Health inspection·August 28, 2024

§ 72523.Resident Care Policies and Procedures. (a) Written Resident care policies and procedures shall be established and implemented to ensure that resident related goals and facility objectives are achieved. F607 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of resident s and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under §483.75. §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. On 7/12/24 at 7:30 AM, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding employee-to-patient abuse. The facility failed to implement the Abuse Prohibition Policy and Procedure during the provision of care and services for Patient 1 by failing to: 1. Report the alleged verbal abuse reported by Patient 1 against two unidentified certified nursing assistants (CAN’s), immediately to the Administrator, state agency, adult protective services (a social services program serving older adults and adults with disabilities) and to all other required agencies within two hours. 2. Investigate the allegation of verbal abuse made by Patient 1 regarding two unidentified CNA’s. The above failures resulted in the facility under reporting allegations of abuse and not thoroughly investigating all allegations of abuse, and place Patient 1 at risk for further verbal abuse. During a review of Patient 1’s Admission Record, indicated the patient was initially admitted to the facility on 6/18/2024 with diagnoses of hepatic encephalopathy (a decline in brain function that occurs as a result of severe liver disease) and type two (2) diabetes (a disease that occurs when your blood sugar is too high). During a review of Patient 1’s History and Physical Examination (H&P), dated 6/19/2024, H&P indicated the patient had the capacity to understand and make decisions and could make needs known but could not make medical decisions due to debilitated state (physically weak) and pain management (the process of providing medical care that alleviates or reduces pain). During a review of Patient 1’s Minimum Data Set (MDS – a standardized patient assessment care screening tool), dated 6/24/2024, the MDS indicated the patient was assessed moderately impaired with cognitive (ability to think, remember, and reason) skills of daily decision making, but needed partial/moderate assistance (helper does less than half the effort) with chair-to-bed transfers, needed substantial/maximal assistance (helper does more than half the effort) with toilet transfers, going from lying to sitting on the side of the bed and with dressing (how patient puts on, fastens and takes off all items of clothing) and needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity) with eating. During an interview on 7/12/2024 at 9:18 AM with Family Representative (FR), FR stated Patient 1 complained to the facility Case Manager (CM) on 7/3/2024 about an allegation of verbal abuse that she experienced on the night of 7/2/2024 when two CNAs (unable to identify) had used foul language (expressions such as swear words that are regarded as coarse, obscene [rude or shocking] or otherwise unacceptable in polite or formal speech) towards Patient 1 while assisting the patient. During an interview on 7/12/2024 at 10:15 AM with CM, CM stated they met with Patient 1 and FR on 7/3/2024 where Patient 1 told them that on 7/2/2024 in the evening shift, the patient was being assisted by two CNAs and one of the CNAs was using foul language with the patient and CNA told the patient “What do you want, are you f***ing done?” and “What do you need now?”. Patient 1 told CM that the CNAs were working in pairs and that the other CNA (unable to identify) was behaving the same way. CM stated that Patient 1 also gave a description of the CNAs and that they had communicated about the incident regarding the 2 CNAs to the facility Administrator (ADM), Director of Nursing (DON) and Social Services Director (SSD) on 7/3/2024 at 12:40 PM. CM further stated they only reported the incident to the facility’s leadership team and did not report the alleged abuse to CDPH, the police of the Ombudsman. The CM could not state whether the alleged abuse from patient 1 was investigated. During an interview on 7/12/2024 at 10:24 AM with ADM, ADM stated he was not notified of the incident regarding the alleged verbal abuse that Patient 1 had reported on the evening of 7/2/2024. The ADM stated the alleged verbal abuse of Patient 1 was not reported, since the ADM was responsible in reporting to proper agencies (CDPH, ombudsman, and local police department). ADM stated he would “most definitely” consider facility staff using foul language with a patient as an allegation of verbal abuse, there for the allegation should have been investigated right away. During an interview on 7/12/2024 at 12:48 PM with Registered Nurse 1 (RN 1), RN 1 stated the use of foul language towards a patient from the facility staff was considered verbal abuse, therefore should be reported within 24 hours to the ADM, the DON, CDPH, the ombudsman, and the police. During an interview on 7/12/2024 at 3:47 PM with the Director of Nursing (DON), the DON stated only being notified previously regarding Patient 1’s allegation of verbal abuse from two unidentified CNA’s. The DON stated investigation and reporting to appropriate agencies were not done. During a review of the facility’s policy and procedure (P&P) titled “Identifying Types of Abuse” revised September 2022, the P&P indicated verbal abuse may be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to patients within hearing distance. During a review of the facility’s P&P titled “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating” revised September 2022, the P&P indicated all reports of patient abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of patient property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigation are documented and reported. The P&P also indicated: Reporting Allegations to the Administrator and Authorities 1. If patient abuse, neglect, exploitation, misappropriation of patient property or injury of unknown source is suspected, the suspected, the suspicion must be reported immediately to the administrator and to the other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. b. The local/state ombudsman. c. The patient’s representative. d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials. f. The patient’s attending physician; and g. The facility’s medical director. 3. Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury; or Investigating Allegations - All allegations are thoroughly investigated. The administrator initiates investigations. The facility failed to implement the Abuse Prohibition Policy and Procedure during the provision of care and services for Patient 1 by failing to: 1. Report the alleged verbal abuse reported by Patient 1 against two unidentified certified nursing assistants (CAN’s), immediately to the Administrator, state agency, adult protective services (a social services program serving older adults and adults with disabilities) and to all other required agencies within two hours. 2. Investigate the allegation of verbal abuse made by Patient 1 regarding two unidentified CNA’s. The above failures resulted in the facility under reporting allegations of abuse and not thoroughly investigating all allegations of abuse, and place Patient 1 at risk for further verbal abuse. The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients 1 and all other residents be cared for by the two unidentified CNA’s.