Other·November 15, 2024

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 10/10/24 at 11 AM to investigate a facility reported incident received by the California Department of Public Health (CDPH) on 10/9/24 regarding a patient restraint. The facility failed to report an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) to the long-term care (LTC) ombudsman (advocates for patients of nursing homes), Law Enforcement, and State Survey Agency within 2 hours after the allegation of physical restraint (any manual method or physical or mechanical device, material or equipment attached or adjacent to the patient’s body that the individual cannot remove easily, which restricts freedom of movement or normal access to one’s body) to Patient 1 in accordance with the facility’s Restraint Prevention Policy. This deficient practice had the potential to place Patient 1 at risk for further abuse and delay of investigation. A review of Patient 1’s Admission Records indicated the resident was admitted to the facility on 4/22/23 and re-admitted on 6/1/24 with diagnoses including hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (stroke - damage to the tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Patient 1's History and Physical Examination (H&P) dated 4/27/24, the H&P indicated Patient 1 did not have the capacity to understand and make decisions. A review of Patient1’s Minimum Data Set (MDS-a federally mandated patient assessment tool), dated 7/30/24, indicated Patient 1 was assessed to be cognitively (a mental process of acquiring knowledge and understanding) impaired. The MDS indicated Patient 1 was assessed requiring substantial/maximal assistance (helper does more than half the effort) from staff for upper body dressing and personal hygiene and was totally dependent on staff for lower body dressing, shower/bathe self, and toilet hygiene. During a concurrent interview with License Vocational Nurse (LVN) 2 on 10/10/24 at 2:14 PM. LVN 2 stated that Patient 1 was confused and had episodes of trying to pull her G-tube (a flexible, soft tube that’s surgically inserted into a person’s stomach to provide nutrition and medication) and incontinent brief. LVN 2 stated she observed a white sheet wrapping around Patient 1’s stomach while she was making rounds on 10/3/24 at 11:15 PM. LVN 2 stated Certified Nursing Assistant (CNA) 3 told LVN 2 that CNA 3 used the white sheet to wrap Patient 1’s stomach to prevent the patient’s access to the patient’s abdominal area. LVN2 stated she immediately reported the incident to Registered Nurse (RN) 1. During an interview with RN 1 on 10/10/24 at 3:25 PM, RN 1 stated the incident happened on 10/3/24, at 11:15 PM, CNA 3 wrapped Patient 1’s torso (main part of the body that contains the chest, abdomen {stomach}, pelvis, and back) with a white sheet to prevent Patient 1’s access to the patient’s abdominal area and from removing the incontinent brief. RN 1 stated LVN 2 reported the allegation of physical restraint/abuse (by CNA 3) to RN 1, however, RN 1 forgot to report it to the Administrator (ADM). During an interview with the ADM on 10/10/24 at 4:18 PM, ADM stated she was informed of an alleged physical restraint to Patient 1 which happened on 10/3/24 during the staff meeting on 10/8/24 at 6:36 PM. The ADM stated the staff should have reported the incident to her immediately after the suspected abuse/ restraint on 10/3/24, so she could report the incident to the State Survey Agency within two (2) hours per facility policy. During a review of the facility’s policy and procedure titled, “Restraints” dated 3/27/24, indicated that the facility honors the patient’s right to be free from any restraints that are imposed for reasons other than that of treatment of the patient’s medical symptoms. Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the Interdisciplinary Team (IDT, a group of health care professional with various areas of expertise who work together toward the goals of their patients), and in accordance with the patient’s assessment and Plan of Care. During a review of the facility’s policy and procedure titled, “Abuse Prevention and Management” dated 6/12/24, indicated “use of physical or chemical restraints for discipline or convenience” was defined as using such restraints when they were not required to treat the patient’s medical symptoms. The policy also indicated allegations of abuse, or reasonable suspicion of a crime were to be reported to the ADM or designated representative immediately. The ADM or designated representative would notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than two (2) hours of an initial report and send a written SOC341 report to the LTC ombudsman, Law Enforcement, and CDPH Licensing and Certification within 2 hours. The facility failed to report an allegation of abuse to the LTC ombudsman, Law Enforcement, and State Survey Agency within 2 hours after the allegation of physical restraint to Patient 1 in accordance with the facility’s Restraint Prevention Policy. This deficient practice had the potential to place Patient 1 at risk for further abuse and delay of investigation. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.