Other·December 8, 2022

F 609 §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. §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. § 72527.Patients' Rights. 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. On 10/04/2022 at 10:30 a.m., the California Department of Public Health (DPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding an allegation of abuse to Patient 1. As a result of the investigation, DPH determined that the facility failed to report an allegation of abuse for Patient 1 within two hours after the allegation was made to the proper authorities including to DPH in accordance with State law and the facility’s policy and procedure (P&P). As a result of this failure, Patient1’s protection had the potential to be compromised or impeded. A review of Patient 1’s Admission Record indicated Patient 1 is a 91 year old female and was admitted to the facility on 7/26/2022, with diagnoses that included essential (primary) hypertension (high blood pressure), unspecified psychosis (a mental health problem that causes people to perceive or interpret things differently from those around them), dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and anxiety disorder (a mental health disorder characterized by persistent and excessive feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Patient 1’s Minimum Data Set (MDS, a patient assessment and care-screening tool) dated 7/30/2022, indicated Patient 1 was severely impaired for cognitive skills (ability to think and reason) for daily decision making. The MDS indicated Patient 1’s mood had symptoms of feeling down, depressed or hopeless, hallucinations (perceptual experience in the absence of real external sensory stimuli) and totally dependent requiring extensive assistance with activities of daily living. A review of Patient 1’s History and Physical dated 9/13/2022, indicated Patient 1 could make needs known but could not make medical decisions. A review of Patient 1’s Interdisciplinary Team Notes (IDT, a group of healthcare professionals with various areas of expertise who work together as a team, along with the patient toward the goals of the patient), dated 9/29/2022, timed at 3:31 p.m., indicated “Per patient: There was a male present standing in room, moved sheet and had touched her leg and made her feel a bit nervous, but that was it.” During an interview on 10/4/2022, at 10:30 a.m., the Director of Nursing (DON) stated, the facility's investigation of Patient 1's allegation of abuse was currently ongoing. During an interview on 10/4/2022, at 11:25 a.m., the DON stated, the facility reported the allegation of abuse made by Patient 1 and the Responsible Party (RP) to a police officer who came to the facility on 10/1/2022. During an interview on 10/4/2022, at 12:20 p.m., the RP stated, she wanted Patient 1 to be transferred out, “because of the assault,” that she found out from Patient 1 on 9/24/2022 at 7:30 p.m. The RP stated, Patient 1 told her, a large Latino man dressed in black, fat, wearing black framed glasses entered Patient 1’s room and stood at her left side of the bed and lifted the sheet and, “placed his hand into her leg, her inner thigh, touching or rubbing and going up higher into her diaper area, that she was assaulted.” The RP stated Patient 1 did not provide a date of the incident. The RP stated she tried to report the allegation to the Registered Nurse (RN) but the RN disregarded it and was more concerned about RP’s visitation overstay. The RP stated, she did not report the allegation, but her therapist reported it to DPH, the Ombudsman (the primary responsibility of the program is to investigate and endeavor to resolve complaints made by, or on behalf of, individual patient in long-term care facilities), and the police department. During a concurrent interview and record review on 10/4/2022, at 3:56 p.m., with the SSD, Patient 1’s IDT dated 9/29/2022, timed at 3:31 p.m. was reviewed. The SSD stated, Patient 1, “mentioned a male individual, tall, with glasses, with a mask on, that opened her sheet and put his hand on her thigh, nothing sexual was mentioned.” The SSD stated, during the IDT meeting, this was the first time that RP and Patient 1 mentioned about this incident and the facility reported it to DPH on 10/1/2022. During an interview on 10/4/2022, at 5:03 p.m., the DON stated, it was important to report allegation of abuse timely so that law enforcement can come, an investigation can happen immediately, and to remedy the situation right away for the safety of the patient. A review of Patient 1’s Progress Notes dated 10/1/2022, timed at 6:10 p.m., indicated, a police officer arrived at the facility to ask a few questions based on allegations made by the family that Patient 1 was sexually abused. The Progress Notes indicated, RN notified Patient 1's physician, RP, and the DON. A review of the facility’s facsimile confirmation receipt, indicated, facility reported the allegation of abuse concerning Patient 1 to DPH on 10/2/2022 at 9:40 p.m. A review of the facility’s P&P titled, “Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment,” revised 11/28/2017, indicated, in response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: 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 two (2) hours after the allegation was made if the events that cause the allegation involves abuse or results in serious bodily injury. As a result of the investigation, the DPH determined that the facility failed to report an allegation of abuse, for Patient 1 within two hours after the allegation was made to the proper authorities including to the DPH in accordance with State law and the facility’s policy and procedure. As a result of this failure, Patient1’s protection had the potential to be compromised or impeded. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety or security of Patient 1.