Other·March 16, 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. The facility failed to report an allegation of sexual abuse (non-consensual sexual contact of any type with a) to the California Department of Public Health (CDPH) within two hours. This violation had 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 Admission Record indicated the facility admitted Patient 1 on 9/20/22 with diagnosis of paraplegia (impairment or loss of the legs and lower body caused by spinal injury or disease), anxiety disorder (fear characterized by behavioral disturbances) and schizophrenia (mental disorder that disordered thinking and behavior that impairs daily functioning). A review of Patient 1's Minimum Data Set (MDS, standardized assessment and care planning tool), dated 10/7/22, indicated Patient 1 had moderate impairment in cognitive skills (ability to understand and make daily decisions). Patient 1 required extensive assistance (Patient involved in activity, staff provide weight bearing support) for bed mobility, transfer, and locomotion (how patient moves to and returns between locations). A review of the Situation, Background, Assessment, Recommendation (SBAR), dated 12/16/2022, indicated Patient 1’s CNA came out of Patient 1’s room bleeding from the back of his head. CNA 1 claimed that Patient 1 hit him on the back of his head with a soda can while she was changing her. SBAR indicated Patient 1 was asked what had happened and she stated, “He raped me. He raped my daughter also.” Patient 1 was not able to provide the date when this happened. During an interview on 1/4/2023 at 10:12 AM, the Director of Nursing (DON) stated on 12/16/2022 at 8:30 PM, she interviewed Patient 1 due to an incident when Patient 1 struck Certified Nurse Assistant 1 (CNA 1). The DON stated during this interview, Patient 1 stated CNA 1 had raped her. The DON stated Patient 1 was not able to give any other information including date or time of the allegation of rape. The DON stated that he forgot to notify CDPH within 2 hours regarding the abuse allegation. The DON further stated he had reported the sexual abuse allegation three (3) days later on 12/19/22. During an observation in Patient 1's room and interview on 1/4/2023 at 11:12 AM, Patient 1 was observed groomed and with poor eye contact. Patient 1 was alert and oriented. Patient 1 stated CNA 1 raped her, her daughter and granddaughter three (3) or four (4) times but does not remember when. During an interview on 1/4/2023 at 11:40 AM, the Administrator (ADM) stated that the investigation had started on 12/16/2022, but had not been reported until 3 days later, on 12/19/2022. The ADM stated the DON should have reported the abuse allegation within 2 hours because it's the law and it was for the protection of all patients. A review of the facility's policy and procedure titled, "Abuse Investigation and Reporting," dated 7/2017, indicated an alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately, but not later than 2 hours if the alleged violation involves abuse or has resulted in serious bodily injury. This violation had the potential to result in unidentified abuse in the facility and failure to protect patients from abuse. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.