Other·October 26, 2023

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint #: CA00858552 Survey Re-licensing/Re-certification) Event ID: 18ZR11 Representing the Department, HFEN #42334 State Citation B was written. T22 § 72529. Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including § 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. F609 §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. The facility failed to report alleged violations of misappropriation of properties in accordance with the facility’s Theft Prevention policy when an alleged or suspected case of misappropriation of patient property is reported, the Administrator, or designee, is to notify the following person or agencies within 24 hours: Department of Public Health, Ombudsman, Law enforcement officials for Patient 1. This deficient practice had the potential to result in Patient 1's loss of rights to be free from theft, loss of property, including the loss of a silver white ring and a broken necklace. A review of Patient 1, a 95 years old male Admission Record indicated the facility admitted the patient on 5/21/2023 with diagnoses that included dysphagia (difficulty swallowing foods or liquids), dementia (a group of thinking and social symptoms that interferes with daily functioning), and malignant neoplasm of the prostate (cancer of a man's reproductive system that has spreading to other parts of the body). A review of Patient 1's Minimum Data Set (MDS, a standardized patient assessment and care screening tool), dated 5/13/2023, indicated Patient 1 had impaired decision-making. The MDS indicated, Patient 1 was unable to walk and was extensively dependent on facility staff for dressing, grooming, toileting), except earing that required limited assistance. During interview on 9/6/2023 at 9:30 am, the facility Administrator (ADM) stated that she was aware of Patient 1's son reporting of the patient’s ring missing. She stated that facility staff had seen the ring on the Patient 1's hand prior to the allegation. During an interview on 9/6/2023 at 10:10 am, Social Services Designee (SSD) stated when ADM called and asked her about the lost ring that was the time she made aware of the patient’s missing ring. After the facility could not locate the ring, the next step is to report and investigate the missing property. During an interview on 9/6/2023 at 10:35 am, Licensed Vocation Nurse (LVN1) stated unknown of the date, she saw Patient 1’s son put the patient’s ring, a chain, and sunglasses on Patient 1. Since that time, she had not seen the ring again. She stated she was aware of the allegation that the ring was stolen. During an interview on 9/6/2023 at 10:45 am, Certified Nursing Assistant (CNA1) stated she was aware of the allegation that the ring was stolen. CNA1 stated that misappropriation of property is a form of abuse and that it should be reported to the administrator immediately. During an interview and concurrent record review of Patient 1's medical chart on 9/6/2023 at 11:20 am, ADM stated the patient’s son wrote on Patient 1's inventory of personal effects (belongings), "missing ring! Filed police report." ADM stated we never reported the allegation to authorities because the item in question was not on the inventory. ADM stated the facility did their own investigation, following the facility's policy. During an interview on 9/6/2023 at 11:35 am, ADM stated the facility became aware of the allegation of misappropriation of property on the night of the 8/23/2023 (14 days prior to the interview on 9/6/2023, 11:45 am). During an interview and concurrent record review of Patient 1's medical chart on 9/6/2023 at 1:40 pm, ADM stated the missing ring was not documented anywhere in the medical chart until it was missing. ADM stated we did not report missing ring because it was not documented. ADM stated that it was a form of misappropriation of property and misappropriation of property is a form of abuse and facility did not report it to authorities. A record review of Patient 1's nurses' progress notes dated 8/25/2023 indicated Patient 1’s son informed the facility of the allegation of the theft of his father's ring. A record review of Patient 1's nurses progress notes dated 8/31/2023 indicated Patient 1’s son signed Patient 1's inventory of personal effects (belongings) and wrote on it indicated "missing ring and filed police report." A review of the facility's policy titled, "Abuse Prevention and Prohibition Program," dated 5/1/2023, indicated that, "Facility staff are mandated (required) reporters," and that, "the facility will report allegations of misappropriation of patient property, no later than 24 hours after the alleged violation." A review of the facility's policy titled," Theft Prevention," dated 11/1/2023, indicated that, " When an alleged or suspected case of misappropriation of patient property is reported, the Administrator, or designee, notifies the following person or agencies within 24 hours: Department of Public Health, Ombudsman, Law enforcement officials." The facility failed to report alleged violations of misappropriation of properties in accordance with facility’s Theft Prevention policy when an alleged or suspected case of misappropriation of patient property is reported, the Administrator, or designee, is to notify the following person or agencies within 24 hours: Department of Public Health, Ombudsman, Law enforcement officials for Patient 1. This deficient practice had the potential to result in Patient 1's loss of rights to be free from theft, loss of property, including the loss of a silver white ring and a broken necklace. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.