Health inspection·November 26, 2024

REGULATORY VIOLATIONS: California Code of Regulations, Title 22, § 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. § 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. Code of Federal Regulations, Title 42 F607 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of patients and misappropriation of patient property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, On 10/30/2024 at 1 PM, an unannounced visit was made by the California Department of Public Health [CDPH] to the facility to investigate a facility reported incident regarding an incident of employee to patient abuse. During the investigation, CDPH determined that the facility failed to ensure that facility staff implement the facility’s policies and procedures on “Abuse, Neglect, Exploitation and Misappropriation Prevention Program” and “Abuse, Neglect, Exploitation and Misappropriation, Reporting and Investigating” during the provision of care and services for Patient 1. The facility failed to: 1. Identify and investigate all possible incidents of abuse when Patient 1 reported she did not want Certified Nursing Assistant (CNA)1 providing her pericare (the practice of washing the genital and anal areas of the body) on 10/27/2024. 2. Investigate and Report all alleged possible incidents of abuse immediately to the Administrator, state licensing agency within two hours, in accordance with the federal regulations. As a result, Patient 1 was assigned again to CNA 1 on 10/28/2024, a day after (10/27/2024) she had reported to RN 1, not wanting CNA 1 to care for Patient 1. A review of Patient 1’s Admission Record indicated a 73 year old, female patient, admitted to the facility on 9/10/2024, with diagnoses that included acute chronic respiratory failure, unspecified atrial fibrillation (an irregular heartbeat that begin in the hearts top chambers). A review of Patient 1’s History and Physical Assessment dated 09/11/2024, indicated Patient 1 does not have the capacity to understand and make decisions. A review of Patient 1’s Minimum Data Set (a federally mandated Patient assessment tool) dated 9/20/2024 indicated Patient 1 was severely impaired. The MDS indicated the Patient 1 is dependent (helper does all of the effort) on facility staff for oral hygiene, toileting, shower personal hygiene, The MDS indicated Patient 1 requires maximal assistance (helper does more than half the effort) for upper body dressing. A review of Patient 1’s care plan titled “Patient and /or responsible party have been made aware that the facility has stable system in place to identify not only abuse but also those practices and omission that lead to abuse, neglect and misappropriation of property,” initiated on 10/15/2024. The care plan goals indicated the facility would promptly identify and take appropriate measures to protect patients from abuse. The care plan included interventions such as staff would immediately separate all involved parties, conduct head to toe assessments of affected all involved parties, conduct head to toe assessment of affected Patient, document all findings and notify Physician accordingly. A review of Patient 1’s care plan for “Patient states that a male CNA spends too much time doing peri-care while providing incontinence brief change” initiated on 10/29/2024. The care plan goals indicated: facility will promptly identify and take appropriate measures to protect Patients from abuse. A review of a facility document titled “Daily staffing assignment” dated 10/27/1024, indicated CNA 1 was assigned to provide care to Patient 1. A review facility document titled “Daily staffing assignment” dated 10/28/2024 indicated CNA 1 was assigned to provide care to Patient 1, on 10/28/24 during the 3:00 PM – 110:00 PM shift. During an interview on 10/30/2024 at 1:55 PM with the Assistant Director of Nursing (ADON), the ADON stated he was notified on 10/28/204 around 5:00 PM to 5:30 PM by CNA 2 that Patient 1 verbalized she did not want CNA 1 being assigned to her. The ADON stated he went to interview Patient 1 with the Social Services Director. The ADON stated he asked Patient 1 if she had issues with any of the facility staff and Patient 1 responded she preferred female CNA’S and did not elaborate anything else. The ADON stated he changed Patient 1’s assignment and informed CNA 1 on 10/28/24 that he would no longer be assigned to Patient 1. During an interview on 10/30/2024 at 2:30 PM with Patient 1, Patient 1 stated she did not want CNA 1 providing peri care to her. Patient 1 stated the last time CNA 1 provided peri care to her, CNA 1 kept wiping her vaginal area over and over in the same spot making her feel uncomfortable. Patient 1 stated she told the staff she did not want CNA 1 providing care to her, but he was again assigned to her (10/28/2024) and that made her feel unsafe in the facility. Patient 1 stated she told another facility staff [RN 1] on a different date [10/27/24] but could not recall the date she did not want CNA 1 being her nurse. During an interview on 10/30/2024 at 3:20 PM with CNA 1, CNA 1 stated he was assigned to provide care to Patient 1 on 10/27/2024 and 10/28/2024. CNA 1 stated on 10/27/2024 he provided peri care to Patient 1, one time during his 8-hour shift during the beginning of the shift. CNA 1 stated when he attempted to provide peri care again to Patient 1 on 10/27/24, Patient 1 refused. CNA 1 stated towards the end of his shift on 10/27/24, he attempted for again to offer to provide peri care to Patient 1, who verbalized she did not want to be changed by him (CNA1). CNA 1 stated he left Patient 1’s room and informed RN 1. CNA 1 stated he did not enter Patient 1’s room anymore on 10/27/2024. CNA 1 stated when he arrived to work at the facility on 10/28/2024, he saw that he had been assigned to care for Patient 1 again. CNA 1 stated he went to Patient 1’s room and offered help to which Patient 1 refused stating she did not need anything. CNA 1 stated a few hours later into his shift on 10/28/24, he was approached by the ADON who informed him he would no longer be caring for Patient 1 that day. During an interview on 10/30/2024 at 4:45 PM with the Director of Staff Development (DSD), the DSD stated she was in charge of completing the staffing assignment for the facility. The DSD stated she was not aware when she completed the assignment for 10/29/2024, that Patient 1 had verbalized she did not want CNA 1 providing her care. The DSD stated if she would have been aware she would not have scheduled CNA 1 to care for Patient 1 again on 10/28/2024. During an interview on 10/30/2024 at 3:38 PM with RN1, RN 1 stated on 10/27/2024, CNA 1 approached her stating Patient 1 did not want CNA 1 providing care for her. RN 1 stated she interviewed Patient 1 who told her she did not feel comfortable with having male CNAs and preferred to having females provide her care. RN 1 stated she did not have any additional females at that time and asked Patient 1 if it was ok if CNA 2 who is also a male provide her care to which Patient 1 responded it is ok as she felt “comfortable with CNA 2.” RN 1 stated she did not inform to the DON, SSD or ADON or Administrator that Patient 1 had verbalized not wanting CNA1 providing her care. During an interview and concurrent record review on 10/30/2024 with Director of Nursing (DON)1, DON 1 stated there was no care plan initiated on 10/27/2024 or 10/28/2024 when Patient 1 first informed RN 1 not wanting CNA 1 or male CNAs providing her care. DON 1 stated when Patient 1 first informed RN 1 she did not want CNA 1, RN 1 should have reported and informed the DON or ADM as ADM is the abuse coordinator. A review of the facility’s P&P titled,” Abuse, Neglect, Exploitation and Misappropriation Prevention Program” 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment. Or misappropriation of patient property. 9. Investigate and report any allegations within timeframes by federal requirements. A review of the facility’s P&P titled Abuse, “Abuse, Neglect, Exploitation and Misappropriation -Reporting and Investigating” 1. If Patient abuse, neglect, exploitation, misappropriation of resident property or injury is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2.The administrator or the individual making the allegation immediately reports his or hers suspicion to the following agencies: the state licensing. The local/state ombudsman, the resident representative, law enforcement officials, the resident attending physician and the facility medical director, 3.“Immediately” is defied as a. within two hours of an allegation involving abuse or result in serious bodily injury; withing 24 hours of an allegation that does not involve abuse or result in serious bodily injury. As a result of the above violations, CDPH determined that the facility failed to ensure that facility staff implement the facility’s policies and procedures on “Abuse, Neglect, Exploitation and Misappropriation Prevention Program” and “Abuse, Neglect, Exploitation and Misappropriation, Reporting and Investigating” during the provision of care and services for Patient 1. The facility failed to: 3. Identify and investigate all possible incidents of abuse when Patient 1 reported she did not want Certified Nursing Assistant (CNA)1 providing her pericare (the practice of washing the genital and anal areas of the body) on 10/27/2024. 4. Investigate and Report all alleged possible incidents of abuse immediately to the Administrator, state licensing agency within two hours, in accordance with the federal regulations. This deficient practice resulted to Patient 1 being assigned again to CNA 1 on 10/28/2024, a day after (10/27/2024) she had reported to RN 1, not wanting CNA 1 to care for Patient 1. This violation had a direct or immediate relationship to the health, safety, or security of Patient 1.