Health inspection·August 25, 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. T22 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. An unannounced visit was made on 6/20/2023 to investigate an allegation of employee to patient abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish). The facility failed to notify California Department of Public Health (CDPH), Ombudsman (advocates for patients in nursing homes), and local Police Department (PD) within 2 hours of an allegation of abuse to Patient 1. This failure has the potential to result in unidentified abuse in the facility and failure to protect Patient 1 and other patients from abuse. A review of Patient 1’s Face Sheet indicated Patient 1 was admitted on 2/2/2022, with diagnoses including Alzheimer's disease (a progressive disease beginning with mild memory loss possibly leading to loss of the ability to carry on a conversation and respond to the environment), bipolar disorder (a mental disorder that causes periods of depression [a common and serious medical illness that negatively affects how a patient feel, think and act] and periods of abnormally elevated mood), and hyperlipidemia (high cholesterol). A review of the History and Physical, dated 4/5/2023, indicated that Patient 1 does not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 4/14/2023, indicated Patient 1 was assessed as usually makes self-understood and usually understands others. MDS indicated Patient 1’s cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. Patient 1 required supervision with eating. Patient 1 required limited assistance for bed mobility, dressing, toilet use and personal hygiene. Patient 1 required extensive assistance during transfer. A review of Patient 1’s Situation Background Assessment Recommendation (SBAR, an acronym for Situation-Background-Assessment-Recommendation is a technique used to provide a framework for communication between members of the health care team) form and progress note, dated 6/10/2023, timed at 1 PM, indicated Patient 1 alleged Certified Nurse Assistant 1 (CNA 1) handled her roughly during care. During an interview on 6/20/2023 at 3:30 PM, Registered Nurse 1 (RN 1) stated alleged abuse should be reported to local agencies, which included California Department of Public Health, Ombudsman, and local enforcement agency within two hours. RN 1 stated alleged physical abuse should be reported right away to the Director of Nursing (DON) and ADMIN so they can report it to local agencies timely. RN 1 added that reporting to other local agencies was important so other agencies can conduct their investigation for patient/s safety, protection, and prevent reoccurrence of abuse. During an interview on 6/20/2023 at 3:50 PM, the DON stated she conducted the investigation regarding Patient 1’s alleged rough handling incident, which happened on 6/20/23. The DON said that rough handling was an allegation physical abuse. The DON stated alleged physical abuse should be reported within 24 hours. The DON stated that reporting to other local agencies was important so other agencies can conduct their investigation about the alleged abuse incident. The DON stated that she was not aware of the facility’s abuse policy and procedure because she just started working in the facility not long ago. During a concurrent interview and record review of the SBAR on 6/20/2023 at 4 PM. the DON stated that the ADMIN was notified of the physical abuse allegation on 6/10/2023. The DON stated the physical abuse allegation was reported to the police the next day, on 6/11/23. The DON stated a call was not made to CDPH and Ombudsman on 6/10/2023. The alleged abuse was only reported to CPDH and Ombudsman through fax on 6/11/2023. A review of the facility’s policy and procedure titled, “Abuse Investigation and Reporting,” revised 7/2017, indicated an alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of patient 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 notify CDPH, Ombudsman and local PD within 2 hours of an allegation of abuse to Patient 1. This failure has the potential to result in unidentified abuse in the facility and failure to protect Patient 1 and other patients from abuse. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.