Other·April 29, 2022

F610 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §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.    The California Department of Public (CDPH) conducted an unannounced visit to the facility on 1/30/2022 to investigate a complaint regarding sexual abuse. The facility failed to report an allegation of abuse to the Department within two hours following the incident on 1/28/21 for Patient 1. The facility also failed protect Patient 1 from the perpetrator during the investigation process for the allegation of sexual abuse. As a result, Patient 1 was at risk for further abuse and other patients in the facility were at risk for potential retaliation from staff after being identified as the perpetrator. A review of Patient 1's Face Sheet (admission information) indicated the patient was readmitted to the facility on 1/19/22 with diagnoses that included paranoid schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real). A review of Patient 1's Minimum Data Set (MDS, a standardized resident assessment screening tool), dated 12/31/21, indicated the patient had an intact cognition (ability to understand and process information). During a concurrent observation and interview with Patient 1 on 1/31/21 at 1:09 p.m., Patient 1 was standing across from the Nurses Station and refused to be interviewed. During an interview with the Director of Nursing (DON) on 1/31/22 at 1:44 p.m., the DON stated she initially became aware of the allegation that Patient 1 got assaulted on 1/28/22 at 5:30 p.m. by the Unit Secretary (US) from a General Acute Care Hospital (GACH). The DON stated on 1/28/22 at 7:29 p.m. the Police Officer (PO) came to the facility and stated he was investigating an alleged statement that Patient 1 got raped at the facility. The DON stated she called the Administrator (ADM) to report the alleged abuse. The DON stated the ADM told her since GACH's staff had already reported the incident then he will not report it to Department of Public Health (DPH). The DON stated the ADM is the abuse coordinator. The DON stated the ADM is the person who contacts DPH to report abuse. The DON stated Certified Nurse Assistant (CNA) 4 was the one Patient 1 alleged raped her. The DON stated CNA 4 came to back to work full time in the Red Zone (covid positive unit) on 1/27/22. The DON stated CNA 4 worked in the Red Zone on 1/27/22, 1/28/22, 1/29/22, and 1/30/22. The DON stated 1/31/22 and 2/1/22 were CNA 4's days off and CNA 4 would be back to work with his regular schedule in the Red Zone on 2/2/22. During an interview with the ADM on 1/31/22 at 2:44 p.m., he stated the DON called him on 1/28/22 at 9:00 p.m. to report alleged rape by staff and the PO came to investigate the allegation. The ADM stated he did not report the allegation to CDPH because he assumed and knew GACH's staff had already made the report since the PO came to the facility. The ADM stated he did not want to double report. The ADM stated Surveyor (SV) 1 called the ADM on 1/29/22 to report Patient 1 had pointed to Certified Nurse Assistant (CNA) 4 as the alleged sexual abuser. The ADM stated Surveyor (SV) 1 called the ADM on 1/29/22 to report Patient 1 pointed to CNA 4 as the alleged sexual abuser. The ADM stated he had not talked to CNA 4 because CNA 4 had been working in the Red Zone. During an interview with the DON on 1/31/22 at 2:55 p.m., the DON stated she had not talked to CNA 4. The DON stated she is planning on talking to CNA 4 today, but he is not at work. During an interview with Licensed Vocational Nurse (LVN) 1 on 1/31/22 at 3:05 p.m., LVN 1 stated SV 1 informed her Patient 1 pointed to CNA 4 stating CNA 4 sexually assaulted Patient 1. LVN 1 stated she notified the ADM and the DON regarding Patient 1 had pointed to CNA 4 as the alleged sexual abuser. During an interview with the DON on 1/31/22 at 3:27 p.m., the DON stated CNA 4 worked 1/30/22. The DON stated she should have told CNA 4 not to come to work on 1/30/22. The DON stated in a normal situation once she found out, she would have come together and sent CNA 4 home on 1/29/22 and suspended CNA 4 until the investigation is completed/resolved. A review of CNA 4's timecard indicated CNA 4 worked 1/27/22, 1/28/22, 1/29/22, and 1/30/22. During an interview with the Director of Staff Development (DSD) on 2/3/22 at 2:46 p.m., the DSD stated reporting time frame of abuse is within two hours to the CDPH. The DSD stated the importance of reporting within the time frame is because the information is fresh for those who may have witnessed the abuse and knows of the details. A review of the facility's policy and procedure, titled "Abuse & Mistreatment of Residents," undated, indicated facility shall report the incident by notifying the CDPH within two hours of the knowledge of abuse. A review of the facility's policy and procedure, titled "Abuse & Mistreatment of Residents," undated, indicated if the suspected perpetrator is a staff member, the staff member is to be placed immediately on administrative suspension and the employee will be suspended until investigation is completed. The facility failed to report an allegation of abuse to the Department within two hours following the incident on 1/28/21 for Patient 1. The facility also failed protect Patient 1 from the perpetrator during the investigation process for the allegation of sexual abuse. As a result, Patient 1 was at risk for further abuse and other patients in the facility were at risk for potential retaliation from staff after being identified as the perpetrator. These violations jointly, separately, or in combination had a direct or immediate relationship to the health, safety, or security of Patient 1.