Other·May 5, 2023

F609 §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. T22 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 3/21/23 at 3PM, the State Survey Agency (SSA or the Department) made an unannounced visit to the facility to investigate a facility reported incident regarding an allegation of patient-to-patient abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish). The facility failed to notify SSA and local law enforcement within 2 hours of an allegation of abuse for Patients 1 and 2. This deficient practice resulted in a delay of investigation and had the potential to subject Patient 1 to further abuse and/or cause a decline in the patient's mental or emotional well-being. A review of Patient 1's Admission record indicated Patient 1 was admitted on 12/19/16 with a diagnoses that included congestive heart failure (CHF, a condition in which the heart does not pump blood as well as it should) and morbid obesity (excessive amount of body fat). A review of Patient 1's Minimum Data Set (MDS, a standardized care assessment and care screening tool), dated 10/14/22, the MDS indicated Patient 1’s cognitive skills (thought process) was intact. Patient 1 could understand and be understood by others. The MDS indicated Patient 1 required total dependence on staff for bed mobility, transfer, dressing, eating, personal hygiene and toileting. A review of Patient 1 's change in condition (COC), dated 3/13/23, timed at 1:31 PM, indicated on 3/13/23 between 10AM to 11AM, Patient 1 was in psychological distress because Patient 2 was socially inappropriate and had inappropriate verbal behavior towards Patient 1. A review of Patient 1’s Nurses Progress Notes, dated 3/13/23, timed at 1:56 PM, the NPN indicated facility called the local law enforcement at 1:56 PM (three hours from the verbal abuse incident) to report verbal altercation between Patient 1 and Patient 2. A review of Patient 2’s Admission Record indicated Patient 2 was initially admitted on 8/15/18 and re-admitted on 9/01/20 with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), major depressive disorder (a mood disorder causing severe symptoms that may affect daily activities, such as sleeping and eating) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). A review of Patient 2’s MDS, dated 8/19/22, indicated Patient 2's cognitive skills was intact. Patient 2 could understand and be understood by others. The MDS indicated Patient 2 required one physical help with bed mobility, transfer, dressing, toilet use, and personal hygiene. A review of Patient 2’s COC noted, dated 3/13/23, timed at 11:39 AM, indicated Patient 2 had a behavioral change as described by episode of inappropriate verbal behavior towards Patient 1 while in the activity room on 3/13/23 between 10AM to 11AM. The COC notes indicated Registered Nurse 3 (RN3) went to the activity room and witnessed Patient 2 exhibiting socially inappropriate verbal behavior towards Patient 1. A review of Patient 2’s Social Service Notes (SSN), dated 3/13/23, timed at 7:32 PM, indicated Social Service Director (SSD) was notified by Activity Director (AD) about the incident between Patient 1 and Patient 2 on 3/13/23 at around past 10:00 AM. During an interview on 3/22/23 at 11:00 AM, the Administrator (ADM) stated he received the verbal report from SSD on 3/13/23 after 10 AM (unable to remember exact time) about the patient-to-patient altercation between Patient 1 and Patient 2 on 3/13/23. The ADM stated the incident should have been reported within two hours to California Department of Health (CDPH), Ombudsman (advocated for patients in the nursing home) and local police department, but he did not report on time. The ADM verified that he reported the incident by fax to CDPH on 3/13/23 at 4:05 PM (five hours after allegation of abuse) and to Ombudsman on 3/13/23 at 5:25 PM (6 hours after allegation of abuse). The ADM stated he did not call the SSA, Ombudsman, and local police department to report the allegation of abuse between Patient 1 and Patient 2 because the ADM did not know there was a 2-hour time frame to report verbal abuse. During an interview on 3/22/23 at 12 PM, Patient 2 stated she did not want to talk about the incident that happened with Patient 1. During an interview on 3/22/23 at 12:27 PM with Patient 1 in the dining area, Patient 1 stated she did not want to talk about the past incident (verbal abuse) with Patient 2. During an interview with SSD 3/24/23 at 11:27 AM, SSD stated Activity Director (AD) reported on 3/13/23 that Patient 2 called Patient 1 “Fat ass” and stated, “I will kill you.” SSD stated AD could not remember the exact time of the incident but it happened between 10:00 AM to 11:00 AM. During a review of the facility's abuse in-service, preventing, reporting violations from 1/26/23 to 3/23/21, the Abuse in- service sign in sheet indicated SSD and ADM did not attend or complete the training on 1/26/23, 3/13/23 and 3/23/23. During a review of the facility's policies and procedures (P&P) titled "Abuse prohibition and procedure" dated 2/23/21, the P&P indicated "Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the designee will perform the following, that includes: -Report allegations involving abuse (physical, verbal, sexual, menta) not later than two hours after the allegation is made." Notify local law enforcement, Ombudsman, Licensing District Office, Licensing Boards, Registries and other agencies as required. The facility failed to notify SSA and local law enforcement within 2 hours of an allegation of abuse for Patients 1 and 2. This deficient practice resulted in a delay of investigation and had the potential to subject Patient 1 to further abuse and/or cause a decline in the patient's mental or emotional well-being. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.