Health inspection·October 8, 2024

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. §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.

F610 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. On 9/5/2024 an unannounced visit to the facility for an employee to patient abuse allegation. The facility failed to implement its policy for abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for Patient 1 by failing to: 1.Conduct a thorough investigation of an allegation of physical abuse (intentional bodily injury) reported by Patient 1's family representative (FR) on 8/22/24. 2. Failed to report to the state agency (CDPH, California Department of Public Health), the state ombudsman (advocates for patients of nursing homes, board and care homes and assisted living facilities), and local law enforcement of an allegation of physical abuse (intentional bodily injury) for Patient 1. 3. Provide a written report to the State Survey Agency of the findings of the physical abuse allegation investigation within five (5) working days of the incident. These deficient practices had the potential to place Patient 1 and other patients at risk for physical abuse, which could result to harm/injury. A review of Patient 1's Admission Record, indicated Patient 1 is an 86 year old male patient who was initially admitted to the facility on 7/31/24 with diagnoses of encephalopathy (any disease, damage, or disorder that affects the brain structure or function) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out daily tasks). A review of Patient 1's History and Physical Examination (H&P), dated 8/23/24, indicated the patient has fluctuating capacity to understand and make decisions. A review of Patient 1's Minimum Data Set (MDS, a standardized Patient assessment care screening tool), dated 8/5/24, indicated the patient was severely impaired (difficulty with or unable to make decisions, learn, remember things) with cognitive (ability to think, remember, and reason) skills for daily decision making. Patient 1 needed substantial/maximal assistance (helper does more than half the effort) with walking 10 feet, transfers (how Patient moves to and from bed, chair, wheelchair, standing position), personal hygiene and lower body dressing (the ability to dress and undress below the waist, including fasteners). Patient 1 needed partial/moderate assistance (helper does less than half the effort) with upper body dressing (the ability to dress and undress above the waist, including fasteners) and eating. During a concurrent interview and record review on 9/5/24 at 2:57 PM with the Director of Nursing (DON), a facility form titled, "Investigation Statement," dated 8/22/24, indicated according to Licensed Vocational Nurse 1 (LVN 1) Patient 1's family representative (FR) had stated that Patient 1 informed her that he was hit by a male nurse. The DON stated that the physical abuse allegation was not and should have been reported to CDPH, the state ombudsman or local law enforcement as indicated on the facility's policy. During an interview on 9/5/24 at 3:09 PM with LVN 1, LVN 1 stated that on 8/22/24 Patient 1's FR brought it to their attention that Patient 1 stated that he was hit by a male nurse. LVN 1 stated that when she asked Patient 1 what happened, he had said that a male nurse had hit him but could not remember the specific time or date. LVN 1 also stated that the incident was then reported to the DON but was not sure whether it was reported to CDPH, the state ombudsman or local law enforcement. During an interview on 9/5/24 at 3:29 PM with DON, the DON stated that Patient 1 stated that someone hit him on a Thursday but could not recall who and could not give the specific time or date. The DON also stated that when the facility receives any allegation of abuse, the abuse coordinator would conduct an investigation, report the allegation to CDPH, the state ombudsman and the police immediately within 2 hours, and conduct an abuse in-service for staff. During an interview on 9/5/24 at 3:53 PM with LVN 2, LVN 2 stated that any allegation of abuse needs to be reported to CDPH, the state ombudsman and the police within 2 hours. During an interview on 9/5/24 at 3:57 PM with Certified Nurse Assistant (CNA 1), CNA 1 stated that on 8/22/24 Patient 1 told his FR that a male nurse hit him and that she reported the allegation to LVN 1. During an interview on 9/5/24 at 4:10 PM, the DON stated that the facility nursing staff should have reported Patient 1’s physical abuse allegation to the Administrator who was the facility's abuse coordinator. The DON stated the abuse allegation should have been reported to the state ombudsman, the local law enforcement and CDPH. The DON also stated that there was no interdisciplinary team (IDT, a group of professionals with various areas of expertise who work together towards the goal of their clients) meeting done for the alleged physical abuse incident with Patient 1. The DON further stated that an IDT meeting should have been done. During an interview on 9/5/24 at 5:06 PM with the Administrator (ADM), the ADM stated that an investigative report was not and should have been done for Patient 1's allegation of abuse. The ADM also stated there should have been a documentation indicating that the facility had looked into any possible male staff members in relation to Patient 1's physical abuse allegation. During an interview on 9/5/24 at 5:51 PM with the DON, the DON stated that there was no documentation that the male staff working on 8/22/24 was investigated regarding Patient 1's physical abuse allegation. The DON stated that it should have been documented and followed up. A review of the facility's policy and procedure (P&P) titled, "Abuse Investigation and Reporting," revised July 2017, indicated, "All reports of patient abuse, neglect, exploitation, misappropriation of patient property, mistreatment and/or injuries of unknown source ("abuse") shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported." The P&P indicated: Role of the Administrator O If an incident or suspected incident of patient abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. Role of the Investigator O Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator. Reporting- The administrator or his/her designee will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within 5 working days of the occurrence of the incident. The P&P further indicated under "Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman. c. The patient's representative (Sponsor) of record; d. Adult Protective Services (where state law provides jurisdiction in long term care); e. Law enforcement officials; f. The patient's Attending Physician; and g. The facility Medical Director 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of patient property) will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. A review of the facility's P&P titled, "Abuse Prevention Program," revised August 2006, the P&P indicated:"Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our Patients. Our abuse prevention program provides policies and procedures that govern , as a minimum: O Timely and thorough investigations of all reports and allegations of abuse. O The reporting and filing of accurate documents relative to incidents of abuse." The facility failed to implement its policy for abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for Patient 1 by failing to: 1. Conduct a thorough investigation of an allegation of physical abuse (intentional bodily injury) reported by Patient 1's family representative (FR) on 8/22/24. 2. Provide a written report to the State Survey Agency of the findings of the physical abuse allegation investigation within five (5) working days of the incident. 3. Provide a written report to the State Survey Agency of the findings of the physical abuse allegation investigation within five (5) working days of the incident. These deficient practices had the potential to place Patient 1 and other patients at risk for physical abuse, which could result to harm/injury. This violation had a direct or immediate relationship to the health, safety, or security of Patient 1 and other Patients in the facility.