Health inspection·July 17, 2024

F609 CFR §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. 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 6/3/2024, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit at the facility to investigate a facility reported incident regarding resident abuse. As a result of the investigation, the facility failed to follow its Policy and Procedure on Abuse Reporting and report an alleged physical abuse for Resident 5 to the CDPH when Resident 9 hit Resident 5 on the left side of Resident 5's face on 5/21/2024. This violation violated Resident 5’s right, had the potential to compromise Resident 5’s safety and exposed Resident 5 to further abuse from Resident 9. A review of Resident 5’s Admission Record indicated Resident 5, a 44-year-old female was admitted to the facility on 5/7/2024 with diagnoses that included schizoaffective and insomnia. A review of Resident 5’s Progress Notes, dated 5/21/2024 at 10:49 PM, indicated Resident 5 was hit on the right shoulder by another resident. A review of Resident 9's Admission Record indicated Resident 9, a 27-year-old female was admitted to the facility on 10/26/2023 with diagnoses that included schizophrenia and tobacco use. A review of Resident 9's untitled care plan initiated on 2/28/2024, indicated on 5/21/204, Resident 9 hit another resident (Resident 5) on the right shoulder. The care plan goal was for Resident 5 to not harm herself or others. The care plan interventions included for staff to intervene as needed to protect the rights and safety of others. A review of Resident 9's Minimum Data Set dated 5/3/2024 indicated Resident 9's cognitive abilities were intact. A review of Resident 9's Nursing Notes dated 5/21/2024 at 10:42 PM, indicated on 5/21/24 at around 6:00 PM Resident 9 hit another resident (Resident 5) "on the right shoulder." During an interview on 6/3/2024 at 10:02 AM with Resident 5, Resident 5 stated Resident 9 hit Resident 5 on the left side of the face a couple of weeks ago at around 6:00 PM to 7:00 PM. Resident 5 stated Resident 9 hit Resident 5 in the hallway when Resident 5 was coming out of Resident 5's room. Resident 5 stated Resident 5 reported the incident to the charge nurse. Resident 5 stated Resident 5 stated Resident 5 was concerned that Resident 5 would get into another altercation with Resident 9 because both residents share the same bathroom. During an interview on 6/3/2024 at 12:32 PM with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated CNA 3 was aware of Resident 9 hitting Resident 5 two weeks ago (5/21/2024). CNA 3 stated CNA 3 was unsure if the incident was reported to the CDPH, Police, or Ombudsman. During an interview on 6/3/2024 at 2:57 PM with Resident 9, Resident 9 stated Resident 9 hit Resident 5 on the left side of Resident 5's face in the hallway two weeks ago (5/21/2024) at around 6:00 PM. During an interview on 6/3/2024 at 3:09 PM with RN Supervisor 1 (RN Sup 1), RN Sup 1 stated Resident 5 and Resident 9's rooms are connected by a restroom. RN Sup 1 stated Resident 9 was in the hallway when the incident on 5/21/2024 occurred. RN Sup 1 stated RN Sup 1 did not witness the alleged physical abuse. RN Sup 1 stated RN Sup 1 did not report the incident to the Administrator because RN Sup 1 did not see any physical injuries on Resident 5 or Resident 9. RN Sup 1 stated RN Sup 1 considered the incident as alleged physical abuse because Resident 5 said Resident 9 hit Resident 5. RN Sup 1 stated the risk of not reporting alleged abuse is that the incident would happen again, especially since both residents are sharing the same bathroom. During an interview on 6/3/2024 at 4:05 PM with the Director of Nursing (DON), the DON stated the incident between Resident 5 and Resident 9 on 5/21/2024 was not reported to the DON nor the ADM. The DON stated the risk of not reporting alleged physical abuse was that it could happen again. A review of the facility's Policy and Procedure titled "Abuse Prevention and Prohibition Program," dated 10/1/2023 indicated the facility staff are mandated reporters and indicated staff are obligated by the Elder Justice Act and the California Elder Abuse and Dependent Adult Civil Protection Act to report known or suspected instances of abuse of dependent adults. The policy indicated facility staff will report known or suspected instances of abuse to the ADM. The P&P indicated the facility is to report allegations of abuse immediately but no later than two hours after forming the suspicion to the state survey agency, adult protective services, law enforcement, and the Ombudsman. The facility failed to follow its Policy and Procedure on Abuse Reporting and report an alleged physical abuse for Resident 5 to the CDPH when Resident 9 hit Resident 5 on the left side of Resident 5's face on 5/21/2024. This violation violated Resident 5’s right, had the potential to compromise Resident 5’s safety and exposed Resident 5 to further abuse from Resident 9. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 5.