Other·December 30, 2022

F610 CFR §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)(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. T22 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. The facility failed to report a physical abuse (the willful action of injury resulting in physical harm which includes, but not limited to, hitting, slapping, punching, biting, and kicking) allegation to the California Department of Public Health (CDPH) within two hours and reporting to CDPH of the results of the investigation within five working days of the alleged incident between Patient 1 and 2. This violation had the potential to result in unidentified abuse in the facility and failure to protect patients from abuse. On 10/18/2022, an unannounced visit was made to the facility to investigate a complaint regarding quality of care/treatment and patient client abuse. A review of Patient 1's Admission Record indicated the facility admitted Patient 1 on 10/9/2017 with diagnoses of cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels that supply it), chronic kidney disease (progressive damage and loss of function in the kidneys), spinal stenosis (a tightening of the spinal canal that causes nerve pain), and orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down). A review of Patient 1's History and Physical (H&P) Examination, dated 1/1/2022, indicated Patient 1 had the capacity to understand and make decisions. A review of Patient 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 7/15/2022, indicated Patient 1 had cognitively intact (mental action or process of acquiring knowledge and understanding) skills for daily decision making and required supervision (the act of overseeing or watching over someone or something) with transfers (how the resident moves between surfaces including to and from bed, wheelchair, standing position), locomotion on unit, dressing, toilet use, and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). A review of Patient 2's Admission Record indicated the facility admitted Patient 2 on 3/7/2019 with diagnoses of acute kidney failure (when the kidneys suddenly become unable to filter waste products from the body), hypertension (high blood pressure), and functional quadriplegia (complete immobility due to frailty or severe physical disability). A review of Patient 2's History and Physical (H&P) Examination, dated 1/8/2022, indicated Patient 2 had the capacity to understand and make decisions. A review of Patient 2's MDS, dated 8/5/2022, indicated Patient 2 had cognitively intact skills for daily decision making and required extensive assistance (the individual would not be able to perform or complete the activity without another person to aid in performing the complete task) with one to two plus persons physical assist with transfers, walking in room, locomotion on unit, dressing, toilet use, and personal hygiene. A review of GACH Emergency Department Provider Note, dated 10/5/2022, indicated Patient 1 stated someone pushed her. The Provider Note indicated Patient 1 had an extensive silver dollar size stellate laceration (a tear in the skin or in an internal organ caused by blunt trauma) of the center of the forehead above the nose and it was deep. During an interview on 10/17/2022 at 3:40 p.m., General Acute Care Hospital (GACH) Social Worker (SW) stated Patient 1 came to GACH after a fall. GACH SW stated Patient 1 said Patient 2 (room mate) pushed her in her room. GACH SW stated she informed the facility's Social Service Director (SSD) regarding Patient 1’s report of being pushed by her roommate in her room. During a concurrent observation and interview with Patient 1 on 10/18/2022 at 11:24 a.m. in Patient 1’s room, Patient 1 was noted with purplish discoloration and laceration (a deep cut or tear in skin or flesh) across the forehead with stitches. Patient 1 stated, "I was pushed by a lady. It's over. I did not tell on the lady who pushed me. I went to the hospital and was treated, and it's over." During an interview on 10/18/2022 at 12:08 p.m., the Director of Nursing (DON) stated Patient 1 had an unwitnessed fall (unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) on 10/5/2022 during the 3 p.m. to 11 p.m. shift. The DON stated GACH SW called the facility's SSD on 10/7/2022 and reported Patient 1 was pushed by Patient 2 The DON stated on 10/7/2022 GACH SW called the facility and said Patient 1 stated she was pushed by the roommate. DON stated the facility did not notify the local enforcement or CDPH. The DON stated when GACH SW called the facility, Patient 1 was still at the hospital. During an interview on 10/18/2022 at 12:34 p.m., Licensed Vocational Nurse (LVN) stated if a patient alleged to have been pushed by another patient, it would be considered as abuse and would have to be reported to the administrator (ADM), police, and CDPH within two hours. During an interview with the SSD on 10/18/2022 at 1:13 p.m., SSD stated the GACH SW called her on 10/7/2022 around 4:30 p.m. to 5:30 p.m. and stated Patient 1 fell because she was pushed by Patient 2. SSD stated after the call, she reported the allegation to the DON and Administrator. During an interview with the DON on 10/18/2022 at 3:37 p.m., DON stated since Patient 1 stated she was pushed in her room by Patient 2, this was considered physical abuse. The DON stated the report was not made because Patient 1 was not at the facility, and she could not interview the patient. The DON stated for abuse allegations, a report is made to the abuse coordinator and then a suspected dependent adult/elder abuse form report is sent out to CDPH, and the Ombudsman and the police are notified within 2 hours of the alleged incident. There was no documented evidence that the result of the alleged abuse investigation was reported to CDPH within five working days of the incident. A review of the facility's policy and procedure titled, "Abuse, Neglect, Mistreatment and Misappropriation of Resident Property," revised 9/2017, indicated abuse allegations (abuse, verbal abuse, physical abuse, sexual abuse, mental abuse, neglect, isolation, financial abuse, and/or exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will 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. The policy and procedure also indicated a follow up investigation will be submitted to the State Agency within five days. The facility failed to report a physical abuse (the willful action of injury resulting in physical harm which includes, but not limited to, hitting, slapping, punching, biting, and kicking) allegation to the California Department of Public Health (CDPH) within two hours and reporting to CDPH of the results of the investigation within five working days of the alleged incident between Patient 1 and 2. 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.