Other·July 22, 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 On 5/3/22 at 2:50 p.m., the California Department of Public Health (CDPH) conducted an unannounced visit to investigate an allegation of abuse. The facility failed to report an alleged incident of abuse for Patient 1 to the California Department of Public Health (CDPH) per facility’s policy and procedures by reporting allegations of abuse being reported promptly to the local agencies within 2 hours of initial report of abuse. This deficient practice resulted in no report of alleged abuse by the facility and had the potential to result in delayed protection and further abuse to Patient 1. A review of Patient 1's Admission Record indicated that the patient had a history of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and cerebral infarction (disrupted blood flow to the brain). A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 3/17/22, indicated the patient was severely impaired in cognition (ability to think and process information). A review of Patient 1's care plan dated 4/6/22, indicated that there was a concern/problem that Patient 1 accused his roommate of, "physical contact on him," and Patient 1 had skin discoloration with swelling on the left facial area up to the lower lip area. A review of Patient 1's Physician orders dated 4/6/22, indicated to monitor any adverse (harmful) changes of the left cheek redness with swelling daily. A review of Patient 1's Physician orders dated 4/9/22, indicated to monitor for any adverse changes of left cheek bruising daily. A review of Patient 2's Admission Record indicated the patient had a history of dementia, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and major depressive disorder (a mood disorder characterized by persistent feeling of sadness and loss of interest). A review of Patient 2's progress notes dated 4/6/22, indicated Patient 1's family member made a claim that a man similar to Patient 2's likeness had hit Patient 1. During an interview with the Director of Nursing (DON) on 5/3/22 at 1:11 pm, she stated that during an interview with Patient 1's family member (FM 1), FM 1 stated that a "black man" hit Patient 1 on 4/6/22. The DON stated that the abuse allegation was not reported to DPH because there was no, "black man," in the facility. During an interview with the Administrator (ADM) on 5/3/22 at 1:22 pm, he stated that Patient 1 said yes to all the possibilities of what caused the facial bruising and that is why abuse allegation from the family member was not reported. According to the ADM, all staff are mandated reporters for alleged abuse. A review of the facility's policy and procedure titled, "Abuse Investigation and Reporting," dated 12/2018, indicated that all reports of abuse shall be promptly reported to local agencies as defined by current regulations. The ADM or designated representative will also notify the DPH by telephone and in writing using form SOC341 (Report of Suspected Dependent Adult/Elder Abuse) within 2 hours of initial report of abuse. The ADM will provide a written report of the results of abuse investigations and appropriate action taken to DPH within 5 working days of the reported allegation. The facility failed to report an alleged incident of abuse for Patient 1 to the CDPH per facility’s policy and procedures by reporting allegations of abuse being reported promptly to the local agencies within 2 hours of initial report of abuse. This deficient practice resulted in no report of alleged abuse by the facility and had the potential to result in delayed protection and further abuse to Patient 1. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1 and other patients residing in the facility.