Other·May 4, 2023

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 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. 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. An unannounced visit was conducted by California Department of Public Health on 2/23/23 at 12:05 PM to investigate two facility reported incidents regarding an allegation of resident- to- resident abuse. The facility failed to notify California Department of Public Health [CDPH], Ombudsman and local Police Department (PD) within 2 hours of an abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) allegation that occurred for Patients 1 & 2. This deficient practice had the potential to subject Patients 1 & 2 to further abuse and/or cause a decline in the patient's mental or emotional well-being. A review of Patient 1’s Face Sheet (a document that gives a patient's information at a quick glance) indicated the facility originally admitted Patient 1, 96 years- old female on 9/9/2022 with diagnoses of type 2 diabetes mellitus (impairment of the body regulates and uses sugar (glucose) as a fuel), hypertension (elevated blood pressure, and dementia (condition characterized by progressive or persistent loss of intellectual functioning). A review of Patient 1’s Minimum Data Set (MDS, an assessment and care screening tool), dated 12/11/2022, indicated Patient 1 is severely impaired with cognitive skills (ability to think, understand, and reason). The MDS also indicated the patient is totally dependent and needs assistance for mobility, walking, eating, toilet use, dressing and personal hygiene care. A review of Patient 1’s change of condition (COC) notes dated 2/11/2023 signed at 4 PM indicated the LVN 1 asked Patient 1 what happened to the patient’s forehead and Patient 1 said someone hit her on the forehead. The COC indicated, LVN 1 notified physician, and patient’s family but did not indicate the administrator, police department, ombudsman, and CDPH was notified within 2 hours from the abuse allegation or suspected abuse. A review of the facility’s 5 days follow- up report (full report after facility conducts their investigation of the allegation of abuse) for Patient 1’s allegation of physical abuse (willful act of hitting and/ or slapping) dated 2/14/2023, indicated on 2/11/2023 (3-11 shift) certified nurse assistant (CNA) noticed Patient 1 had discoloration on forehead and right forearm. The report indicated CNA informed License Vocational Nurse (LVN1) and but did not indicate that the administrator (ADM) and/ or Director of Nursing (DON) were made aware. The 5- day report did not indicate that the allegation of abuse for Patient 1 was reported to CPDH, local police department and ombudsman office. During an interview on 2/21/2023 4:10 PM, the DON stated she found about the allegation of abuse incident around noon time on 2/13/2023. The DON stated the charge nurse did not notify the local agencies (CDPH, Police Department and Ombudsman office) within 2 hours of abuse allegation when Patient 1 reported someone hit her on the forehead on 2/11/2023 afternoon. The DON stated, it was important to report any allegations abuse resulting from unknown discolorations to the local agencies to make sure timely investigation and for prompt action to ensure patient’s safety. A review of Patient 2’s Face Sheet indicated the facility originally admitted Patient 2, 46 years- old- female on 3/21/2021 with diagnoses of chronic obstructive pulmonary disease (COPD, diseases that cause airflow blockage and breathing-related problems), morbid obesity (Body Mass Index of over 40, or have a BMI of over 35 and are experiencing severe negative health effects, such as high blood pressure or diabetes, related to being severely overweight); muscle weakness (lack of muscle strength), and Schizophrenia (serious mental disorder in which people interpret reality abnormally). A review of Patient 2’s MDS, dated 12/14/2022, indicated Patient 2 is moderately impaired with cognitive skills [ability to think, understand, and reason]). The MDS also indicated Patient 1 is total care and required 100% assistance for mobility, walking, eating, toilet use, dressing and personal hygiene care. A review of Patient 2’s COC evaluation dated 2/13/2023 timed at 1:10 PM, the abuse incident between Patients 2 & 3 happened on 2/12/23. The COC indicated, Patient 2 stated Patient 3 (Patient 2’s roommate) tried to unplug her air loss mattress (an air mattress covered with tiny holes used to prevent pressure related wound on patients) and then tapped her right-hand last night (2/12/2023) around midnight. A review of the facility’s 5- day report (for Patient 2’s allegation of abuse) dated 2/14/2023, indicated Administrator (ADM) interviewed licensed vocational nurse (LVN) 4 who was the charge nurse during the patient-to-patient abuse allegation between Patient 2 and Patient 3 on 2/12/2023. The 5- day report indicated ADM asked LVN 4 why LVN 4 did not report the incident to the local agencies (CDPH, police department and Ombudsman office), LVN was not able to explain why she did not report. The 5- day report also indicated the Registered Nurse (RN 1) did not report the abuse incident between Patient 2 and Patient 3 to the local agencies, ADM, and/ or DON. During an interview on 2/21/2023 12:15 PM, ADM stated both LVN 4 and RN 1 failed to notify administrator, police department, ombudsman and CDPH within 2 hours window period regarding the abuse incident between Patient 2 and Patient 3 on 2/12/2023 (around midnight). The ADM stated, LVN 4 did not even document in Patient 2’s records for abuse allegation that happened during her shift. During an interview on 2/21/2023 at 2:45 PM, director of staff development (DSD) stated any abuse allegation should be reported to charge nurse and charge nurse should immediately notify CDPH, Police Department and Ombudsman office within 2 hours when the allegation of abuse has been made. A review of the facility’s policy and procedure for Abuse and Neglect Prohibition Policy revised March 2018, indicated all alleged violations should be reported to administrator or designated representative immediately. Notification of outside agencies including law enforcement, ombudsman and CDPH will be notified not later than 2 hours from the abuse allegations. The facility failed to notify California Department of Public Health [CDPH], Ombudsman and local Police Department (PD) within 2 hours of an abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) allegation that occurred for Patients 1 & 2. This deficient practice had the potential to subject Patients 1 & 2 to further abuse and/or cause a decline in the patient's mental or emotional well-being. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1 and 2.