Other·July 7, 2021

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. §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 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 4/20/2021 at 10:10 a.m., an unannounced visit was conducted at the facility to investigate a Facility-Reported Incident (FRI) regarding resident abuse. The facility failed to respond to an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) for Resident 1 by failing to immediately (within two hours) report the allegation to the Department of Public Health and other agencies as indicated in the facility’s Abuse Prohibition policy. As a result, the sexual abuse allegation was reported late, violated the facility’s policy, and had the potential to cause harm to Resident 1 and other residents in the facility. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on 3/5/20. Resident 1’s diagnoses included gastrointestinal hemorrhage (forms of bleeding in the gastrointestinal track, from the mouth to the rectum) and unspecified atrial fibrillation (an irregular and often rapid heart rate). A review of a facility form titled, “Client Diagnosis Report,” indicated Resident 1 had a diagnosis of unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). A review of Resident 1's, Minimum Data Set (MDS a resident assessment and care-screening tool), dated 3/11/21, indicated Resident 1 was assessed as severely impaired with cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) for daily decision making. A review of Resident 2's Record of Admission indicated the resident was admitted to the facility on 2/10/20. Resident 2’s diagnoses included type 2 diabetes mellitus (an adult onset chronic disease characterized by high levels of sugar in the blood) and essential hypertension (high blood pressure). A review of a facility form titled, “Client Diagnosis Report,” indicated Resident 2 had a diagnosis of unspecified dementia. A review of Resident 2's MDS dated 2/14/21, indicated, Resident 2 was assessed as being moderately impaired in cognitive skills for daily decision making. A review of Resident 1's Change of Condition (SBAR-Situation Background Assessment Recommendation), dated 4/17/21, at 11:15 a.m., indicated, Resident 1 and Resident 2 were sitting side by side in the dining room. LVN 2 separated them and noticed Resident 2 was holding Resident 1's hand and placed it by Resident 2’s crotch. LVN 2 separated the residents. During an interview, on 4/20/21, at 10:30 a.m., with the Social Worker (SW), the SW stated, during a meeting that occurred day prior, the Director of Nursing (DON) reported there was an incident over the weekend where Resident 2 put Resident 1's hand under his brief. The SW stated, “It did not sound like it was reported at that time and was just doing my diligence as a social worker, so I reported it." During an interview on 4/20/21, at 11:40 a.m., the DON stated she received a report from LVN 2 on Saturday, 4/17/21, before noon, who noticed Resident 2 was holding Resident 1's hand and tried to put it on his crotch. The DON stated, she reported it to the Administrator (ADM), but ADM did not respond. The DON stated, the incident was not reported to the appropriate agencies right away. DON stated, "That's my mistake, I take responsibility. It's important to report for the resident safety." During an interview, on 4/20/21, at 12:14 p.m., the ADM stated, in the case of Resident 1 and 2, who both have dementia, the facility policy would be to report within 24 hours to the Ombudsman (the primary responsibility of the program is to investigate and endeavor to resolve complaints made by, or on behalf of, individual residents in long-term care facilities) or the police, not necessarily to CDPH. Unless there was an injury, then it would be within two hours. During an interview on 4/20/21, at 3:30 p.m., the DON stated, the incident between Resident 1 and 2 happened on Saturday (4/17/21) and was not reported until Monday (4/19/21). During a telephone interview on 4/21/21, at 10:34 a.m., LVN 2 stated, she noticed Resident 1 and Resident 2 were holding hands and looked like Resident 2 was trying to put Resident 1's hand over his groin or crotch, outside of his clothing on Saturday morning (4/17/21). LVN 2 stated, abuse has to be reported right away. According to 42 Code of Federal Regulations (CFR), section §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. A review of the facility’s Abuse Prohibition policy and procedure dated 6/10/2010, indicated for all allegations of abuse or neglect, associates of the facility should immediately contact the vice president. The policy did not address the new changes to report with two hours. The facility failed to respond to an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) for Resident 1 by failing to immediately (within two hours) report the allegation to the Department of Public Health and other agencies as indicated in the facility’s Abuse Prohibition policy. As a result, the sexual abuse allegation was reported late, violated the facility’s policy, and had the potential to cause harm to Resident 1 and other residents in the facility. The above violation had a direct or immediate relationship to the health, safety or security of Resident 1.