Health inspection·July 28, 2023

§483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under §483.75. §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. §483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. §483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act. §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. §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. §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. 22 CCR §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 6/23/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint investigation about a sexual assault allegation. The facility failed to implement its abuse prevention, investigation, and reporting policies and procedures for Resident 1 by not reporting to CDPH and not investigating Resident 1's allegation of being sexually abused by Licensed Vocational Nurse 1 (LVN 1) on 6/16/2023. Registered Nurse 1 (RN 1) also failed to remove LVN 1 from Resident 1’s care immediately when the abuse allegation was made. As a result, this had the potential for unidentified abuse and failure to protect other residents from abuse. A review of Resident 1’s Admission Record indicated the facility admitted the 65-year-old male resident on 11/17/2022 with diagnoses including metabolic encephalopathy (a condition in the brain caused by chemical imbalance in the blood due to an illness or organs in the body that are not working well as they should), epilepsy (a general term for conditions with recurring seizures [a sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain]), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life). A review of Resident 1’s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 5/25/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and did not have behavior issues. The MDS indicated Resident 1 required supervision from staff with eating, limited assistance with bed mobility and locomotion on and off unit, and extensive assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 1’s Situation, Background, Assessment, and Recommendation (SBAR) Communication Form and Progress Note, dated 6/16/2023, indicated Resident 1 was restless, yelling and cursing, verbally abusive to staff and other residents, and accused LVN 1 of touching his buttocks. Resident was self-responsible, and the primary care clinician was notified on 6/16/2023 at 1 p.m. A review of Resident 1’s Progress Notes dated 6/22/2023 written by the Administrator (Adm), indicated Resident 1 approached the Adm at 11:30 a.m. regarding a grievance that he was sexually assaulted by a medication nurse. During an interview on 6/23/2023 at 9:10 a.m., Resident 1 stated that at the beginning of the current month, a medication nurse touched his buttocks after giving his morning medication. During an interview on 6/23/2023 at 9:50 a.m., LVN 1 stated Resident 1 accused him of touching his buttocks on 6/16/2023, reported the allegation to RN 1, and documented in the SBAR. LVN 1 stated he continued to work until 11 p.m. and remained assigned to Resident 1. LVN 1 stated the allegation of abuse should have been reported to the Adm for Resident 1 and other residents’ safety. During an interview on 6/23/2023 at 10:25 a.m., RN 1 stated LVN 1 notified her regarding Resident 1 yelling, cursing, and false accusations of sexual abuse by LVN 1. RN 1 stated the allegation was not reported to the Adm and LVN 1 continued to work until 11 p.m. and remained assigned to Resident 1. RN 1 stated LVN 1 should have been sent home and the allegation of sexual abuse reported to the Adm then to CDPH within two (2) hours the allegation was made per facility policy for Resident 1 and other residents’ safety. During an interview on 6/23/2023 at 1:34 p.m., the Director of Nursing (DON) stated that she was on vacation when the incident happened and was not notified of the alleged sexual abuse on 6/16/2023. The DON stated the allegation of sexual abuse should have been reported to the Adm and SSA per facility's policy for Resident 1’s and other residents’ safety and well-being. During an interview on 6/23/2023 at 4:30 p.m., the Administrator stated that she is the facility’s Abuse Coordinator. The Adm stated LVN 1 should have been sent home when the allegation of sexual abuse was reported to RN 1 on 6/16/2023. The Adm stated that the allegation of sexual abuse was not reported to her and that per facility's policy, any allegations of abuse should be reported to CDPH, Ombudsman, and to the law enforcement for timely investigation and for Resident 1 and other residents’ safety and well-being. A review of the facility’s policy and procedure titled, “Abuse - Reporting and Investigations,” last reviewed on 1/26/2023, indicated a purpose that all reports of resident abuse are promptly reported and thoroughly investigated to protect the health, safety, and welfare of residents in the facility. The policy also indicated the following: 1. Allegations of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime to be reported to the Administrator or designated representative immediately. 2. The Adm or designated representative will notify CDPH by telephone and in writing within two hours of initial report. 3. If the suspected perpetrator is an employee, remove and suspend immediately pending outcome of the investigation. The facility failed to implement its abuse prevention, investigation, and reporting policies and procedures for Resident 1 by not reporting to CDPH and not investigating Resident 1's allegation of being sexually abused by LVN 1 on 6/16/2023. RN 1 also failed to remove LVN 1 from Resident 1’s care immediately when the abuse allegation was made. As a result, this had the potential for unidentified abuse and failure to protect other residents from abuse. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1.