Health inspection·May 4, 2022

F609 §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of Patient 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 The facility failed to report the findings of sexual abuse allegation investigation to the State Survey Agency within five working days per facility's abuse investigation and reporting policy and procedures for Patient 2. On 12/19/2019, Patient 1 was seated in a wheelchair when Patient 2 allegedly touched Patient 1's right breast, then walked away. This deficient practice resulted in a (3) three-day delay to provide the State survey Agency with abuse allegation investigation findings and had the potential to compromise the safety of patients in the facility. A review of Patient 1's Face Sheet (admission record) indicated the facility admitted Patient 1 on 11/26/19, with diagnoses that included difficulty in walking and muscle weakness. A review of Patient 1's Minimum Data Set (MDS- a patient assessment and care-screening tool), dated 12/3/19, indicated Patient 1 had severe cognitive (The ability to understand and make decisions of daily living) impairment. The MDS indicated Patient 1 was assessed requiring extensive staff assist for activities of daily living (ADL-walking in corridors, dressing, eating, toileting, and personal hygiene). The MDS indicated Patient 1 uses a walker or a wheelchair for mobility. A review of Patient 2's Face Sheet indicated the facility initially admitted Patient 2 on 4/25/18 and was readmitted on 8/31/18 with diagnoses included dementia (A group of symptoms affecting memory, thinking, and social abilities severe enough to interfere with daily life) with behavioral disturbance. A review of Patient 2's MDS, dated 12/3/19, indicated Patient 2 had severe cognitive impairment. The MDS indicated Patient 2 was independent in most ADL (Walking in room and corridors and eating). The MDS indicated Patient 2 required limited one-person staff assist for toilet use and for personal hygiene. The MDS indicated that Patient 1 uses a walker for mobility. A review of facility's SOC 341 form dated 12/19/2019, indicated the facility faxed the SOC 341 form to The California Department of Public Health (CDPH) reporting sexual abuse allegation that Patient 1 was seated in a wheelchair when Patient 2 touched Patient 1's right breast and then walked away. A review of the facility's letter to CDPH dated 12/27/2019, indicated that on 12/18/19 at around 8 PM, Patient 1 reported to Registered Nurse (RN) supervisor that Patient 1 was seated in her wheelchair in front of her room when a male Patient walking with a front wheel walker touched Patient 1's breast. The letter further indicated that upon investigation, Patient 2 was identified as the perpetrator (A person who carries out a harmful, illegal, or immoral act). The letter indicated the facility conducted a complete and thorough investigation of the incident and determined through interview and record review that the sexual abuse allegation occurred due to Patient 2's medical condition. The facility sent the letter to the State Survey Agency on 12/27/2019, more than nine (9) days the abuse allegation had occurred. During an interview with the administrator (ADM) on 1/6/2020 at 10:54 AM, the ADM stated that she immediately reported the abuse allegation to the State Survey Agency on 12/18/19 after the RN Supervisor informed reported the incident. The ADM stated that the facility conducted a thorough investigation of the allegation, however, failed to report the investigation results to the State Survey Agency within five (5) working days of the abuse allegation. A review of the facility's policy and procedures titled, "Abuse Investigation and Reporting," revised in July 2017, indicated that all reports of Patient abuse shall be promptly reported to local, state, and federal agencies. The administrator or his/her designee would provide the appropriate agencies a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. The facility failed to report the findings of sexual abuse allegation investigation to the State Survey Agency within five working days per facility's abuse investigation and reporting policy and procedures for Patient 2. On 12/19/2019, Patient 1 was seated in a wheelchair when Patient 2 allegedly touched Patient 1's right breast, then walked away. This deficient practice resulted in a (3) three-day delay to provide the State survey Agency with abuse allegation investigation findings and had the potential to compromise the safety of patients in the facility.