Other·May 5, 2022

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 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. §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. 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 an allegation of abuse for Patients 1 and 2. Patient 2 allegedly bit Patient 1's right forearm on 09/11/21 at 5:30 p.m. This deficient practice resulted in a delay reporting to the California Department of Public Health (CDPH) of the alleged abuse incident and implementing the facility's policy and procedure to protect patients from further altercations. A review of Patient 1's Face Sheet indicated the facility admitted Patient 1 on 08/18/14 with diagnoses that included Parkinson's Disease (PD, a disorder of the central nervous system that affects movement, often including tremors [shaking]) and hypertension (HTN, high blood pressure). A review of Patient 1's History and Physical (H & P) dated 03/30/21, indicated Patient 1 did not have the capacity to understand and make decisions for daily living. Further review of the H&P indicated Patient 1 had dementia (a loss of cognitive [ability to understand and make decision] functioning, thinking, remembering, and reasoning daily life and activities). A review of Patient 1's Minimum Data Set (MDS, a standardized patient screening and care-planning tool), dated 09/07/21, indicated Patient 1 had moderately impaired cognition (The mental ability to process, acquire knowledge and understand). The MDS indicated Patient 1 required supervision for activities of daily living (ADL, daily life activities like walking, personal hygiene, eating and toilet use). A review of Patient 1's Situation, Background, Assessment and Recommendation (SBAR, a tool to provide aid in facilitating and strengthening communication between healthcare workers and the prescribers), dated 09/11/21, indicated Patient 2 bit Patient 1 on the right forearm. A review of Patient 2's Face Sheet indicated the facility admitted Patient 2 on 09/08/20 with multiple diagnoses that included polyneuropathy (a group of damaged peripheral nerves that are located outside of the brain and spinal cord), HTN, and psychosis (a mental condition that affects the mind that caused loss contact with reality). A review of Patient 2's Physician Psychiatric Evaluation Note (a specialized doctor in mental health, including substance use disorder) dated 08/28/21, indicated Patient 2 was alert and oriented to person, place, time. The evaluation note further indicated Patient 2 had auditory hallucination (hearing voices or other sounds that have no physical source) and poor judgment (inability to make appropriate decisions). A review of the facility's reporting records titled "Report of Suspected Dependent Adult and Elder Abuse" (known as SOC 341, a legal document that facility required to filled in the event of any alleged abuse), dated 09/13/21, indicated CDPH and other agencies were notified of the incident between Patients 1 and 2 on 09/13/21 two days after the alleged incident. During an observation of Patient 1 on 09/22/21 at 2:13 p.m., Patient 1's right forearm wound was observed closed and healed with no redness or swelling. During a concurrent interview with Patient 1, the patient stated Patient 2 has not bothered him again and that he felt safe at the facility. During an interview with the Administrator on 09/22/21 at 5:13 p.m., the Administrator stated the alleged incident between Patients 1 and 2 happened on 09/11/21 around dinner time. The Administrator stated she found out about the altercation through the change of condition (COC) records on 09/13/21. The Administrator stated the Director of Nursing (DON) was aware of the altercation and the DON should have informed her that same night. During a follow up interview with the Administrator on 12/02/21, the Administrator stated the facility should have reported the altercation to CDPH within two hours of the incident. During a telephone interview with Licensed Vocational Nurse 1 (LVN 1) on 03/01/22 at 11:10 a.m., LVN 1 stated any abuse must be reported within two hours to the Administrator, DON, CDPH, Ombudsman and to the local authority. A review of the facility's policy and procedures (P&P) titled "Reporting Abuse to State Agencies and Other Entities and or Individuals", revised date 12/2009, 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. Verbal and or written notices to agencies will be made within twenty-four hours of the occurrence of such incident and such notice may be submitted via special carrier, fax, e-mail, or by telephone." The facility failed to report an allegation of abuse for Patients 1 and 2. Patient 2 allegedly bit Patient 1's right forearm on 09/11/21 at 5:30 p.m. This deficient practice resulted in a delay reporting to the California Department of Public Health (CDPH) of the alleged abuse incident and implementing the facility's policy and procedure to protect patients from further altercations. This violation had a direct or immediate relationship to the health, safety, or security of Patient 1.