Other·August 31, 2023

F 609 FCR§ 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. §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. CCR§ 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 8/1/2023 at 9:25 am., the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding an allegation of financial abuse involving Patient 1. The facility failed to report an allegation of financial abuse to the CDPH, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within two hours and according to the facility's Policy and Procedure (P&P). As a result, the facility violated Resident 1’s right due to late reporting allegation of financial abuse and had a potential for Patient 1's money to be stolen or misused. During a review of Patient 1's "Face Sheet (Admission Record)," the Face Sheet indicated Patient 1 was an 81-year-old female and was admitted to the facility on 6/13/19, with multiple diagnoses including spinal stenosis (a narrowing of the spinal canal), pain in the right shoulder, and presence of cardiac pacemaker (medical device which sends electrical pulses to help your heartbeat at a normal rate and rhythm). During a review of Patient 1's "Minimum Data Set" (MDS, a standardized assessment and care screening tool), dated 5/31/23, the MDS indicated the Patient 1 had no impairment in cognitive skills (able to make own decisions). The MDS indicated Patient 1 required assistance from staff for dressing and toilet use. During an interview on 8/1/23 at 9:25 a.m., with the Administrator (ADM), the ADM stated he was informed on 7/16/23 that Patient 1 alleged that someone had taken $1,600 from her. The ADM stated that on 7/15/23 Patient 1's daughter told Certified Nursing Assistant (CNA) 1 that Patient 1's money was missing. The ADM stated that on 7/20/23, he reported the allegation to the Department, Ombudsman, and local law enforcement (5 days after the allegation of abuse was reported to facility staff). The ADM stated the allegation should have been reported to the Department, Ombudsman, and local law enforcement within 2 hours. The ADM stated there was a potential for a negative outcome due to not reporting allegations of abuse timely and residents could experience actual financial abuse. During an interview on 8/1/23 at 10:38 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, on 7/16/23 in the morning, Patient 1's daughter informed LVN 1 that Patient 1 was missing $1,600. LVN 1 stated she informed the Director of Nursing (DON) of the missing money. LVN 1 stated she did not report the missing money to the Department, Ombudsman, or local law enforcement. During an interview on 8/1/23 at 11:00 a.m., with the DON, the DON stated that on 7/16/23, LVN 1 informed her that Patient 1 was missing money. The DON stated she did not ask LVN 1 if the allegation had been reported to the Department, Ombudsman, and local law enforcement. The DON stated she notified the ADM of the allegation on 7/16/23. During an interview on 8/1/23 at 1:05 p.m., with CNA 1, CNA 1 stated that on 7/15/23, around 4:30 p.m., Patient 1 alleged that someone got in Patient 1's wallet and took Patient 1's money. CNA 1 stated she did not report the allegation to the Department, Ombudsman, and local law enforcement. During a review of the facility's P&P titled, "Adult Abuse," revised April 2018, the P&P indicated, anyone who is an owner, operator, employee, manager, agent or contractor of the facility who has observed, suspects or has knowledge of an allegation of abuse shall report to the Department of Public Health Licensing Division, the Ombudsman, law enforcement and the administrator immediately, but not later than 2 hours. The facility failed to report an allegation of financial abuse to the CDPH, Ombudsman, and to the local law enforcement, within two hours and according to the facility's P&P. As a result, the facility violated Resident 1’s right due to late reporting allegation of financial abuse and had a potential for Patient 1's money to be stolen or misused. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.