Health inspection·November 19, 2024

California Code of Regulations, Title 22 Section § 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. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (2) Nursing services policies and procedures which include: (A) A current nursing procedure manual. Code of Federal Regulations, Title 42 F607 Section §483.12 Develop/Implement Abuse/Neglect, etc. Policies §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 §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. On 10/9/20204, at 8:30 AM the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding patient abuse. As a result, CDPH determined that the facility failed to implement the facility’s policy and procedure, titled “Abuse, neglect, Exploitation or Misappropriation – Reporting and Investigating,” to identify, protect, report, and initiate an investigation immediately from a suspected sexual abuse allegation reported by Patient 1 to the facility staff on 9/30/2024 and 10/6/2024, by failing to: 1. Identify an allegation of sexual abuse such as being touched inappropriately at nighttime by unknown man reported by Patient 1. 2. Report Patient 1’s allegation of sexual abuse by unknown man to CDPH, local law enforcement, ombudsman (state agency that advocates for the patients) and Adult Protective Services (agency that protects the adults and elderly). 3. Investigate Patient 1’s allegation of sexual abuse immediately and thoroughly as indicated in the facility’s policy and procedure for Patient 1’s abuse allegation. As a result of these deficiencies Patient 1felt unsafe at the facility and tried to elope on 9/30/2024. These deficient practices also had the potential to affect other vulnerable patients in the facility to experience abuse and result decline in psychosocial (interrelation of social factors and individual thought and behavior) well-being. A review of Patient 1's “Admission Record” indicated the facility admitted Patient 1 on 5/17/2017 with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), Covid-19 (a severe infection usually affect the lungs and result in difficulty breathing), and fibromyalgia (a disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping). A review of Patient 1’s “Minimum Data Set (MDS, a federally mandated patient assessment tool),” dated 8/21/2024, indicated Patient 1’s cognition (a term for the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) was moderately impaired, and needed supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity) in eating, oral (by mouth)/personal hygiene, bathe self. A review of Patient 1’s “Change in Condition Evaluation,” and “Health Status Notes,” dated 9/30/2024, indicated “Patient 1 attempted to elope on 9/30/2024, at approximately 2PM. Upon interview Patient 1 stated, “I want to leave, I feel unsafe because I believe a men went into my room.” A review of Patient 1’s “Program Counselor Note,” dated 9/30/2024, indicated “Patient stated that she tried to leave because she felt unsafe in the facility. Patient 1 also stated that men or boys occasionally comes into her room to touch her, and she knows this because she feels irritation in her private parts (breast and vagina) the next morning.” A review of Patient 1’s “Change in Condition Evaluation,” dated 10/7/2024, indicated on 10/7/2024 at 4:58 PM, “two deputies came, stated that Patient 1 called the police to report someone walked into her room the previous night and touched her. Deputies interviewed Patient 1, LVN 1 and RNS 1. Based on the patient’s diagnosis and interview, the deputies concluded that the story was not true.” During a concurrent observation on 10/9/2024 at 9:15 AM in Patient 1’s room, Patient 1 was lying in bed. In a concurrent interview Patient 1 stated she did not feel safe in the facility. Patient 1 stated, she felt like she was sexually abused because somebody touched her in her private area during the night. Patient 1 stated, she could not remember when the incident happened, and but she reported the incident to Licensed Vocational Nurse 2 immediately when it occurred. During an interview on 10/9/2024 at 11:10 AM with LVN2, LVN 2 stated, she was aware that Patient 1 reported being touched one day before Patient 1 called the police on 10/7/2024. LVN 2 stated, on 10/6/2024, Patient 1 went to the Nursing Station and reported that she had irritation “down there” and stated somebody went into her room and touched her with dirty hands.” LVN 2 stated, she brought Patient 1 to see Registered Nurse Supervisor (RNS) 1 for examination in the treatment room. During an interview on 10/9/2024 at 1:15 PM with the Administrator (ADM), the ADM stated, when a patient state she was touched during the night, the facility should take it seriously and start a thorough investigation right away to make sure the patient felt safe and protected. The ADM stated, per facility’s policy and procedure, the RN supervisor was responsible to start interviewing the patient, patient’s roommate, staffs that were working during the shift, and report the alleged abuse within 2 hours to CDPH, Police and Ombudsman. During a concurrent record review and interview on 10/9/2024 at 1:55 PM with Program Counselor (PC) 1, Patient 1’s “Program Counselor Note,” dated 9/30/2024, was reviewed. PC 1 stated, he was doing a follow up visit after Patient 1 attempted to elope on 9/30/2024. Patient 1 reported to him that she tried to elope because she felt unsafe at the facility because she was being touched occasionally by men at night time in her room. PC 1 stated, he reported Patient 1’s concern to the Program Counselor Manager (PCM) 1 right after his visit session with Patient 1. During an interview on 10/9/2024 at 2:55 PM, RNS 1 stated, Patient 1 refused to be examined in her private part after she complained somebody touched her in the private part on 10/6/2024. RNS 1 stated, Patient 1 had a history of reporting being touched in her private parts, but she could not provide information regarding the abuser’s identity or describe his face. RN1 stated, she knew it was a false claim, so she did not report Patient 1’s allegation of abuse to the abuse coordinator and she did not start an investigation. until 10/7/2024 when Patient 1 called the police. During an interview on 10/9/2024 at 3:40 PM with Program Counselor Manager (PCM) 1, PCM 1 stated, she was aware that Patient 1 reported feeling unsafe and being touched on 9/30/2024 and after Patient 1 attempted to elope. PCM 1 stated, she did not report Patient 1’s sexual allegations to the Administrator or the nursing staffs. During an interview on 10/9/2024 at 4 PM with the Director of Nurses (DON), the DON stated, any alleged abuse should be reported within 2 hours. The DON stated, on 9/30/2024 and on 10/6/2024 when Patient 1 reported being touched in the private parts and feeling unsafe to PC 1 and LVN 1 who reported the incident to PC 1 and LVN 1 should have reported the incidents right away so that they could start the investigation immediately. The DON stated, the staffs should not assume that all alleged abuse was false before a thorough investigation has been conducted. During a concurrent record review and interview on 10/9/2024 at 4:10 PM with the DON, Patient 1’s “Investigation Form,” dated 10/8/2024, was reviewed. The DON stated, there was no records of interviews from the staffs and patient’s roommates documented. The DON stated, per facility’s policy, the investigation for the abuse incident on 10/7/2024 was not thorough. The DON stated, if an alleged abuse was not reported, and the investigation was not thorough, the facility could not determine if the abuse was true, anything could happen to the patient and the facility would not be able to protect the patient and other patients in the facility from further abuse. A review of the facility’s policy and procedure (P&P) titled, “Abuse, neglect, Exploitation or Misappropriation – Reporting and Investigating," dated September 2022, indicated the following information: - All reports of patient abuse are reported to local, state, and federal agencies and thoroughly investigated by facility management. - The individual conducting the investigation as a minimum that included: interviews the person reporting the incident; interviews any witnesses to the incident; interviews the patient; interviews staff members (on all shifts) who have had contact with the patient during the periods of the alleged incident; interviews the patient’s roommate, family members, and visitors; documents the investigation completely and thoroughly. As a result, CDPH determined that the facility failed to implement the facility’s policy and procedure, titled “Abuse, neglect, Exploitation or Misappropriation – Reporting and Investigating,” to identify, protect, report, and initiate an investigation immediately from a suspected sexual abuse allegation brought up by Patient 1 to the facility staff on 9/30/2024 and 10/6/2024, by failing to: 1. Identify an allegation of sexual abuse such as being touched inappropriately at nigh time by unknown man reported by Patient 1. 2. Report Patient 1’s allegation of sexual abuse by unknown man to CDPH, local law enforcement, ombudsman and Adult Protective Services. 3. Investigate Patient 1’s allegation of sexual abuse immediately and thoroughly as indicated in the facility’s policy and procedure for Patient 1’s abuse allegation. As a result of these deficiencies Patient 1felt unsafe at the facility and tried to elope on 9/30/2024. These deficient practices also had the potential to affect other vulnerable patients in the facility to experience abuse and result decline in psychosocial well-being. The above violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.