Health inspection·September 1, 2023

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. 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. An unannounced visit was made on 7/17/2023 to investigate an allegation of patient to patient abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish). The facility failed to notify California Department of Public Health (CDPH), Ombudsman (advocates for patients in nursing homes), and local Police Department (PD) within 2 hours of an allegation of physical abuse between Patient 1 and Patient 2. This failure had the potential to place Patient 1 and Patient 2 at risk for further abuse, and in a delay for abuse allegation investigation which could result in unidentified abuse in the facility. A review of Patient 1’s Admission Record indicated the patient was initially admitted to the facility on 3/28/2023, with diagnoses of chronic diastolic heart failure (occurs when the left ventricle muscle becomes stiff or thickened and the body does not get as much blood as it needs), diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin [a hormone released from the pancreas that controls the amount of glucose in the blood], causing blood sugar [glucose] levels to be abnormally high) with diabetic chronic (having an illness persisting for a long time or constantly recurring) kidney disease, and abnormalities of gait (a manner of walking or moving on foot) and mobility. A review of Patient 1’s History and Physical (H&P, the initial clinical evaluation and examination of the patient) Examination, dated 3/31/2023, indicated the patient had the capacity to understand and make decisions. A review of Patient 1’s Minimum Data Set (MDS, a standardized patient assessment and care screening tool) dated 5/20/2023, indicated Patient 1 had cognitively intact (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated the patient required supervision (oversight, encouragement or cueing) with one-person physical assist for bed mobility (how patient moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and transfers (how the patient moves between surfaces including to and from bed, wheelchair, standing position). The MDS indicated Patient 1 required limited assistance (Patient highly involved in activity; staff provided guided maneuvering of limbs or other non-weight being assistance) with one-person physical assist for dressing and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). A review of Patient 2’s Admission Record indicated the Patient was admitted to the facility on 2/7/2023, with diagnoses of abnormalities of gait and mobility, cerebral ischemia (a condition in which a blockage in an artery restricts the delivery of oxygen-rich blood to the brain resulting in damage to brain tissue), and seizures (a sudden and temporary change in the electrical and chemical activity in the brain which leads to a change in a person’s movement, behavior, level of awareness and/or feelings). A review of Patient 2’s H&P Examination dated 2/8/2023, indicated the patient had the capacity to understand and make decisions. A review of Patient 2’s Minimum Data Set dated 5/12/2023, indicated the patient had cognitively intact skills for daily decision making. The MDS indicated Patient 2 required supervision with one-person physical assist for bed mobility, transfer, eating, and toileting use. The MDS indicated Patient 2 required limited assistance with one-person physical assist for dressing and personal hygiene. A review of Patient 1’s Change in Condition dated 7/2/2023, indicated Patient 1 was struck on the left eye by roommate after a disagreement about the volume on roommate’s television. A review of Patient 1’s Nursing Progress Note by Registered Nurse Supervisor (RN 1) dated 7/2/2023, indicated at 9:10 PM, Certified Nurse Assistant (CNA) 2 reported Patient 1 was on the floor. Patient 1 informed RN 1 he had asked Patient 2 to turn down the television volume and Patient 2 refused. Patient 1 then got up and turned the television off. Patient 2 became angry and struck Patient 1 on the left eye. Patient 1 then struck back at Patient 2 on the right cheek and Patient 1 lost his balance and guided himself to the floor. During an interview with the Director of Social Services (DSS) on 7/17/2023 at 12:43 PM, DSS stated Patient 1 informed her Patient 2 tried to hit him, but he moved and slid to the ground. SSD stated Patient 2 informed her Patient 1 threw a punch and hit him on the right side of the head, then he struck Patient 1 on the right side. SSD stated this was physical abuse and needed to be reported withing two hours to the State Agency, local law enforcement, and Ombudsman. During an interview with Patient 1 on 7/17/2023 at 1:52 PM, Patient 1 stated Patient 2 tried to hit him in the face. Patient 1 stated he moved back to avoid Patient 2’s fist to his face which resulted in his fall. During an interview with Patient 3 on 7/17/2023 at 2:15 PM, Patient 3 stated he heard Patient 1 tell Patient 2 to turn off the television, then Patient 2 hit Patient 1. During a telephone interview with Licensed Vocational Nurse 1 (LVN 1) on 7/17/2023 at 2:22 PM, LVN 1 stated Patient 1 informed her Patient 2 wanted to hit him in the left eye. LVN 1 stated Patient 1 informed her both Patients 1 and 2 got into each other’s faces. LVN 1 stated this was a case of abuse. LVN 1 stated on 7/2/2023 after the incident, she made the report to the RN 1. During a telephone interview with the RN 1 on 7/17/2023 at 2:34 PM, RN 1 stated from her investigation Patient 1 and Patient 2 had an argument about the television. RN 1 stated Patient 1 got up and turned off the television and Patient 2 swung at Patient 1 and grazed his cheek or left eye. RN 1 stated this is an alleged abuse since both Patients swung at one another. RN 1 stated LVN 1 had texted the Director of Nursing (DON) to report the alleged abuse. RN 1 stated she did not inform the DON nor contact anyone about the abuse. During an interview with the DON on 7/17/2023 at 2:43 PM, DON stated he found out about the incident of abuse in the morning of 7/3/2023 around 8:30 AM. The DON stated he was the first person to notify the Administrator about the physical altercation. The DON stated the alleged physical altercation occurred during the 3 to 11 PM shift the night before on 7/2/2023. The DON stated he did not receive a text on 7/2/2023 regarding the incident between Patient 1 and Patient 2. The DON stated allegations of abuse were supposed to be reported within two hours. The DON stated the facility did not make the report within two hours after the abuse. The DON stated the RN 1 was supposed to contact him after the incident. The DON stated everybody was a mandated reported, either the LVN 1 or RN 1 supervisor should had made the report to CDPH, local law enforcement, and Ombudsman. A review of the facility’s policy and procedure titled, “Abuse Investigation and Reporting,” revised July 2017, indicated all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: the State licensing/certification agency responsible for surveying/licensing the facility; the local/State Ombudsman; and law enforcement officials. An alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately, but no later than two (2) hours if the alleged violation involves abuse. The facility failed to notify CDPH, Ombudsman, and local PD within 2 hours of an allegation of physical abuse between Patient 1 and Patient 2. This failure had the potential to place Patient 1 and Patient 2 at risk for further abuse, and in a delay for abuse allegation investigation which could result in unidentified abuse in the facility. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.