Health inspection·May 23, 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. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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. 22CCR §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. Patient's 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: (10) To be free from mental and physical abuse. H &S § 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse 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 4/22/2024, the California Department of Public Health (CDPH) received a complaint regarding an allegation that Resident 1 was verbally attacked and physically assaulted by a nurse (unnamed) in Resident 1's room. The allegation indicated the perpetrator refused to leave Resident 1's room. On 4/23/2024 at 10 a.m., CDPH conducted an unannounced visit at the facility to investigate the allegations. The facility failed to: 1). Implement its policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating", which indicated to report suspicions of abuse to the state licensing/certification agency, immediately or within two hours of the abuse allegation. This violation delayed the investigation by the CDPH. A review of Resident 1's Admission record, dated 4/23/2024, indicated Resident 1 was a 71-year-old male, originally admitted to the facility on 7/8/2021 and readmitted on 11/2/2022 with diagnoses including hypertension (high blood pressure), arthritis (joint pain and stiffness), and quadriplegia (inability to move all parts of the body below the neck). A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/9/2024, indicated Resident 1 had an intact cognition (mental capacity). The MDS indicated Resident 1 required extensive assistance from staff for toileting hygiene, lower body dressing, and putting on footwear. The MDS indicated Resident 1 required partial assistance from staff for upper body dressing and personal hygiene and supervision from staff for oral hygiene. The MDS indicated Resident 1 was dependent on staff for sit to stand, required supervision for chair/bed to chair transfer, toilet transfer, and shower transfer, and was independent rolling left and right, sit to lying, and lying to sitting on side of bed. A review of Resident 1's electronic mail (email) sent to the Social Service Director (SSD), dated 4/20/2024, indicated Licensed Vocational Nurse (LVN 3) allegedly intimidated (frightened) and threatened Resident 1 on 4/20/2024. During an interview with the Director of Nursing (DON) on 4/24/2024 at 3:01 p.m., the DON stated if an abuse allegation occurred, the charge nurse would initiate the investigation by completing the interviews, reports, and contact the police and CDPH. The DON stated the timeframe for reporting to the agencies was 2 hours. The DON stated it was important to report to CDPH any allegation of abuse so (the department) can conduct their own investigation. During an interview with the Administrator (ADM) on 4/25/2024 at 4:28 p.m., the ADM stated the physical or verbal abuse allegations was not reported to CDPH and the Ombudsman immediately, or within 2 hours, because the ADM thought it was a customer service issue. A review of the facility's P&P, titled "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating", dated April 2021, indicated all reports of resident abuse must be reported to local, state, and federal agencies within two hours of the abuse allegation. The facility failed to: 1). Implement its policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating", which indicated to report suspicions of abuse to the state licensing/certification agency, immediately or within two hours of the abuse allegation. This violation delayed the investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.