Health inspection·July 19, 2024

California Code of Regulations, Title 22, Section 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. (c ) Each facility shall establish and implement policies and procedures, including but not limited to: (2) Nursing services policies and procedures which include: (D)Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. Code of Federal Regulations, Title 42, §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(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. The facility failed to investigate and report allegation of verbal abuse (a range of words of behaviors used to manipulate, intimidate and maintain power and control over someone) within two hours for Patient 1 and 2, to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), the state ombudsman (advocates for patients of nursing homes, board and care homes and assisted living facilities), and local law enforcement, in accordance with the facility's abuse policy. These deficient practices have the potential to result in unreported abuse in the facility and failure to protect Patient 1 and other patients from abuse. 1. During a review of Patient 1 Admission Record, indicated Patient 1, a 87 years old female was initially admitted to the facility on 12/24/2014 and readmitted 6/29/2017 with diagnoses of bilateral (both) primary osteoarthritis (degenerative joint disease in which the tissues in the joint break down over time) of the knee and hemiplegia (one sided muscle paralysis or weakness) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the right dominant side. During a review of Patient 1's History and Physical Examination (H&P), dated 4/1/2023, the H&P indicated the patient has the capacity to understand and make decisions. During a review of Patient 1's Minimum Data Set (MDS - a standardized patient assessment care screening tool), dated 3/4/2024, the MDS indicated the patient had intact cognitive (ability to think, remember, and reason) skills for daily decision making. Patient 1 was assessed being dependent ( helper dopes all of the effort) for bed-to-chair transfers and needed substantial/maximal assistance (helper does more than half the effort) with dressing (how a patient puts on, fastens, and takes off all items of clothing). Patient 1 was also assessed needing supervision or touching assistance (helper provides verbal cues/or touching/steadying and/or contact guard assistance as patient completes activity) with personal hygiene & needed setup or clean-up assistance (helper sets up or cleans up; patient completes activity) with eating. 2. During a review of Patient 2's Admission Record, indicated Patient 2, a 64 years old male was initially admitted to the facility on 4/5/2024 with diagnoses of atherosclerotic heart disease (involves plaque buildup in artery walls) and cerebral infarction. During a review of Patient 2's H&P, dated 4/25/2024, the H&P indicated the patient has the capacity to understand and make decisions. During a review of Patient 2's MDS, dated 4/12/2024, indicated the patient had intact cognitive skills for daily decision making. Patient 77 was dependent with transfers (how patient moves to and from bed, chair, wheelchair, standing position), lower body dressing and personal hygiene, and needed setup or clean-up assistance (helper set up or cleans up; patient completes activity) with eating. During a review of Patient 2's Interdisciplinary Team (IDT; team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Note dated 5/6/2024, indicated Certified Nursing Assistant 2 (CNA 2) was assisting Patient 1 to the shower, Patient 2 yelled at Patient 1 and used socially inappropriate verbal language towards her. During a concurrent interview and record review on 6/6/2024 at 3:49 PM with Social Services Director (SSD), Patient 2's IDT Meeting Note, dated 5/6/2024, was reviewed. Patient 2's IDT Meeting Note addressed an incident that occurred when Patient 2 yelled at Patient 1 using socially inappropriate verbal language. SSD stated that the language Patient 2 used toward Patient 1 was considered verbal abuse. During an interview on 6/6/2024 at 4:00 PM with Patient 1, Patient 1 stated that on the morning of 5/8/24 Patient 2 used socially inappropriate verbal language towards her as CNA 2 was helping her to the shower. Patient 1 stated that the next day, she spoke with SSD and MDS Nurse (MDSN) about the incident and told them that no one is allowed to or has the right to speak to her like that and that. Patient 1 further stated that Patient 2 using inappropriate language towards her made her feel very angry. During an interview on 6/7/2024 at 2:40 PM with SSD, SSD stated that verbal abuse is when someone says something to someone that is offensive and unacceptable and stated that what Patient 2 said to Patient 1 offended her and was unacceptable. SSD stated that the timeline for reporting is within two hours and that CNA 2 should have reported the incident to the supervisor and charge nurse since she was the one who witnessed the incident. SSD further stated that it was important that allegations of abuse be reported to SA so it will not happen again for the safety and wellbeing of the patients and staff involved. SSD also stated that the Administrator (ADM) is the facility's abuse coordinator and that there was no documentation of the allegation being investigated. During an interview on 6/7/2024 at 3:18 PM with CNA 3, CNA 3 stated, "Verbal abuse is when bad words are used, yelling, saying something degrading or negative." CNA3 also stated the incident that happened between Patient 2 using inappropriate language toward Patient 1 was considered verbal abuse. CNA 3 also stated that the incident should have been reported within two hours to CDPH, the ombudsman, and the police. During an interview on 6/7/2024 at 3:26 PM with the Director of Nursing (DON), the DON stated that verbal abuse is when a person directly screams at another person by swearing and using foul language. The DON also stated that if a patient was offended by this type of behavior, then it was not acceptable and should be considered an allegation of abuse. The DON stated the allegation of abuse should have been reported by CNA 2 within two hours or earlier to the authorities and the facility's abuse coordinator. The DON further stated that if an allegation of abuse was not investigated, it could psychologically (affects the mind or relates to the emotional state of a person) harm the patient, could be detrimental (formal way of saying "harmful") to the patient's mental health and the incident could possibly happen again. During a review of the facility's Policy and Procedure (P&P) titled, "Identifying Types of Abuse," revised March 2024, the P&P indicated, "Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to patients within hearing distance, regardless of age, ability to comprehend, or disability and Examples of mental and verbal abuse include, but are not limited to: a. Harassing a patient; b. Mocking, insulting, ridiculing; c. Yelling or hovering over a patient, with the intent to intimidate." During a review of the facility's P&P titled, "Abuse Investigation and Reporting," revised March 2024, the P&P indicated: 1. "All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Patient's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The patient's Attending Physician; and 2. 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: - Two (2) hours if the alleged violation involves abuse of any kind." During a review of the facility's policy and procedure (P&P) titled "Abuse Reporting" revised 4/2023, the P&P indicated that, "If you suspect an incident of abuse has occurred, you must report the event to the first three agencies listed below via telephone within two (2) hours of the suspected abuse incident. Follow the steps below to report: " Step 1 - Call California Department of Public Health (CDPH), Long term Care (LTC) Ombudsman, and Police Department (PD) within two hours of the alleged event." During a review of the facility's P&P titled, "Abuse Investigation and Reporting," revised March 2024, the P&P indicated: " All reports of patient abuse, neglect, exploitation, misappropriation of patient property, mistreatment, and/or injuries of unknown source ("abuse") shall be thoroughly investigated by facility management. " If an incident or suspected incident of patient abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The facility failed to investigate and report allegation of verbal abuse (a range of words of behaviors used to manipulate, intimidate and maintain power and control over someone) within two hours for two (2) of patients (Patients 28 and 77) to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), the state ombudsman (advocates for patients of nursing homes, board and care homes and assisted living facilities), and local law enforcement, in accordance with the facility's abuse policy. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1 and other patients.