to hurt him. On 11/7/2023, CDPH conducted an unannounced investigation at the facility to investigate the allegation. The facility failed to: Follow its policy and procedure(P&P) titled, “Abuse Reporting & Investigations,” which indicated the facility will send a written SOC 341 (abuse reporting document) to the appropriate government agencies within 2 hours of a suspected abuse incident. As a result, there was a potential to delay the investigation of the abuse allegation by the CDPH and a potential to place Resident 2 and other residents at risk for abuse. A review of Resident 2’s Admission Record, dated 10/31/2022, the Admission Record indicated Resident 2, was an 80-year-old male, who was admitted to the facility on 11/3/2023. Resident 2’s diagnoses included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). A review of Resident 2’s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/29/2023, the MDS indicated Resident 2 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 2 required extensive assistance (resident involved in activity; staff provide weight-bearing support) for eating, toilet use, personal hygiene, and total dependence (full staff performance every time) for dressing. A review of Resident 2’s History and Physical (H&P), dated 10/7/2023, indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 1’s Admission Record, dated 10/31/2023, indicated Resident 1, was an 80-year-old male admitted to the facility on 6/8/2023. Resident 1’s diagnoses included dementia. A review of Resident 1’s minimum data set (MDS-a standardize care screening and assessment tool), dated 9/15/2023, the MDS indicated Resident 1 was severely cognitively impaired. The MDS indicated Resident 1 required extensive assistance for dressing, eating, toileting, and personal hygiene. A review of Resident 1’s H&P, dated 6/9/2023, the H&P indicated Resident 1 could make his needs known but could not make medical decisions. A review of the facility's e-mail to the state agency, dated 11/1/2023, timed 10:07 a.m., indicated the facility reported the abuse allegation to the state agency 3 hours and 15 minutes after the incident (the incident occurred at 6:52 a.m.) between Resident 1 and Resident 2. During an observation on 11/7/2023, at 10:25 a.m., Resident 1 was observed in bed with a 4x4 centimeter ([cm] unit of measurement) bruise on his upper left cheek, and a small thin 0.5x2 cm bandage below his eye. During an interview on 11/7/2023, at 11:20 a.m., a Registered Nurse (RN) 1, stated any resident abuse had to be reported to the state agency within 2 hours. During an interview on 11/7/2023, at 12:00 p.m., the Director of Nursing (DON), stated the incident between Resident 1 and Resident 2 occurred on 11/1/2023 6:52 a.m. during the 11:00 p.m. to 7:00 a.m. shift. The DON stated a Certified Nursing Assistant (CNA) 1 witnessed Resident 1 hovering over Resident 2’s bed, with the bed’s remote control. The DON stated RN 2 who was in charge on 11/1/2023 during the 11:00 p.m. to 7:00 a.m. shift called him (the DON) to report the abuse incident between Resident 1 and 2. The DON stated he did not know what time the facility’s Administrator reported the abuse incident to the state agency, but knew it had to be reported within 2 hours. During an interview on 11/7/2023, at 12:56 p.m., the Assistant Administrator (AADMIN), stated sometime during the previous week (11/1/2023) at 7 a.m., he received a phone call from the DON about the incident between Resident 1 and 2. The AADMIN stated he notified the Administrator (ADMIN). The AADMIN stated he was assigned to report the abuse incident to the state agency on 11/1/2023, but due to technical difficulties with the facility's fax machine, the e-mail report to state agency was sent around 10:00 a.m. The AADMIN stated any suspected resident abuse should be reported within 2 hours to the state agency. The AADMIN also stated he did not have any fax receipts of when the initial fax report was sent because the fax machine did not produce any. A record review of the facility’s P&P titled, “Abuse Reporting & Investigations”, dated 3/2018, indicated the Administrator or designated representative will send a written SOC 341 to the appropriate government agencies within 2 hours of suspected abuse incident. The facility failed to: Follow its P&P titled, “Abuse Reporting & Investigations,” which indicated the facility will send a written SOC 341 to the appropriate government agencies within 2 hours of a suspected abuse incident. As a result, there was a potential to delay the investigation of the abuse allegation by the CDPH and a potential to place Resident 2 and other residents at risk for abuse. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents