Health inspection·June 18, 2024

California Code of Regulations, Title 22, Section, 72315 (b) 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. Code of Federal Regulations, Title 42, Section, §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 The facility failed to implement its own abuse policy and procedure (P&P) by failing to investigate and report allegation of abuse and submit the follow up investigation report in a timely manner for Patient 1 and Patient 2. These deficient practices put Patient 1, Patient 2 and other facility's patients at risk for potential abuse by failing to identify and report abuse in timely manner. A review of Patient 1's Admission record, indicated Patient 1 a 80 years old male was admitted to the facility on 9/26/2023 with diagnoses including depression (a constant feeling of sadness and loss of interest, which stops you from doing your normal activities), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread and uneasiness), schizoaffective disorder (a chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors), and insomnia (a sleep disorder that can make it hard to fall asleep or stay asleep). A review of Patient 1's History and Physical (H&P), dated 1/25/2024, indicated Patient 1 has the capacity to understand and make decisions. A review of Patient 1's Minimum Data Set (MDS, standardized care and screening tool), dated 4/1/2024, indicated Patient 1 had moderate cognitive impairment (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Patient 1 required partial/ moderate assistance (helper does less than half the effort) on eating, oral hygiene, toileting, shower bath, personal hygiene. The MDS also indicated Patient 1 has little interest or pleasure in doing things, has been feeling depressed, has trouble falling or staying asleep, and has been feeling tired or having little energy. A review of Patient 2's Admission record, indicated Patient 2, a 65 years old male was admitted on 2/3/2024 with diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder, and insomnia. A review of Patient 2's H&P, dated 2/4/2024, indicated that Patient 2 has no capacity to understand and make decisions. It also indicated that patient also gets easily agitated. A review of Patient 2's Minimum Data Set (MDS, standardized care and screening tool), dated 2/16/2024, indicated Patient 2 had moderate cognitive impairment (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Patient 2 required partial/ moderate assistance (helper does less than half the effort) on eating, oral hygiene, personal hygiene. The MDS also indicated Patient 1 has little interest or pleasure in doing things. During a concurrent interview and record review on 4/30/2024 at 11:25 AM, with Licensed Vocational Nurse (LVN) 1, Patient 1 change of condition (COC) dated 4/22/2024 was reviewed. Patient 1's COC indicated Patient 1 alleged an abuse but did not indicate who was the abuser. LVN 1 stated, on 4/21/2024 she wrote the change in condition for Patient 1. LVN 1 stated that Patient 1 told her that he had his television on, and Patient 2 started banging on the adjoining bathroom door in his side of the room and yelling at Patient 1. LVN 1 stated that Patient 1 started yelling back at Patient 2. LVN 1 stated both patients were offered room change and both refused. Patient 1 refused one-to-one monitoring but stated to have Patient 2 closely monitored as he did not feel safe from Patient 2 as Patient 2 can move around in his wheelchair. During a concurrent interview and record review on 5/1/2024 at 4:04 PM with the administrator (ADM) and Director of Nursing (DON), P&P titled "Abuse Prevention and Prohibition Program," revised on 11/1/2017 was reviewed. ADM and DON stated abuse allegation happened on 4/21/2024, was investigated on 4/22/2024. ADM and DON both stated that incident was investigated but did not report it to California Department of Public Health (CDPH) and did not file the follow up investigation report. ADM and DON both stated there was a communication loss between them, admitted that the abuse allegation was not reported and the follow up investigation report was not submitted to the CDPH. ADM and DON were not able to provide copies of their investigation notes for surveyors to prove the investigation was done. A review of facility's P&P titled, "Abuse Prevention and Prohibition Program," revised on 11/1/2017, indicated "The Investigator provides a copy of the completed investigation report to the Administrator within five (5) working days of the initial report of abuse, mistreatment, neglect, or unexplained injury." The P&P also indicated the Administrator will provide a written report of the results of all abuse investigations and consequent actions to the appropriate agencies. The facility failed to implement its own abuse policy and procedure (P&P) by failing to investigate and report allegation of abuse and submit the follow up investigation report in a timely manner for Patient 1 and Patient 2. This violation had a direct or immediate relationship to the health, safety, or security of Patient 1 and 2, and other patients in the facility.