Health inspection·February 16, 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 12/26/2023 the California Department of Public Health (CDPH) received a Facility Reported Incident indicating Resident 1 verbalized he was being abused. On 1/9/2024, the CDPH conducted an unannounced visit at the facility. The facility failed to: 1. Implement its abuse policy and procedure (P&P) to ensure an allegation of abuse was reported to the CDPH within two hours. As a result, there was a potential for a delay in the investigation by the CDPH and placed Resident 1 at risk for continuous abuse at the facility. A review of Resident 1 Admission Record indicated Resident 1 was an 81-year-old male, admitted to the facility on 2/21/2017 and readmitted on 12/20/2023, with diagnoses including metabolic encephalopathy (brain dysfunction), muscle weakness, and schizoaffective disorder bipolar type (mental illness that affects thoughts and mood behavior). A review of Resident 1’s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 11/22/2023, indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required maximum assistance (staff lifts or holds trunk or limbs and provided more than half the effort) for Activities of Daily Living (ADL’s) such as toileting hygiene, showering and lower body dressing. During an interview on 1/9/2024 at 10:40 a.m., Resident 1 stated Certified Nurse Assistant (CNA) 1 was picking on him and beat him with a bucket, on his head. Resident 1 stated he called the paramedics to pick him up because he was beaten up. During an interview on 1/9/2024 at 2:02 p.m., the Administrator (ADM) stated a Licensed Vocational Nurse (LVN) 1, had informed him of Resident 1’s allegation of abuse on 12/23/2023 at 7:17 a.m. The ADM stated he reported the allegation of abuse to the CDPH on 12/23/2023 at 1:09 p.m. The ADM stated, the alleged abuse was not reported within two hours according to the facility’s P&P. The ADM also stated not reporting the abuse in a timely manner could have led to continuous abuse for the resident and a delayed investigation by the CDPH. A review of the facility’s undated P&P titled, “Policy and Procedure on Resident Abuse” indicated it was the policy of the facility to adhere to all local, state, and federal laws pertaining to preventing elder and dependent adult abuse, and to recognize and report suspected abuse. The P&P indicated any mandated reporter, who observed or has knowledge of an incident that appeared to be physical abuse or was told by an elder or dependent adult that he or she had experienced behavior constituting physical abuse, abandonment, isolation shall be reported to the State Agency. The P&P also indicated all alleged violations must be reported immediately but no later than two hours if the alleged violation involved abuse or resulted in serious bodily injury. The facility failed to: 1. Implement its abuse policy and procedure (P&P) to ensure an allegation of abuse was reported to the CDPH within two hours. As a result, there was a potential for a delay in the investigation by the CDPH and placed Resident 1 at risk for continuous abuse at the facility. This violation presented a direct or immediate relationship to the health, safety, security, or welfare of Resident 1.