Health inspection·November 26, 2024

Amended: 12/9/2024 42 CFR §483.12 (c) Freedom from Abuse, Neglect, and Exploitation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. 22 CCR § 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. H&S § 1418.91 (a) A long-term health care facility shall report all incidents of alleged or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class “B” violation. On 10/10/2024 the California Department of Public Health (CDPH) received one complaint indicating the Psychiatric Mobile Response Team ([PMRT] crisis team of clinicians who respond to residents experiencing psychiatric emergencies) was dispatched to evaluate Resident 1 and the resident reported that one staff (Certified Nurse Assistant [CNA] 1) physically abused him. On 10/11/2024, the CDPH conducted an unannounced visit at the facility to investigate this allegation. The facility failed to: 1.Implement its abuse policy and procedure (P&P) titled, “Abuse Reporting and Investigations” which indicated the facility would report allegations of abuse to the CDPH within two hours, after Resident 1 alleged CNA 1 hit him. As a result, there was a potential for a delay in the investigation by the CDPH. Resident 1 was a 64-year-old male, originally admitted to the facility on 9/9/2022 and readmitted on 6/24/2024. Resident 1’s diagnoses included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior), and diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and wound healing). A review of Resident 1’s History and Physical (H&P) dated 5/10/2024, indicated Resident 1 could make needs known but could not make medical decisions. A review of Resident 1’s Minimum Data Set ([MDS], a resident assessment tool), dated 7/12/2024, indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required substantial/maximal assistance (staff does more than half the effort) for Activities of Daily Living (ADLs) such as eating, oral hygiene, toileting hygiene, showering, upper and lower body dressing, and personal hygiene. A review of Resident 1’s SBAR ([Situation, Background, Assessment, Recommendation] a communication tool used by healthcare workers when there is a change in condition among the residents) Communication Form dated, 10/8/2024 indicated Resident 1 was yelling, using profanity, and hitting staff. The SBAR indicated the PMRT was called to evaluate the resident. A review of Resident 1’s Order Summary Report dated 10/11/2024 indicated to transfer Resident 1 to the General Acute Care Hospital (GACH) for psychiatric evaluation on 10/8/2024. During an interview on 10/11/2024 at 1:57 p.m., Registered Nurse (RN) 1 stated on 10/8/2024, one member of the PMRT reported to her (RN 1), of Resident 1’s allegation that CNA 1 hit him. RN 1 stated she did not report the allegation (to the Administrator, Director of Nursing (DON) or CDPH) because she did not see it as abuse and the PMRT was taking Resident 1 to the GACH. During a phone interview on 10/11/2024 at 3:50 p.m., the DON stated, she was not aware that a member of the psychiatric mobile response team reported an allegation that a CNA hit Resident 1. The DON stated, RN 1 should have reported the allegation to the CDPH, but RN 1 did not. The DON stated she did not know why RN 1 did not report it to the CDPH. The DON stated, it was important to report allegations of abuse so it could be investigated. A review of the facility’s P&P titled, “Abuse Reporting and Investigations” dated 3/2018, indicated the facility would report all allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies. The P&P indicated, allegations of abuse, neglect, mistreatment, exploitation or reasonable of crime would be reported to the Administrator or designated representative immediately and the Administrator or designated representative would report the allegation to the CDPH by telephone and in writing within two hours of initial report. The facility failed to: 1.Implement its abuse P&P titled, “Abuse Reporting and Investigations” which indicated the facility would report allegations of abuse to the CDPH within two hours, after Resident 1 alleged CNA 1 hit him. As a result, there was a potential for a delay in the investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of residents.