Health inspection·December 19, 2024

§ 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. Title 22: § 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. Title 22: § 72527 Patients’ Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. F600 §483.12 Freedom from Abuse, Neglect, and Exploitation. The Patient has the right to be free from abuse, neglect, misappropriation of patient property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the Patient’s medical symptoms. §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. An unannounced visit was conducted by California Department of Public Health (CDPH) on 11/22/2024, to investigate a complaint regarding an allegation of employee to patient sexual abuse (non-consensual sexual contact of any type with a resident). As a result of the investigation, the Department determined that the facility failed to: 1. Prevent Patient 1 from being sexually abused by Certified Nurse Assistant (CNA) 1 on 7/20/24. 2. Implement the facility’s policy and procedure “Abuse Prevention and Prohibition Program,” dated 8/1/2023, when CNA 1 sexually abused Patient 1 on 7/20/24. These failures resulted in Patient 1 being subjected to sexual abuse by CNA 1 on 7/20/2024. Based on psychiatric evaluation conducted on 7/24/2024, Patient 1 was assessed being anxious, irritable, making intermittent (not happening regularly or continuously) eye contact, withdrawn (not wanting to communicate with other people), and affect (a response to some event) was tearful and cried unconsolably (in a state of extreme sadness or disappointment where no one can make you feel better). A review of Patient 1's Admission Record indicated the facility admitted the patient on 9/30/2021, a 49-year-old female, with diagnoses including aphasia, hemiplegia and hemiparesis following cerebral infarction () affecting right dominant side, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Patient 1's Minimum Data Set (MDS – a patient assessment tool), dated 5/3/2024, indicated Patient 1 had severe impairment of cognitive (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) skills for daily decision making. The MDS indicated Patient 1 required supervision with eating and required maximal assistance (helper does more than half the effort) from staff with oral hygiene, toileting, showering, dressing and personal hygiene. The MDS indicated Patient 1 required maximal assistance (helper does more than half the effort) for rolling from lying on back to left and right side, transfers, and with wheels herself at least 150 feet once seated on the wheelchair. A review of Patient 1’s Care Plan (CP), dated 4/2/2024, indicated Patient 1 has a communication problem related to aphasia. The staff interventions included were to anticipate and meet Patient’s needs and to monitor/document Patient’s ability to express and comprehend language. A review of Patient 1’s CP, dated 4/1/2024, indicated Patient 1 has an Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily) performance deficit (loss/lacking) related to hemiplegia. The staff interventions included were to check the Patient at least every two hours and as needed for soiling (to make something dirty) and wetness, encourage Patient to complete tasks, and provide reinforcement for activities attempted and/or partially achieved. During an interview on 11/22/2024 at 1 PM, Patient 1 stated there was an incident when a male staff abused her. Patient 1 stated she cannot remember the exact date and time, but she remembered that it was after dinner. Patient 1 stated that while she was in bed, a male CNA (no name, unable to remember) repositioned her in bed and Patient 1 felt pain on her hip. Patient 1 stated she does not want to talk about it further. A review of a facility form titled, “Change in Condition (COC) Evaluation,” dated 7/20/2024, timed 7:38 PM, indicated at 6:50 PM on 7/20/2024, Patient 1 reported to Licensed Nurse that a male CNA touched her private area (genital organs) when CNA was assisting her with incontinent (involuntary loss of bladder or bowel control) diaper change. A review of the Staffing Assignment on dated 7/20/2024, indicated CNA 1 worked in the facility during the 3 PM to 11 PM shift and was assigned to care for Patient 1. A review of the facility's Final Investigation and verification report summary, dated 7/25/2024, indicated on Saturday 7/20/2024 at approximately 6:50 PM,, the Director of Nurses (DON) was notified about Patient 1’s allegation of sexual abuse from CNA1. The report indicated Patient 1 was noted to be visibly upset and claimed assigned male CNA (CNA 1) touched her private area while CNA 1 was assisting her during incontinent brief change. Patient 1 motioned to brief and repeated "Mira, Sangre, Sangre (Spanish for: look, blood, blood)." Scant serosanguineous (a combination of blood and clear fluid) fluid noted on Patient 1’s incontinent brief (diaper) as assessed by LVN 1 and Registered Nurse 1 (RN 1). Patient noted with facial grimacing and continued to motion towards perineal area, but ultimately unable to describe any pain. Upon genitourinary (the urinary and genital organs) assessment, Patient 1 was noted with light pinkish fluid from vaginal area. There were no new skin injuries or discoloration noted to perineal area. During an interview on 7/24/2024 at 10:17 AM, the DON stated Director of Staff Development (DSD) contacted the Registry agency where CNA1 was employed and reported the abuse allegation on 7/20/2024. The DON stated the Registry agency was made aware that the facility will no longer utilize the services of CNA1. During an interview on 11/22/2024 at 3 PM, DSD stated CNA 1 had not been back to the facility to work since 7/20/2024. The DSD stated CNA 1 was detained in jail on 7/20/2024. The DSD added facility made sure CNA 1 was not on the list of registry CNAs that were being sent to the facility. A review of the General Acute Care Hospital (GACH) Emergency Department History and Physical (H&P), dated 7/21/2024, timed 12:27 AM, indicated Patient 1 was brought in from nursing facility who reported Patient 1 had accused a male nursing staff of sexually assaulting (an act of sexual abuse in which one intentionally sexually touches another person without that person's consent) her earlier that day. The H&P also indicated Patient 1 stated that CNA 1 digitally penetrated (to move into or through something) his penis into the Patient’s vagina. A review of the GACH Sexual Assault Response Team (SART), dated 7/21/2024, timed at 2:45 AM, indicated findings included bruising bilaterally on the inner labia minora (a pair of small, hairless folds of skin that form the inner lips of the vulva [female genital]). A review of the GACH SART amended report, dated 7/23/2024, indicated “Upon review of the genital photos, the patient had vaginal bleeding which makes it difficult to fully visualize the genitalia. Therefore, examiner is not able to confirm the bruising documented on the “923 report” (Forensic Medical Report [a report to clearly convey what has or has not happened to a victim based on evidence]: Acute Adult Sexual Assault Examination) as a genital finding. The examiner was not able to also confirm the source of vaginal bleeding. Patient (Patient 1) disclosed to examiner that she does not have menstrual cycles, however due to patient’s history of stroke [damage to the brain from interruption of its blood supply] and verbal impairment as patient was struggling to articulate, examiner is unsure if the bleeding is from a menstrual cycle, or a medical condition and/or from injury.” It also indicated GACH performed a pregnancy test, and results were negative. A review of the Nurse’s Progress Notes dated 7/21/2024, the notes indicated Patient 1 returned from GACH via stretcher accompanied by 2 Emergency Medical Technician (EMT, provide emergency medical care). A review of Patient 1's Psychiatric evaluation (a clinical assessment of a person's mental health that can help diagnose and treat mental health conditions) report, dated 7/24/2024, indicated Patient 1 was anxious and irritable, making intermittent (not happening regularly or continuously) eye contact. Patient 1’s mood was withdrawn (not wanting to communicate with other people), and affect (a response to some event) was tearful. The report indicated that according to staff, Patient 1 had mood instability (when there is no control over moods resulting in difficulty managing behaviors), cried unconsolably (in a state of extreme sadness or disappointment where no one can make you feel better), and had difficulty being redirected. The report also indicated Patient 1 accused CNA1 of sexually assaulting her. A review of the local law enforcement reports released on 11/27/2024, the reports indicated the following: 1. The Police Department (PD) Patrol Report, dated 7/21/2024, indicated Police Officer 1 (PO1) requested local Fire Department to respond to the location with an ambulance to transport Patient 1 to General Acute Care Hospital (GACH). 2. The PD Patrol Investigation Report, dated 7/21/2024, indicated on Saturday, 7/20/2024, at approximately 6 PM, while Patient 1 was lying down on her bed, a male nurse exited the bathroom door and walked over to Patient 1’s bedside. The nurse raised Patient 1’s bed upwards and lifted both of her legs up. The nurse then pulled down his pants and penetrated her with his penis, which caused pain. Patient 1 could not state how many times she was penetrated or how long he penetrated her for. As Patient 1 was explaining what occurred to the Police Officers, Patient 1 kept gesturing with her left hand inward and outward and pointing towards her vagina. Patient 1 also stated, "There is proof inside," and again pointed towards her vagina. Patient 1 described the suspect as a male, white, young, wearing a black hat. 3. The PD Patrol Supplemental report, dated 7/21/2024, indicated CNA 1, CNA 2, and Licensed Vocational Nurse 1 (LVN 1) were interviewed by PO 2. The PD Patrol Supplemental report indicated the following: a. CNA 1 stated he picked up a registry (agency that offers healthcare related contracts for nurses) shift at the facility, which started at 3:20 PM on 7/20/2024. b. CNA 1 stated Patient 1 asked him to have her diaper changed after dinner. CNA 1 stated, at approximately 6:15 PM, Patient 1 was sitting in her wheelchair beside the bed. CNA 1 assisted Patient 1 to her bed and had her lie down on her back. CNA 1 stated he prepared warm wash cloths to conduct the diaper change. CNA 1 stated he had gloves covering his hands and proceeded to wrap the washcloth around his pointer and middle finger and wipe Patient 1’s vagina in a downward action toward her anus. CNA 1 stated he noticed some pus on the washcloth as well as a small amount of blood. CNA 1 stated he showed Patient 1 that she was bleeding, and Patient 1 said "Sí, Sí (Spanish for: yes, yes)." c. LVN 1 stated on 7/20/2024, approximately 6:30 PM, she entered Patient 1’s room and provided her medication. Approximately 30 minutes after, Patient 1 arrived in the nursing station and began telling the nurses that she had been sexually assaulted. d. CNA 2 stated that on 7/20/2024, she was at the nursing station with LVN 1 when Patient 1 rolled toward them in her wheelchair. CNA 2 stated although Patient 1 spoke Spanish, she had a hard time understanding what Patient 1 was saying. CNA 2 stated she began looking at Patient 1’s gestures and believed she was telling them that a man had intercourse (sexual activity involving insertion and thrusting of the male penis inside the female vagina) with her. 4. The Forensic Medical Report, dated 7/21/2024, indicated Patient 1 was examined for Adult Sexual Assault examination (a full body examination, including internal examinations of the mouth, vagina, and/or anus). The forensic medical report indicated Patient 1 stated, "The suspect (CNA1) held her legs up and entered her five (5) or six (6) times.” The report indicated Patient 1 had vaginal bleeding and was crying when describing the attack. It also indicated genital examination was done and specimens (dried and moist secretions, stains, and foreign materials) were collected. 5. The Detective investigation Report, dated 11/19/2024, regarding the incident on 7/20/24, indicated semen was detected in Patient 1’s vagina and perianal area (the area of the body surrounding the anus [butthole]), and that suspect CNA 1 was the contributor. Detective 1 conducted an interview with CNA 1 and the Detective investigation report indicated the following: a. CNA 1 was asked about what happened on 7/20/2024, CNA 1 answered, “He went in Patient’s (Patient 1) room after dinner to change the Patients. CNA 1 said Patient 1 kept tapping her hand on her vagina (over her diaper and gown) and he believed she "wanted me to, like, do stuff with her." CNA1 stated he declined and proceeded to change Patient 1 like “normal.” b. CNA 1 stated Patient 1 went to the nurse's station and told them (CNA2 LVN 1) in Spanish that he (CNA1) stuck his penis inside her and made her bleed. c. CNA 1 was asked about the tapping motion he described Patient 1 did, CNA 1 answered Patient 1 wanted him to touch her vagina because of how she was touching it. d. CNA 1 was asked what made him believe Patient 1 was telling him she wanted him to touch her sexually rather than change her diaper, CNA 1 responded, "I don't know what she wanted me to do" and "I don't know what she was trying to say, like I said, it's a different language, you know what I mean, I don't know what she was trying to say." e. CNA 1 stated he heard Patient 1 claimed CNA 1’s "big fat penis made her bleed." I asked him if it did, and he responded, "I don't know, did it?" f. CNA 1 was asked why his semen would be in Patient 1’s vagina, and he denied putting any semen in her vagina. g. DNA report (a document detailing the results of a DNA analysis, which compares an individual's DNA profile to another sample) was showed to CNA 1, and CNA 1 changed his story to having consensual (with consent) sex with Patient 1. h. CNA 1 stated Patient 1 put her fingers in her vagina and then grabbed his hand and put it in her vagina because she was "horny (feeling or arousing sexual excitement)." CNA 1 said he denied having sex with her because, "It's embarrassing to say you had sex with a 60 something year old woman." He added he is messed up and he did not use good judgment. He repeatedly said he did not rape Patient 1 and that she wanted it. During a concurrent observation and interview on 11/26/2024 at 4:21 PM, with Patient 1 in the conference room, in the presence of Social Service Director (SSD), Patient 1 was observed to have difficulty communicating and agreed to have the SSD help and translate her statement in English. Patient 1 stated there was a time when she told a male CNA (no name, unable to remember) to change her diaper after dinner time. Patient 1 stated that she was in bed when the male CNA came to her room. Patient 1 stated she saw the CNA’s penis in her vagina, and she felt it was inserted twice. Patient 1 stated CNA 1 grabbed and held her leg up and repositioned her that was wh