Health inspection·September 12, 2024

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. An unannounced visit was conducted by California Department of Public Health on 8/5/2024 at 10 AM to investigate a complaint regarding patient- to- patient altercation. The facility failed to report the patient- to- patient altercation to the State Survey Agency (SSA), the state ombudsman (advocates for patients of nursing homes, board and care homes and assisted living facilities), and local law enforcement (Local PD) within two (2) hours in accordance with the facility’s policy and procedure after the allegation of physical abuse (intentional bodily injury to a person, for example slapping, pinching, choking, kicking, shoving) for Patient 1. This deficient practice had the potential to place Patient 1 for further abuse and placed other patients at risk for elder abuse. A review of Patient 1's Admission Record indicated the patient is a 86- years-old- female patient who was originally admitted to the facility on 2/28/2022 and readmitted on 5/09/2024, with diagnoses that included but not limited to bilateral primary osteoarthritis of knee (a degenerative joint disease that affects both knees, causing pain, stiffness, swelling, and decreased mobility), hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 1’s History and Physical (H&P) dated 5/09/2024 indicated Patient 1 has the capacity to understand and make decisions. A review of the Patient 1's Minimum data Set (MDS-an assessment and care screening tool) dated 5/16/2024, indicated Patient 1's was assessed to require substantial to maximal assistance (helper does more than half the effort to complete the activity) for toilet hygiene, shower, upper and lower dressing, and personal hygiene. A review of Patient 1’s Care Plan for abuse initiated on 5/09/2024 indicated, patient shall not be subject to abuse by anyone, including but not limited to facility staff, other patients, consultants or volunteer staff or other agencies, family member or legal guardian. The care plan interventions also indicated, inform patient and/or responsible party of the facility for reporting of abuse. A review of Patient 1’s Change of Condition (COC) dated 7/30/2024 at 9:10 AM indicated, Charge Nurse (CN) goes to room, patient voiced out roommate hit her left arm. Patient 1 is awake and oriented and able to make needs known. A review of Patient 2's Admission Record indicated the patient is a 85- years- old- female patient who was originally admitted to the facility on 4/21/2021 and re admitted on 6/23/2022, with diagnoses that included but not limited to psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). A review of Patient 2’s H&P dated 5/09/2024 indicated Patient 2 has the capacity to understand and make decisions. A review of the Patient 2's MDS dated 7/25/2024, indicated Patient 2 required partial to moderate assistance (helper does less than half the effort to complete the activity) for oral hygiene, shower, upper and lower dressing, and personal hygiene. A review of Patient 2’s COC dated 7/30/2024 at 9:00 AM indicated, roommate voiced out she (Patient 2) hit my left arm. During an interview with the Director of Nursing (DON) on 8/05/2024 at 10:05 AM, the DON stated, “I reported on Thursday 8/1/24, reported on the phone on 7/31/24. I left a message. I got a call back 8/1/24. I did not make a report to the Police department because I was waiting for advice.” The DON also stated the alleged abuse was not reported on 7/30/2024. During a concurrent interview with the DON on 8/05/2024 at 10:11 AM, the DON stated an abuse incident should be reported within 72 hours and “if it can be done in 24 hours that is the better practice.” During an interview with Social Service Director (SSD) on 8/05/2024 at 10:15 AM, SSD stated, SSD considered the incident between Patient 1 and 2 to be a patient- to- patient abuse case even if it is just claimed by one of the patients and even if it was not witnessed it was an allegation abuse. SSD stated the allegation of abuse needed to be reported within 2 hours to California Department Public Health (CDPH/SSA), Ombudsman and the Police Department and would not wait 72 or even 24 hours to report it. SSD also stated, the in services and facility policies indicated it needs to be reported within 2 hours and the documentation using the SOC 341 (abuse reporting form) must be followed up, but the incident must be reported. During an interview with Certified Nurse Assistant 1 (CNA1) on 8/05/2024 at 10:28 AM, CNA 1 stated, an abuse case must be reported immediately to the charge nurse or registered nurse (RN) supervisor, even if the incident was not witnessed and if a patient reports any type of abuse, the staff must take it seriously and report it right away. CNA 1 stated the staff have been taught any allegation of abuse is to be reported within 2 hours and not 72 hours from the allegation of abuse. CNA 1 stated, It is not okay to not report it, even if it was unwitnessed. During an interview with CN 1 on 8/05/2024 at 10:32AM, CN1 stated, “I was there on the day of the incident (Patient 1 and 2), I did the COC. I was at the nursing station. I hear loud voices. I went to the patients’ room.” CN1 stated she saw Patient 1 who pointed to Patient 1’s left arm, and then pointed at Patient 2. CN1 also stated, Patient 1 said Patient 2 hit her. CN1 stated, “I reported it to the DON. It happened on 7/30/2024 around 8:40 AM.” During a concurrent interview with CN1 on 8/05/2024 at 10:47 AM, CN1 stated any type of abuse needs to be reported within 2 hours from the incident or from when the allegation was made. CN1 stated “Waiting 72 hours is not okay. What if something else happened? It could have been worse. This is the reason I reported it to the DON right away. I follow the chain the of command; we can also call CDPH. I believe there is a list of protocols to do inside a binder at the nurse’s station, but we normally follow chain of command.” During a concurrent interview with the DON on 8/05/2024 at 11:02 AM, the DON defined abuse when a patient or patient rights or safety is compromised. The DON stated, “there is different types of abuse, physical, emotional (attempts to frighten, control, or isolate), social (behavior that aims to cut a person off from your family, friends, or community), financial (a common tactic used by abusers to gain power and control), we are mindful of their (patient’s) rights.” The DON confirmed that hitting is considered abuse and stated, “It is physical abuse, but then it is not physical injury, if you have to really investigate, if it was fabricated or something that has been evident.” During an interview and record review with the facility Administrator (Admin) on 8/05/2024 at 11:13 AM, Admin stated, “According to the facility policy, any alleged or witnessed abuse should be reported within 2 hours.” Admin stated the definition of abuse is any act against a patient that would result in harm. During an observation and interview with Patient 1 on 8/05/2024 at 11:56 AM, Patient 1 was sitting up at the side of her bed and stated, “this month (unable to recall exact date), Patient 2 has mental issues in the morning and Patient 2 punched Patient 1 (observed Patient 1 to close her hand and ball up into a fist to show how she was hit) on the left arm).” Patient 1 also stated, “tengtong (pain, ache, hurt), it hurt.” During concurrent interview and record review with the DON on 8/05/2024 at 12:44 PM, the DON stated, she did not know what form to complete to report the abuse and confirmed a SOC 341 (a form to report Suspected Abuse of Dependent Adults and Elders) was not completed. During a review of the facility's policy revised 4/2010, titled "Reporting Abuse to Facility Management" indicated, it is the responsibility of the facility’s employees, facility consultants, attending Physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or patient abuse, including injuries of unknown source, and theft or misappropriation of patient property to facility management. During a review of the facility's policy revised 11/2010, titled "Reporting Abuse to State Agencies and Other Entities/Individuals" indicated, all suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. The policy also indicated: 1. Should a suspected violation or substantiated incident of mistreatment (a behavior shows disrespect for the dignity of others), neglect (to give little attention or respect to) injuries of an unknown source, or abuse (including patient to patient abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: > The State licensing/certification agency responsible for surveying/licensing the facility > The local/State Ombudsman > Law enforcement officials 2. Verbal/written notices to agencies will be made within 2 hours of the occurrence of such incident and such notice may be submitted via special carrier, facsimile (fax), electronic mail (email), or by telephone. During a review of the facility's policy revised 9/2022, titled "Patient to Patient Altercation" indicated, “If two patients are involved in an altercation, staff: report incidents, findings and corrective measure to appropriate agencies as outlined in Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating.” The facility failed to report the patient- to- patient altercation to the SSA, the state ombudsman, and Local PD within 2 hours in accordance with the facility’s policy and procedure after the allegation of physical abuse for Patient 1. This deficient practice had the potential to place Patient 1 for further abuse and placed other patients at risk for elder abuse. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.