Other·February 3, 2022

F609 §483.12(c) Reporting of alleged violations. In response to allegations of, 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)(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. § 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. The Department received a facility reported incident (FRI) on 10/29/2021 indicating a certified nursing assistant (CNA) witnessed a resident (Resident 2) touch another resident (Resident 1) under her shirt. On 11/8/2021, an unannounced investigation was conducted at the facility. The facility failed to implement their abuse prevention program policy and procedure by not reporting an incident of witnessed sexual abuse to the State Survey Agency (SA) within specific timeframes as required by federal requirements. As a result, this failure placed Resident 1 at risk for further abuse and feeling unprotected in the facility. During a review of Resident 1's Admission Record (face sheet), the face sheet indicated the resident, was a 93 year-old female, who was admitted to the facility on 9/27/19 with diagnoses that included type 2 diabetes (abnormal blood sugar), unspecified dementia (memory loss) without behavioral disturbance, transient cerebral ischemic attack (a brief episode during which parts of the brain do not receive enough blood), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), schizophrenia (a chronic and severe mental disorder that affects how the person thinks, feels, and behaves), major depressive disorder (a common but serious mood disorder causing severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working), and unspecified psychosis (mental disorder characterized by a disconnection from reality) not due to a substance or known psychological condition. During a review of Resident 1’s Minimum Data Set (MDS), a standardized assessment and care plan screening tool, dated 9/27/21, the MDS indicated Resident 1 had severe cognitive (ability to think and reason) impairment, and required extensive assistance from staff with bed mobility, transfer, toilet use, and personal hygiene. During a review of Resident 1's History and Physical (H/P) record dated 1/22/21, the H/P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 2's Admission Record (face sheet), the face sheet indicated the resident, was a 72 year-old male, who was admitted to the facility on 12/13/15 and was readmitted on 10/20/17. Resident 2’s diagnoses included Parkinson's disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), type 2 diabetes, hypertension (high blood pressure), hyperlipidemia (a condition that causes the levels of certain bad fats, or lipids, to be too high in the blood), anemia (a condition in which the blood doesn't have enough healthy red blood cells), and unspecified dementia without behavior disturbance. During a review of Resident 2's MDS dated 12/2/21, the MDS indicated the resident had severe cognitive impairment, and required limited assistance from staff with bed mobility and extensive assistance with transfer, toilet use, and personal hygiene. During a review of Resident 2's H/P dated 6/12/21, the H/P indicated the resident had a fluctuating capacity to understand and make decisions due to dementia. During an interview on 12/2/21 at 11:22 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated on 10/3/21, Certified Nursing Assistant 2 (CNA) 2 reported to him that CNA 1 witnessed Resident 2, place his hand underneath Resident 1's shirt. LVN 1 stated he notified Registered Nurse 1 (RN 1) right away and documented the incident in the facility’s computer charting system. LVN 1 stated RN 1 called the former Director of Nursing (FDON) and former Administrator (FADM). LVN 1 stated the facility's policy was to report abuse to the Administrator and the State Survey Agency (SA) immediately. During a telephone interview on 12/2/21 at 2:55 p.m. with CNA 2, CNA 2 stated CNA 1 told him she witnessed Resident 2 placing his hand underneath Resident 1's shirt and touched her breast. CNA 2 stated he reported the incident immediately to LVN 1 and RN 1. CNA 2 stated the process of reporting abuse was to follow the chain of command, reporting to the RN supervisor then the Administrator. CNA 2 stated abuse has to be reported to the SA and police within two (2) hours. CNA 2 stated RN 1 was going to inform FADM of the incident but was unsure whether RN 1 called the SA or police. CNA 2 stated he monitored Resident 2 with visual checks until the end of the shift to ensure the resident was not leaving his room. During a telephone interview on 11/10/21 at 9:40 a.m. with RN 1, RN 1 stated after LVN 1 informed him of the incident between Residents 1 and 2, he and LVN 1 moved Resident 2 to a room across the building and had two CNAs monitoring each resident. RN 1 stated he went to assess Resident 1 for any distress, but the resident did not remember the incident. RN 1 stated he went to Resident 2 to assess him, but the resident did not remember the incident. RN 1 stated he reported the incident to FADM and FDON and asked what forms to fill out. RN 1 stated he was instructed by the FADM and FDON to fill out an incident report and progress note and initiate 72-hour (H) monitoring. RN 1 stated, "The 72H monitoring is to check residents for any distress after the incident." RN 1 stated he completed one incident report for both residents. RN 1 stated FADM told him because the residents have dementia, the incident was not reportable to the SA, but to still take statements and place them in her office and to follow-up with her later. RN 1 stated he received abuse training upon hire. RN 1 stated abuse was to be reported to the abuse coordinator (FADM) within 2 hours. RN 1 stated the process, when abuse between residents, occur was, to separate the residents, monitor and assess their skin, vital signs, and monitor for emotional distress, and to notify the Director of Nursing and Administrator. Also, fill out the incident report and perform a 72-hour monitor charting in the computer charting system. During an interview on 11/8/21 at 3:10 p.m. with the Director of Staff Development (DSD), the DSD stated the facility's policy on timeframe for reporting abuse was immediately, within 2 hours to the SA, Administrator, Director of Nursing, Physician, family, Ombudsman (resident advocate in a long-term care facility) and the police. The DSD stated “anybody” was a mandated reporter and can file a SOC 341 (form to report suspected dependent adult / elder abuse required under Welfare and Institutions Code and adopted by the California Department of Social Services). The DSD stated the incident between Residents 1 and 2 was not reported within the 2 hours and could not explain why it was not reported timely. During an interview on 11/8/21 at 3:40 p.m. with the Social Services Director (SSD), the SSD stated after incidences of abuse, residents were to be monitored for 72 hours, after the incident for psychosocial and emotional distress to ensure resident feels safe and address questions or concerns. The SSD stated if residents are not having 72-hour psychosocial monitoring, their concerns would not be relayed. The SSD stated she monitored Resident 1 closely after the incident but forgot to document. During an interview and record review on 11/8/21 at 3:20 p.m. with the DON, the DON stated incidences of abuse are to be reported within 2 hours to the SA and everyone was a mandated reporter and can complete the SOC 341. The DON stated there was no monitoring done for Residents 1 and 2 because there was no documentation completed for both residents. The DON stated it was important to monitor residents after the incident to check for signs and symptoms of psychosocial and emotional distress and fear. During an interview on 12/2/21 at 10:22 a.m. with the DON, the DON stated any abuse, even if the residents have dementia was reportable to the SA within 2 hours. During a review of the facility's policy and procedure (P/P) titled, “Resident-to Resident Altercations," revised 12/2016, the P/P indicated the facility's staff will monitor residents for aggressive / inappropriate behavior towards other residents. If two residents are involved in an altercation, staff will report incidents, findings and corrective measures to appropriate agencies as outlined in the facility's abuse reporting policy. During a review of the facility's P/P titled, "Abuse Prevention Program," revised 12/2016, the P/P indicated the facility would investigate and report any allegations of abuse within timeframes as required by federal requirements. The facility failed to implement their abuse prevention program policy and procedure by not reporting an incident of witnessed sexual abuse to the State Survey Agency (SA) within specific timeframes as required by federal requirements. As a result, this failure placed Resident 1 at risk for further abuse and feeling unprotected in the facility. These violations had a direct relationship to the health, safety, or security of Resident 1.