Health inspection·January 25, 2023

F 609 §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. T22 Section 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 10/19/2022 at 3:35 pm., the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding an allegation of abuse involving Patient 1. As a result of the investigation, CDPH determined the facility failed to report an allegation of sexual abuse (non-consensual sexual contact of any type with a patient) to the CDPH, the Ombudsman (entity who advocates for patients in skilled nursing facilities), and the local police department within two-hours for Patient 1 in accordance with the facility's policy and procedure. As a result of this failure, there was late reporting and the potential for Patient 1’s safety to be compromised and further abuse to Patient 1 and all other patients in the facility. On 10/17/2022, before lunch, Patient 1 reported to Counselor 1 that Patient 2 touched her inappropriately on her buttocks. The facility reported the incident to CDPH, the Ombudsman, and local police department on 10/18/2022. a. A review of Patient 1’s Admission Record indicated the patient is a 31 year-old female and was admitted to the facility on 10/13/2021 with diagnoses of schizoaffective disorder (combination of symptoms of schizophrenia [mental disorder] and mood disorder) and insomnia (sleeping disorder). A review of Patient 1’s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 7/8/2022, indicated Patient 1 had intact cognitive (mental action or process of acquiring knowledge and understanding) skill for daily decision making. The MDS indicated Patient 1 was independent (required no help or staff oversight at any time) with activities of daily living (ADL, daily task like eating, bed mobility, transfer, walking, toilet use and personal hygiene). A review of Patient 1’s History and Physical (H&P) dated 10/12/2022, indicated Patient 1 had judgement and insight impairment (medical condition that results in a person not being able to make good decisions). A review of Patient 1’s Progress Note-Nursing Interdisciplinary Team (IDT, a group of diverse health care professionals from different fields) Notes, dated 10/17/2022, timed at 2:16 pm, indicated that on 10/16/2022 before lunch time, Patient 1 reported to Counselor 1 that Patient 2 slapped her buttocks, made a kissing noise, and verbally said, “I love you." The notes indicated Patient 1 felt uncomfortable and told Patient 2 not to do that and Patient 2 laughed. The notes indicated Counselor 1 reported the allegation to Licensed Vocational Nurse 1 (LVN 1) and Interdisciplinary Program Consultant 1 (IPC 1). A review of Patient 1’s Progress Notes-1:1 (one staff to one patient, a situation in which two parties come not direct contact) Counseling Note, dated 10/18/2022 timed 4:38 pm, indicated during a 1:1 counselling, Patient 1 reported she was touched inappropriately on her buttocks and felt molested. The document stated Patient 1 felt dirty after the incident. A review of Patient 1's Progress Notes dated 10/18/2022 timed at 5:01 pm, indicated Patient 1 had “a room changed due to feeling uncomfortable with a peer." The notes indicated Patient 1 was moved to a different unit in the facility away from Patient 2. b. A review of Patient 2’s Admission Record indicated the resident is a 52 year-old male who was admitted to the facility on 3/10/2020, with diagnoses of schizoaffective disorder, diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) and hypertension (high blood pressure). A review of Patient 2’s H&P dated 3/23/2022, indicated Patient 2 had judgement and insight impairment. A review of Patient 2’s MDS record dated 9/9/2022, indicated Patient 2 was moderately cognitively impaired (an individual that require supervision and have poor decision making). The record indicated Patient 2 was independent with his ADL’s. A review of the facility investigation report dated 10/19/2022, indicated Patient 1 reported the sexual abuse allegation to Counselor 1 on 10/17/2022. The facility reported the incident to CDPH on 10/18/2022 and started the investigation on 10/19/2022 (two days later). During an interview on 10/19/2022 at 3:51 pm, Patient 1 stated Patient 2 spanked her buttocks, made a kissing sound, and said, “I love you,” to her which made her scared, and could not remember when it happened. Patient 1 stated she felt like Patient 2 wanted to molest her in the room and sexually assault her. Patient 1 stated she told him to stop but he would not stop. Patient 1 stated she wanted to let it go but whenever she saw Patient 2, he laughed about it and made kissing sounds and told her, "I love you," many times. Patient 1 stated she reported the incident to Counselor 1 two days ago (10/17/2022). During an interview on 10/19/2022, at 4:35 pm, Counselor 1 stated on 10/17/2022 before lunch time, Patient 1 reported to her that on 10/16/2022, Patient 2 touched her inappropriately on her buttocks, made a kissing sound and said, “I love you,” and made Patient 1 felt uncomfortable. Counselor 1 reported the incident to Licensed Vocational Nurse 1 (LVN 1) and to the Interdisciplinary Program Consultant 1 (IPC 1). During an interview on 10/19/2022 at 5:05 pm, Counselor 2 stated on 10/18/2022 during her 1:1 counselling Patient 1 reported Patient 2 slapped her buttocks. Counselor 2 stated Patient 1 expressed to her she felt molested, dirty, and uncomfortable. During an interview on 10/19/2022 at 5:19 pm, the Administrator (ADM) stated she should have reported Patient 1’s allegations on 10/17/2022. During a telephone interview on 10/26/2022 at 3:50 pm, the ADM stated the facility’s Director of Nursing (DON), Program Director (PD), and IPC 1 were designees to report the allegations of abuse. The ADM stated after reviewing the counselor’s notes on 10/17/2022, and discussion with the IPC, she stated she should have reported the incident between Patient 1 and Patient 2 on 10/17/2022. A review of facility’s policies and procedure (P&P) titled, “Identifying Abuse and Abuse Prevention," revised 7/2019, indicated to aid in the abuse prevention, all personnel are to report any signs and symptoms of abuse to their supervisor or to the Director of Nursing (DON) immediately. A review of the facility’s P&P titled, “Abuse Reporting," dated 5/9/2018, indicated reporting will be done within one hour for any abuse involving severe bodily injury and within two hours for any abuse. A twenty-four (24) hour reporting for abuse will follow if one is not sent within the one or two-hour period following abuse. An investigation will follow. Reporting will be done in mandated timeframe even if the investigation has not reached a conclusion. A review of facility’s P&P titled, “Facility Management Abuse Reporting," revised date 12/2022, indicated when an alleged or suspected case of abuse is reported, the facility administrator, or his/her designee, will notify the State Agency, local or state Ombudsman and law enforcement within two hours. As a result of the investigation, CDPH determined the facility failed to report an allegation of sexual abuse to the CDPH, the Ombudsman, and the local police department within two-hours Patient 1 in accordance with the facility's policy and procedure. As a result of this failure, there was late reporting and the potential for Patient 1’s safety to be compromised and further abuse to Patient 1 and all other patients in the facility. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety or security of Patient 1.