Health inspection·February 14, 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. Title 22 § 72523. Patient Care Policies and Procedures. § 72523. (b) All policies and procedures required, or these regulations shall be in writing. made available upon request to physicians and other involved health professionals. patients or their representatives. employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually. revised as needed and approved in writing by the patient care policy committee An unannounced visit was conducted by California Department of Public Health (CDPH) on 12/29/2023, 9:10 am to investigate a complaint regarding an allegation of patient neglect (the failure of the facility, its employees or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress). The facility staff failed to implement the facility's policy and procedure, titled "Abuse - Reporting and Investigations," by identifying, protecting, reporting to the Department of Public Health, Ombudsman(an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within two hours, and initiating an investigation immediately from a suspected abuse allegation brought up by a patient's family member (FAM 1) to facility staff on 11/23/2023, 11/24/2023, and 11/25/2023, for Patient 1. The facility failed to: 1. Identify an allegation of abuse against CNA 1 made by Patient 1, when FAM 1 reported he allegation on 11/23/2023 to a night shift (11 p.m. to 7 a.m.) facility staff (unable to recall clear staff name), on 11/24/2023 to LVN 1 during the dayshift (7 a.m. to 3 p.m.), and again on 11/25/2023 to LVN 1 during the dayshift (7 a.m. to 3 p.m.), and on 11/25/2023 to CNA 2 during the evening shift (3 p.m. to 11 p.m. shift). 2. Protect Patient 1 from a suspected abuse when CNA 1 continued to work throughout the 11 a.m. to 7 a.m. shift, on 11/23/2023, after FAM 1 reported the abuse allegation. 3. Protect Patient 1 from a suspected abuse when CNA 1 continued to work and was assigned to care for Patient 1 on 11/24/2023 during the evening (3 p.m. to 11 p.m. shift) and night (11 p.m. to 7 a.m.) shifts. 4. Protect Patient 1 from a suspected abuse when CNA 1 continued to be assigned in the same room where Patient 1 was residing after FAM 1 reported an abuse allegation against CNA 1 to LVN 1 and CNA 2 on 11/25/2023. 5. Report Patient 1's allegation of abuse against CNA 1 to the California Department of Public Health (CDPH; State Survey Agency), local law enforcement, Ombudsman (state agency that advocates for the patients) and Adult Protective Services (agency that protects the adults and elderly) on 11/23/2023, 11/24/2023, and 11/25/2023. 6. Investigate an allegation of abuse immediately and thoroughly as indicated in the facility's policy and procedure and immediate actions taken that a facility wide interview was conducted in lieu of Patient 1's abuse allegation against CNA 1. These deficient practices resulted in the facility under reporting allegations of abuse and Patient 1 verbalizing feeling afraid or scared, uncomfortable, agitated, angry, upset, and anxious to sleep. In addition, this deficient practice had the potential for Patient 1 to be at risk of further abuse and also affect other vulnerable patients in the facility to experience possible abuse. A review of Patient 1's "Admission Record," dated 11/03/2023, indicated Patient 1 a 65 years old male was admitted to the facility on 11/03/2023, with multiple diagnoses including depression (feelings of hopelessness, sadness, and a general disinterest in life, which for the most part have no cause and may be the result of a psychiatric illness), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or inability to move one side of the body) following unspecified cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) affecting left dominant side. A review of Patient 1's "Minimum Data Set" (MDS, a standardized assessment and care screening tool), dated 11/10/2023, indicated the patient had impairments with cognitive skills (unable to make own decisions). The MDS indicated Patient 1 required total dependence from staff for toileting hygiene, upper/lower body dressing and bed mobility. A review of a facility report titled "Communications" with an entry date of 11/25/2023 timed at 3:54 p.m., authored by LVN 1, indicated "Attention DSD: Please don't assign (CNA 1) in (Patient 1's room/bed). Per family request." A review of Patient 1's Progress Notes dated 11/27/2023 timed at 10:35 a.m., indicated a "Late Entry" note indicating FAM 1 had complained to the Administrator about an allegation of abuse against CNA 1. The progress note indicated the allegation of abuse was reported to the local police, ombudsman, and the CDPH... The report indicated Patient 1 was referred to a psychologist for evaluation. A review of Patient 1's Progress Notes written by the Psychologist dated 11/27/2023 timed at 3:20 p.m., indicated Patient 1 was alert to person and place and manifested appropriate behavior during the interview session. The report indicated FAM 1 reported Patient 1 "continues to suffer from visual hallucination and changing cognition." The psychologist progress notes did not indicate a discussion or validation of Patient 1's allegation of abuse against a facility staff (CNA 1). A review of the facility's Daily Assignment Sheets for 3 to 11 and 11 to 7 shifts indicated the following information: -On 11/23/2023 - CNA 1 worked during the 3 to 11 shift but was assigned to another room. -On 11/23/2023 - CNA 1 continued to work during the 11 to 7 shift but was assigned to another room. -On 11/24/2023 - CNA 1 worked during the 3 to 11 shift and was assigned to care for Patients 1 and Patient 4 (roommates). -On 11/24/2023 - CNA 1 continued to work during the 11 to 7 shift and was assigned to care for the same patient assignments, that included Patient 1 and 4’s room. -On 11/25/2023 -CNA 1 worked during the 3 to 11 shift and was assigned to care for Patients 1 and 4. However, the assignment indicated a line across Patient 1's bed number but did not indicate the time Patient 1 was reassigned to CNA 2's care. The assignment indicated Patient 1's roommate, Patient 4 continued to be assigned under CNA 1. -On 11/26/2023 - CNA 1 continued to work the next day, during the 3 to 11 shift, now assigned to a room next to Patient 1's room. A review of an untitled facility document dated 12/02/2023, indicated the facility's "conclusive report" regarding Patient 1's allegation against CNA 1. The report indicated that on "November 27, 2023" (Patient 1) informed (FAM 1) that when he was being changed by CNA 1, after having a bowel movement, (Patient 1) felt CNA 1 on the bed. The report indicated that Patient 1 informed FAM 1 that Patient 1 called out for a nurse as CNA 1 placed Patient 1 on his back and saw CNA 1's zipper was open. The report indicated that CNA 1 was contacted that day (11/27/2023) and suspended pending the findings of the investigation. The report indicated that the Social Services Director (SSD) and Director of Staff Development (DSD) had conducted a "facility wide interview and no patient complained regarding the alleged staff." The report indicated the facility concluded there was no evidence of abuse, and the allegation was unsubstantiated. The report indicated "It is believed that the incident was due to hallucinations that have been observed by the psychologist." A review of a facility document titled "Corrective Action Memo" dated 11/27/2023, indicated CNA 1 was suspended from work (4 days after FAM 1 first notification to facility staff) due to an abuse allegation. During an interview with Patient 1's Family Member (FAM 1) on 12/28/2023 at 4:45 p.m., FAM 1 stated, Patient 1 informed her on 11/23/23 that "he almost got raped." FAM 1 stated Patient 1 informed her that CNA 1 was changing his diaper, "pushed him down, his face was down and against the rail, inside the bar..." FAM 1 stated Patient 1 told her he started to scream "Nurse, nurse, nurse." FAM 1 stated CNA 1 was the CNA taking care of him and he was afraid." FAM 1 stated the incident with CNA 1 happened during the nightshift on 11/23/2023. FAM 1 stated she called the facility during the night shift of 11/23/2023 and spoke to a facility staff (unable to recall a clear name) that Patient 1 did not want CNA 1 and requested not to assign Patient 1 under the care of CNA 1. FAM 1 stated, she informed Licensed Vocational Nurse (LVN) 1 during the dayshift on 11/24/2023. FAM 1 stated that LVN 1 stated that other patients had requested not to be assigned to Patient 1 as well and would bring it up to the supervisor. During the same interview, on 12/28/2023 at 4:45 p.m., FAM 1 stated that when she visited the facility on 11/25/2023, she found out that CNA 1 was still assigned to care for Patient 1 during the evening shift. FAM 1 stated she spoke to LVN 1 again and questioned why CNA 1 was still assigned to care for Patient 1. FAM 1 stated later the same day, 11/25/2023, during the 3 to 11 shift, she found out that Patient 1 was removed from CNA 1's care but was still assigned to the same room. with Patient 1's roommate, Patient 4. FAM 1 stated she spoke to CNA 2, the new CNA reassigned to Patient 1 that evening (3-11 shift, 11/25/2023) and informed CNA 2 about Patient 1's "sexual abuse" allegation against CNA 1. FAM 1 stated she told CNA 2 that Patient 1 was afraid of CNA 1 and anxious to sleep knowing that CNA 1 was still coming in and out of the room all night. FAM 1 stated that CNA 2 informed her that she already told her supervisor, and that Patient 1 would be moved to another room but that evening (11/25/2023) would be the same CNA assignment because CNA 1 was not directly assigned to Patient 1 anymore, and there was nothing else they could do. During an interview with LVN 1, on 12/29/2023 at 9:57 a.m., LVN 1 stated that on 11/25/2023, FAM 1 came to the facility and told her that she did not want CNA 1 to care for Patient 1 because he was not comfortable with CNA 1. LVN 1 stated, she spoke to the SSD and the DSD, so CNA 1 was removed from Patient 1's assignment. LVN 1 stated that FAM 1 informed her that Patient 1 did not want CNA 1. LVN 1 stated she did not suspect abuse because when she asked Patient 1 about it, Patient 1 just stated he was not comfortable with CNA 1, so she did not ask further. LVN 1 stated she reported it to the DSD and noted it in the Staff Communication but did not document Patient 1's concern in Patient 1's progress notes. During a concurrent interview with the DSD and LVN 1, on 12/29/2023 at 10:50 a.m., the DSD stated that LVN 1 called her over the phone on 11/25/2023 and informed her that Patient 1 did not want CNA 1 anymore and said, "It was a preference thing." During the interview, LVN 1 stated she called the DSD on 11/25/2023 to inform her that Patient 1 does not want CNA 1 because he was "Not comfortable, but it was not really abuse." LVN 1 stated that the DSD was the one who makes the CNA assignments and that is why the DSD removed Patient 1 out of CNA 1's assignment. During an interview on 12/29/2023 at 3:35 p.m., with CNA 2, CNA 2 stated FAM 1 informed CNA 2 on 11/25/2023 that Patient 1 was uncomfortable and "scared of CNA 1." CNA 2 stated FAM 1 told her that FAM 1 "did not want CNA 1 near Patient 1." CNA 2 explained she did not report FAM 1's concern on 11/25/2023 to anyone because she thought that her charge nurse was already aware of it and removed CNA 1 from Patient 1's care. CNA 2 stated that the facility policy indicated the facility staffs to consider potential abuse if a patient reported they were scared of anyone. CNA 2 stated she should have reported the allegation right away to the charge nurse, registered nurse supervisor and the administrator. During an interview on 12/29/2023 at 3:45 p.m. with CNA 3, CNA 3 stated if a family member said a patient was scared of a CNA, then staff would have to take action right away and CNA 3 would report it to the supervisor right away per protocol. CNA 3 further stated that even if the previous shift ' s charge nurse said that a patient does not want a particular CNA and the family later said the patient was scared of the CNA, then CNA 3 would speak with the charge nurse and still report it right away because that is their responsibility. During another interview on 12/29/2023 at 3:55 p.m., the DSD stated when FAM 1 informed LVN 1 on 11/24/2023 that Patient 1 was not comfortable with CNA 1, and informed CNA 2 on 11/25/2023 that Patient 1 was "afraid of CNA 1," the DSD expected the facility staff to suspect abuse and reported it right away so CNA 1 could be removed completely out of the room immediately per facility's protocol. The DSD further stated it was unacceptable for CNA 2 to assume a report was already made when CNA 2 received the allegation directly from Patient 1's family member. The DSD stated it was important to suspend CNA 2 right after the allegation was made to prevent Patient 1 from further abuse. The DSD stated, failure to take immediate action could result in potential negative outcomes to the patient such as creating more anxiety, and the patient might actually get hurt. During a concurrent interview and record review of the Daily Staffing Assignment for 11/23/2023, 11/24/2023, and 11/25/2023, on 12/29/2023 at 4:10 PM, the DSD stated CNA 1 worked on 11/23/2023, 11/24/2023, and 11/25/2023. The DSD stated, CNA 1 should already be removed from Patient 1's on the night of 11/24/2023 when FAM 1 reported her concern to LVN 1 and CNA 1 should not be assigned to Patient 1's roommate to allow access to the room once FAM 1 reported the issue to CNA 2. The DSD stated that CNA 1's assignment on 11/25/2023 was changed from Patient 1 to Patient 4 (Patient 1's roommate). The DSD further stated CNA 1 should not have been reassigned to care for Patient 1's roommate (Patient 4) because that means CNA 1 would still be entering Patient 1's room. The DSD stated there are many potential negative outcomes for Patient 1 such as increased anxiety, accidents, and a potential for the patient to get hurt. During an interview on 12/29/2023 at 4:50 p.m. with the Administrator (ADM), the ADM stated they were informed of the abuse allegation on 11/27/2023 (two days after Patient 1's family member notified CNA 1) by Patient 1's family member. The ADM stated the expectation from the facility staff was to report the alleged abuse right away if they suspect any abuse. During another interview on 01/03/2024 at 10:09 a.m. with FAM 1, FAM 1 stated, Patient 1 was afraid, not able to sleep, anxious, agitated, angry and upset since 11/23/2023, until he was moved to another room in a different Nursing Station (FAM 1 could not remember when). During an interview on 01/03/2024 at 3:45 p.m. with the ADM, the ADM stated, FAM 1 reported to him on 11/27/2023 that CNA 1 was trying to get on Patient 1's bed per FAM 1's conversation with Patient 1. The ADM stated, FAM 1 informed the charge nurse on 11/23/2023 that Patient 1 was not comfortable with CNA 1 taking care of him. The ADM stated, he was not informed about the incident until 11/27/2023 when FAM 1 came and spoke to himThe ADM stated, he chose random patients that CNA 1 took care of in November to interview and concluded his investigation when they did not complain about CNA 1. During an interview on 12/29/23 at 4:50 p.m. with Administrator (ADM), ADM stated they were informed of the abuse