Other·May 4, 2022

§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. §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. 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. The facility failed to report to the California Department of Public Health (CDPH/ Licensing and Certification [L&C]) immediately (not later than two hours) of an employee to patient allegation of abuse for Patient 1. The facility reported to CDPH, the allegation of abuse on 10/16/21, however, the incident occurred on 10/14/21. This violated the rights of Patient 1 and had the potential for psychosocial harm for Patient 1. On 10/22/21, the State Survey Agency (the Department) made an unannounced visit to the facility to investigate a Facility Reported Incident regarding Resident Abuse. A review of Patient 1's Admission Record indicated the facility admitted Patient 1 on 02/7/18, with diagnoses that included dementia (A group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment, forgetfulness), generalized weakness, and lack of coordination. A review of Patient'1 Minimum Data Set (MDS-a standardized assessment and care-screening tool) dated 08/25/21, indicated Patient 1 had severe cognitive (Mental ability to understand and make decisions of daily living). The MDS indicated Patient 1 required one to two persons physical assist with activities of daily living (ADL-bed mobility, surface transfer, walk, locomotion on or off unit, dressing, eating, toilet use, and personal hygiene). A review of Patient 3's Admission Record indicated the facility admitted Patient 3 on 7/15/19, with diagnoses that included generalized muscle weakness and lack of coordination. A review of Patient 3's MDS dated 7/23/21, indicated Patient 3 had intact cognition. A review of the facility's In-Service Meeting Minutes on Abuse and Abuse Prevention attended by CNAs 1 and 3 dated 09/21/21, indicated elder abuse in an intentional act or failure to act that causes or creates a risk of harm to an older adult. The in service further indicated there are several important things to do to prevent elder abuse such as reporting conflict/problems to your supervisor any suspected abuse. A review of the facility's In-Service Meeting Minutes on Alleged Violation (Abuse ... Reporting) dated 9/21/21 time from "2-3," indicated "Please note that as a mandated reported a staff who identifies suspected abuse committed against an individual who is a Patient must also report the incident to ... the L&C Program ... within two hours suspected abuse." During an interview on 10/22/21 at 2:23 p.m., Certified Nurse Assistant 3 (CNA 3) stated Patient 1 had difficulties with redirections by staff on 10/14/21 and at approximately between 11:45 p.m. to 12:15 p.m., in the activities room, CNA 3 observed CNA 1 moved Patient 1 to a corner in the activity room because the patient was agitated. CNA 3 stated CNA 1 attempted to redirect Patient 1 multiple times during lunch, but Patient 1 threatened to stab CNA 1 with utensils. CNA 3 stated she informed the Activities Director (AD) of the incident. CNA 3 stated she observed CNA 1 become increasingly upset and offered CNA 1 multiple times to help or take over the assignment. CNA 3 stated CNA 1 did not acknowledge CNA 3's offer. CNA 3 stated CNA 1 continued to express increased signs of aggression and insisted Patient 1 consume her meal. CNA 3 stated she witnessed Patient 1 decline several times, CNA 3 became tired/frustrated and described Patient 1 as "**AH**." CNA 3 stated other patients were present in the activity room and witnessed the incident between Patient 1 and CNA 1. CNA 3 stated Patient 3 was interviewable and had witnessed the incident. CNA 3 stated she observed CNA 1 leave the activity room and Patient 1 calmed down. CNA 3 stated she discussed the incident with a facility staff (unidentified) on 10/16/21 and was advised by the facility staff to report the incident. CNA 3 reported the incident to Registered Nurse (RN) Supervisor on 10/16/21 who then reported the incident to the DSD, DON and Administrator (ADM). During an interview with Patient 3 on 10/22/21 at 3:20 pm, Patient 3 stated she witnessed Patient 1 yell "It's thanksgiving and I have to go home!" and hit CNA 1 in activities room. Patient 3 stated CNA 1 was trying to redirect Patient 1 but Patient 1 was resisting. Patient 3 denied hearing CNA 1 make any negative remarks or name calling to Patient 1. Patient 3 stated Patient 1 was her former roommate and that occasionally Patient 1 would "lose touch with reality." Patient 3 stated Patient 1 described other roommates as her children, and this continued to get worse. A review of the facility's Incident Record, dated 10/18/21 (4 days after the alleged incident) indicated the DSD (Director of Staff Development) received a text message from RN Supervisor that CNA 3 was inquiring about submitting SOC-341 form on 10/16/21 at 3:05 p.m. The record indicated the DSD telephoned the RN Supervisor to gather additional information and instructed to complete Alleged Violation Report and interview the patient. The report indicated DSD spoke with CNA 3 and CNA 3 stated she felt the incident rose to the level of abuse. The report indicated DSD informed CNA 3 that CNA 3 was required to report abuse immediately "so that we are able to report to CDPH within 2 hrs." A review of the facility's Disciplinary Action Report indicated CNA 1 received verbal warning on 8/16/20 after leaving a patient in the bathroom. The report indicated a patient was heard saying "help me" in the bathroom and was found seated on the toilet crying. The report indicated the patient stated she had been in the bathroom "for hours." A review of the facility's Abuse Allegation Investigation Form dated 10/20/21, indicated the date and time of report of allegation was on 10/16/21 approximately 3:00 p.m. The investigation form indicated date and time of alleged occurrence was on 10/14/21 at approximately 11:45 a.m. The investigation form under specific allegation indicated CNA 3 "Activities staff member states she witnessed" CNA 1 "possibly verbally abuse" Patient 1 "by stating I can't deal with this **AH** and being relocated to other side of the room." The investigation form indicated for suspected abuse or serious bodily injury the mandated reported must send a written report to Licensing and Certification ... with 2 (two) hours (Use SOC-341 form). During an interview with ADM, and the DSD on 10/22/21 at 3:53 p.m., the DSD stated CNA 3 notified the RN Supervisor of the incident between Patient 1 and CNA 1 on 10/16/21. The DSD stated RN Supervisor then notified her of the incident and she informed the ADM on 10/16/21. The DSD was not sure why CNA 3 reported the incident late (2 days later). During an interview with CNA 1 on 10/26/21 at 12:42 p.m., CNA 1 stated Patient 1 was agitated throughout the day on 10/14/21 and threatened to stab CNA 1 with a fork in the activity room after CNA 1 attempted to feed the patient multiple times. CNA 1 stated she was unable to recall "using vulgar language to express frustration." A review of the facility's Policies and Procedures, titled “Abuse Prevention” revised 08/21, indicated "Mandated reporter," is any employee ... who has observed or has knowledge of an incident that reasonably appears to be an alleged violation. A review of the facility’s Policies and Procedures, titled “Alleged Violation (Abuse ...) Reporting”, revised 12/18, indicated all alleged violations will be reported by the charge nurse and or supervisor immediately to the Director of Nursing. The P&P further indicated that "Please note that as a mandated reported a staff who identifies suspected abuse committed against an individual who is a Patient must also report the incident to ... the L&C within two hours of suspected abuse." The facility failed to report to the California Department of Public Health (CDPH/ Licensing and Certification [L&C]) immediately (not later than two hours) of an employee to patient allegation of abuse for Patient 1. The facility reported to CDPH, the allegation of abuse on 10/16/21, however, the incident occurred on 10/14/21. As a result, this violated the rights of Patient 1 and had the potential for psychosocial harm for Patient 1. The above violations jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.