Health inspection·May 18, 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. 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. 22 CCR 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. On 04/19/2023, the California Department of Public Health (State Survey Agency [SSA]) made an unannounced visit to the facility to investigate a complaint related to employee to resident abuse. The facility failed to report the allegation of abuse to the SSA within 2 hours after Resident 1 alleged on 4/17/23, the licensed vocational nurse (LVN 1), grabbed her hands. As a result, Resident 1 stated she developed bruises on the left and right hands and there was a delay of the investigation of the allegation of abuse, placing Resident 1 at risk for further abuse. During a review of Resident 1's Admission Record indicated Resident 1 was admitted on 12/15/21 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and major depression. A review of Resident 1's Minimum Data Set (MDS, standardized care and screening tool) dated 3/24/23 indicated Resident 1 was oriented to year, month, and day. Resident 1 needed supervision (oversight, encouraging or cuing) with bed mobility, transfer, eating, toilet use and limited assistance (resident highly involved with activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) with dressing, personal hygiene, and bathing. A review of Resident 1's Nursing Progress Notes dated 4/18/23 at 3:53 a.m., indicated Resident 1, came out of her room, and wanted to see the old bottle of the Latanoprost eyedrops (medication for glaucoma [a group of eye diseases that can cause vision loss and blindness by damaging the nerve in the back of the eyes]. The Notes indicated Licensed Vocational Nurse 1 (LVN 1) showed Resident 1 the bottle of the Latanoprost, and Resident 1 stated she would keep the bottle in her room. LVN 1 informed Resident 1 that she cannot keep the bottle in her room. The Notes indicated Resident 1 held on to the medication bottle tightly with her hands and refused to return the bottle. Resident 1 started yelling, grabbed, and pulled on LVN 1 ' s jacket and clothes. Resident 1 finally opened her hand and released the bottle of eyedrops. Resident 1 was assisted back to her room and into her bed. A review of Resident 1's Change in Condition Evaluation dated 4/18/23 at 11:53 a.m., indicated Resident 1 had senile purpura (bruises due to fragile skin) on the back of the right and left hand. The primary physician was notified and gave order to monitor the site for 72 hours. During an observation and a concurrent interview on 4/19/23 at 11:11 a.m., Resident 1 was observed with bruises on the back of the left and right hands. Resident 1 (through a translator) stated on 4/17/23, at about 9 p.m., LVN 1 instilled eyedrops in her eyes and her eyes became irritated. Resident 1 stated she wanted to see the eyedrop bottle, keep it and discard the bottle. Resident 1 stated LVN 1 grabbed her hands to get the bottle and as a result bruises developed in her hands. Resident 1 stated LVN 1 " ...was a mean nurse, and no one hurt me like that before". Resident 1 further stated she was scared of LVN 1. During an interview on 4/19/23 at 12:33 p.m., Certified Nurse Assistant 1 (CNA 1) stated Resident 1 told him about the abuse allegation on 4/18/23 that LVN 1 grabbed her hands and caused the bruises. CNA 1 stated on 4/18/23, he informed LVN 2 and LVN 3 about Resident 1's abuse allegation. During an interview on 4/19/23 at 1:55 p.m., the director of nursing (DON) stated no one reported Resident 1's allegation of abuse. DON stated everyone is a mandated reporter. DON stated we must know so the facility can properly investigate what happened. DON further stated any allegation should be reported to the administrator or to the DON. During an interview on 4/19/23 at 2:06 p.m., the administrator (ADM) stated no one reported any allegation of abuse involving Resident 1. ADM stated if he had known, he would report within two hours of knowing the allegation to the SSA and provide a five-day report. During a telephone interview on 4/19/23 at 4:15 p.m., LVN 1 stated on 4/17/23 at about 11 p.m., Resident 1 asked to see the bottle of the eyedrop and wanted to keep it. LVN 1 stated she gave the bottle to Resident 1 and Resident 1 wanted to keep the bottle. LVN 1 stated she asked for the bottle back but Resident 1 refused. Resident 1 became angry, agitated, and started pulling on LVN 1's jacket and clothes. LVN 1 stated she did not grab Resident 1's hand. During a telephone interview on 4/19/23 at 4:31 p.m., CNA 2 stated Resident 1 tried to keep the empty bottle of the eyedrops and started pulling on LVN 1 ' s jacket and clothes. CNA 2 stated LVN 1 placed her hand on Resident 1's hands and asked Resident 1 to "please let go". CNA 2 stated LVN 1 did not forcefully held Resident 1 ' s hands. During a telephone interview on 4/20/23 at 12:04 p.m., LVN 2 stated no one reported Resident 1 ' s allegation to him. During a telephone interview on 4/20/23 at 3:38 p.m., LVN 3 stated no one reported Resident 1 ' s allegation of abuse. During a review of the facility's policy and procedures titled Abuse Investigation and Reporting, reviewed on 1/31/23, indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ("abuse") shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The same policy indicated an alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two hours if the alleged violation involves abuse or has resulted in serious bodily injury or b. 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. The facility failed to report the allegation of abuse to the SSA within 2 hours after Resident 1 alleged on 4/17/23, the licensed vocational nurse (LVN 1), grabbed her hands. As a result, Resident 1 stated she developed bruises on the left and right hands and there was a delay of the investigation of the allegation of abuse, placing Resident 1 at risk for further abuse. The above violation had a direct relationship to the health, safety, and security of Resident 1.