Other·June 9, 2022

§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 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. §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. §483.12{c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12{c){4) Report the results of all investigations to the administrator or his or her designated representative and to mistreatment, neglect, misappropriation of patient property will be reported to the supervisor, administrator, or director of nursing immediately. other officials in accordance with State law. including to the State Survey Agency I within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. T22 72523 (a). 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. The California Department of Public (CDPH) conducted an unannounced visit to the facility on 3/16/22, at 12:40 pm to investigate a complaint regarding physical abuse. The facility failed to report an allegation of abuse to California Department of Public Health (CDPH) after two hours and thoroughly investigate the alleged abuse that allegedly occurred on 1/28/22 made by Patient 1. CDPH received the report on 3/15/22 at 5:31 pm. The facility also failed protect Patient 1 from the alleged perpetrator (Certified Nurse Assistant 1/CNA 1) by allowing CNA 1 providing care for Patient 1 after Patient 1 made an allegation against CNA 1. As a result, Patient 1 and other patients residing in the facility was placed at risk for further abuse and potential retaliation by CNA 1 after CNA 1 was identified as the alleged perpetrator. A review of Patient 1 ' s Admission Record indicated the patient was admitted to the facility on 1/19/22 with diagnoses which included hemiparesis (paralysis on one side of the body) following a stroke (when blood flow to the brain is interrupted). A review of the Licensed Nurse Weekly Summary, dated 3/12/22, indicated Patient 1 was alert, oriented to name, time, and place with episodes of confusion, and was able to verbalize her needs. Patient 1 required one-person total assistance with activities of daily living. A review of Patient 1 ' s Care Plan initiated by the Minimum Data Set (MDS, a standardized assessment and care planning tool) Nurse (MDSN), dated 1/28/22, indicated Patient 1 stated staff pulled her hair in the shower and was verbally abusive towards her. A review of Patient 1 ' s clinical record indicated there was no documented evidence Patient 1 ' s allegation of abuse was reported to the local Ombudsman, to the local law enforcement, and to the State Survey Agency. During a phone interview with the Administrator on 3/17/22 at 10:16 am, he stated he was unsure about Patient 1 ' s allegation of abuse. During a phone interview with DON 1 on 3/17/22 at 10:30 am, she reviewed Patient 1 ' s clinical record and did not find documented evidence Patient 1 ' s allegation of abuse was reported to the Ombudsman, local law enforcement, and to the State Survey Agency. DON 1 stated for any allegation of abuse, the facility will investigate, and interview patients and staff. If the allegation was determined to be actual abuse, then it will be reported to the Ombudsman, local law enforcement, and the State Survey Agency. During a phone interview with the MDSN on 3/17/22 at 12:43 pm, she stated the previous DON (DON 2) told her to initiate a care plan for Patient 1 ' s allegation that someone pulled her hair in the shower. The DON 2 wanted MDSN to do an investigation regarding Patient 1 ' s allegation of abuse. MDSN assessed Patient 1 and asked the patient if someone pulled her hair in the shower; Patient 1 said no. MDSN relayed her assessment and interview with Patient 1 to DON 2 but did not document in Patient 1 ' s clinical record. The MDSN stated she was a mandated reporter. She added, she reported the incident to DON 2, but did not know if DON 2 reported the allegation of abuse to the Ombudsman, local law enforcement or to the State Survey Agency. The MDSN stated a mandated reporter should immediately investigate any allegation of abuse and report it to the DON, the Administrator, and to the State Survey Agency. The MDSN stated according to the facility Abuse Policy, for any allegation of abuse staff will fill out an incident report, initiate a care plan, discuss incident with the DON, Administrator, Registered Nurse (RN), and Social Worker, do an investigation, try to find a solution, notify the primary physician and the psychiatrist, notify the family or responsible party, provide staff in-service, ensure patients are safe, do a 72-hour monitoring of patients involved, and document the allegation as a change of condition in the assessment tab of the electronic medical record. During an interview with the Administrator on 3/17/22 at 9:52 am, he stated DON 2 told him the facility completed an investigation regarding Patient 1 ' s allegation of abuse. A review of the Concern Record (Theft/Loss and Grievance Report), dated 1/28/22, indicated Patient 1 alleged that she was being mistreated by staff. The Social Services Director did an investigation and spoke to Patient 1. Patient 1 told the Social Services Director staff pulled her hair and then Patient 1 changed her story and stated she had never been mistreated by staff. The Social Services Director also spoke with Patient 1 ' s roommates who stated they had never been mistreated by staff and had never seen staff mistreat others. There was no documented evidence staff were interviewed as part of the investigation. There was no documented evidence the allegation of abuse was reported to the local Ombudsman, local law enforcement, and to the State Survey Agency. The Administrator signed the Concern Record (Theft/Loss and Grievance Report) on 1/31/22. A review of the facility policy and procedure, titled "Abuse Allegation Reporting," dated 12/7/21, indicated as a mandated reporter, an employee who identifies suspected abuse committed against a patient must also report the incident to one local law enforcement entity by phone within 2 hours and provide a written report to the local Ombudsman and the State Survey Agency. The Administrator/Abuse Coordinator will report all allegations of abuse according to the Abuse Allegation Investigation time frames. The conclusion of all abuse allegations will be reported to the Department of Public Health and Ombudsman within five working days The facility failed to report an allegation of abuse to California Department of Public Health (CDPH) after two hours and thoroughly investigate the alleged abuse that allegedly occurred on 1/28/22 made by Patient 1. CDPH received the report on 3/15/22 at 5:31 pm. The facility also failed protect Patient 1 from the alleged perpetrator (Certified Nurse Assistant 1/CNA 1) by allowing CNA 1 providing care for Patient 1 after Patient 1 made an allegation against CNA 1. As a result, Patient 1 and other patients residing in the facility was placed at risk for further abuse and potential retaliation by CNA 1 after CNA 1 was identified as the alleged perpetrator. This violation had a direct or immediate relationship to the health, safety or security of Patient 1 and other patients residing in the facility.