Health inspection·June 5, 2024

F609 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual’s obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. §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 § 72315. Nursing Service - Patient Care. (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. § 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. On 4/19/24 at 11:40AM, an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care and treatment. The facility failed to: 1. Report an allegation of abuse to California Department of Public Health State Agency in accordance with the facility's policy and procedure. 2. Investigate the alleged incident of abuse after local law enforcement visited Patient 1. The above failures resulted in patient 1 verbalizing feelings of being sexually and verbally abused while residing in the facility and feeling upset, and the facility underreporting allegations of abuse. A review of Patient1’s Admission Record indicated the facility admitted a 67-year-old male on 4/3/2024 with diagnoses including hemiplegia (paralysis on one side of body) and hemiparesis (muscle weakness on one side of body) following cerebral infarction (stroke) affecting left non-dominant side, A review of Patient1’s History and Physical Examination dated 4/9/2024, indicated Patient1 had the capacity to understand and make decisions. A review of Patient1’s Minimum Data Set (MDS, an assessment and screen tool) dated 4/7/2024 indicated Patient1 had moderately impaired cognition and needed some help with self-care, indoor mobility (ambulation) and function cognition (the need for assistance with planning regular tasks). A review of Patient1’s Progress note dated 4/14/2024 timed at 2:13 PM indicated two (2) uniformed local enforcement officers came to facility to speak with Patient1. The progress note indicated Patient1 had concerns about a suppository (a solid but readily meltable cone or cylinder of usually medicated material for insertion into a bodily passage or cavity) not being given. During an interview with Patient1 on 4/19/2024 at 1:14 PM, Patient1 stated he felt sexually and verbally abused by the Administrator (ADM) because the ADM did not respect Patient1’s privacy when discussing the use of a plastic applicator for Patient 1’s prescribed suppository. Patient1 stated the ADM verbalized to Patient1, in a common area within the facility that “you told staff you want the thing up and to twirl it around.” Patient1 stated he was upset with the ADM. During an interview with the Social Services Director (SSD) on 4/19/2024 at 1:38 PM, SSD stated she attempted to speak with Patient1 multiple times after the local enforcement came to the facility to speak with Patient1, however SSD stated she did not document any follow up note after the local enforcement came since the SSD did not speak with the resident. During a concurrent interview and record review of Patient1’s Progress notes with the Director of Nursing (DON) on 4/19/2024 at 2:25 PM, the DON could not find documented evidence to indicate an investigation was done after the local law enforcement was at the facility for Patient1. The DON could not find documented evidence that the SSD attempted to follow up with Patient1 after local law enforcement came to see resident. The DON stated the SSD should have documented that she attempted to follow up with Patient1. The DON stated there should be an investigation and follow up with Patient1 to address what the patient was feeling and make sure Patient1’S psychosocial well-being is intact. A review of the facility’s policy and procedure titled “Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating,” dated 4/2024 indicated all reports of patient abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of patient property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management, findings of all investigations are documented and reported. The facility failed to: 3. Report an allegation of abuse to California Department of Public Health State Agency in accordance with the facility's policy and procedure. 4. Investigate the alleged incident of abuse after the local law enforcement visited Patient 1. The above failures resulted in Patient 1 verbalizing feelings of being sexually and verbally abused, while residing in the facility and feeling upset, and the facility underreporting allegations of abuse. The above violations cause or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Patient 1.