Palos Verdes Health Care Center
26303 Western Ave Lomita, CA 90717
Citation Number: 910007238
Citation Date: 10/3/2013
Violation Date: 10/30/2009
Class: B
Penalty: $2,000

CLASS B CITATION - ABUSE/FACILITY NOT SELF REPORTED

F 225 Abuse
483.13(c) (2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).

483.13(c)(3)
The facility must have evidence that all alleged violations are thoroughly Investigated, and must prevent further potential abuse while the Investigation is in progress.

483.13 (c)(4)
The results of all investigation must be reported to the administrator or his designated representa1ive and to other officials In accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

F226 483.13(c) Staff Treatment of Residents
The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.

The Department received an entity reported incident (CA00206906) on November 2, 2009, and two complaints, received in December 2009 (CA00209940 and CA00210360) after a resident (Resident 1) alleged that a licensed vocational nurse (LVN 1) sexually abused her on three separate occasions while providing care. First kissing her, then grabbing her breast, and most recently touching her private area.

On November 17, 2009, an unannounced visit to the facility to Investigate the complaint was conducted.

Based on interview and record review, the facility failed to protect Resident 1 and implement its abuse policy and procedure by failing to:

1. Report the allegation of sexual abuse to the oncoming shift, since the allegation occurred at 6 a.m.

2. Notify the Department of Public Health and/or Ombudsman of the abuse allegation timely.

3. Immediately remove LVN 1, during the investigation to keep the resident safe. as indicated in its policy.

These failures resulted in Resident 1 feeling depressed. anxious, and unsafe.

On November 17, 2009, a review of Resident 1's clinical record indicated she was a 55 year-old female admitted to the facility on June 5, 2009, with diagnoses that included hypothyroidism (thyroid gland does not produce a sufficient amount of the thyroid hormones), bipolar disorder (alternating moods of mania with episodes of depression}, and insulin dependent diabetes mellitus (requiring insulin to control blood sugar levels).

A review of an annual Minimum Data Set (MDS), a standardized assessment and care screening tool, dated September 2, 2009, indicated the resident's long and short-term memory was intact. The resident's cognitive skill for daily decision-making was moderately impaired (with some difficulty in new situations). She had the ability to make herself understood and understand others. The resident required limited assistance (one-person assist) with transferring, personal hygiene, and toilet use, and extensive assistance with dressing and bathing.

A review of a Resident Abuse Report Form, dated November 2, 2009, indicated the incident occurred on October 30, 2009, between the hours of 6-6:30 a.m., on the 11 p.m.-7 a.m. shift in Resident 1's room. The report, which was written by 1he director of nursing (DON), indicated the resident had no behaviors such as sexual misconduct, making similar allegations, and/or any verbal or physical behaviors. The form Indicated the department was not notified of the abuse allegation until November 2, 2009.

On November 17, 2009, a review of the facility's inves1igation indicated the allegation was not thoroughly investigated. The interviews only consisted of interviews with the resident, the residen1's family member, the alleged perpetra1or (LVN 1), and a certified nursing assistant (CNA 1). There was no indication the facility had interviewed any other residents that LVN 1 provided care to or any other night-shift staff LVN 1 supervised as indicated in the facility's abuse policy.

During an interview, on November 17, 2009, at 3:15 p.m., the DON stated the investigation of LVN 1 touching Resident 1 was still in progress, which was 18 days after the allegation. According to the schedule LVN 1 was working during the facility's investigation.

On November 17, 2009, at 3:30 p.m., during an interview, Resident 1 stated that in the early morning of October 30, 2009, LVN 1 came into her room to administer her insulin (used to remove excess glucose from the blood, which otherwise would be toxic) and put his hand down her stomach and touched "her crotch" (her private part). The resident stated she yelled out and CNA 1 came into the room and she told CNA 1 what had occurred. The resident stated CNA 1 brought LVN 1 back into her room and he was very angry and called her a liar in front of CNA 1. Resident 1 stated LVN 1 had kissed and fondled her breast on two other occasions while he was providing care to her. Resident 1 stated CNA 1 told her to call the police the next time the LVN did something to her. According to the resident, and as indicated in the social service progress note, dated October 30, 2009, and timed at 8:30 a.m., it was the resident who reported the sexual abuse and not LVN 1 or CNA 1.

On November 17, 2009, at 5 p.m., the administrator stated LVN 1 was not suspended,but should have been until the investigation was completed. The administrator stated, l have to weigh things, because I have known the LVN since the year 2000."

On December 7, 2009, at 9:05 a.m., during an interview, LVN 1 stated he went into Resident 1's room on October 30, 2009, at around 6 a.m., to give her insulin. LVN 1 stated after giving the insulin injection to the resident he went back to the nursing station. He stated CNA 1 called him into Resident 1's room because the resident had complained that he held her private part. LVN 1 stated he made documentation in the resident's chart regarding the incident, but did not call the administrator, DON, and/or report the incident to the oncoming shift. LVN 1 stated he was too tired to call and tell anyone when his shift was over. He stated he wrote a narrative report on November 2, 2009, to give to the administrator regarding the incident. LVN 1 stated he was not suspended until November 18, 2009, which was a day after the allegation was investigated by the Department, and 19 days after the alleged sexual abuse.

LVN 1 stated the policy of the facility for an abuse allegation was to report the allegation to the administrator, the DON, and to the police as soon as possible, but stated he did not do so. He also stated the investigation should start immediately and the alleged perpetrator should be suspended.

A review of the facility's policy titled, "Abuse Investigation Protocol" dated June 2000, the following was included under investigation:

1. Upon receipt of any allegation, the administrator or designee will thoroughly investigate the situation.
2. The individual in charge of the abuse investigation will notify the ombudsman.
3. Employees accused of resident abuse will be suspended from duty while investigation is pending.
4. Interview other residents to whom the accused employee provides care or services.
5. Interview staff members who have had contact with the resident during the 48-hour period prlor to the time of the incident.

On December 10, 2009, at 9 a.m., during a telephone interview, CNA 1 stated on October 30, 2009, around 6 a.m., she heard Resident 1 screaming her name. CNA 1 stated she went into Resident 1's room and had to calm her down. CNA 1 stated Resident 1 showed her how LVN 1 grabbed her crotch. CNA 1 stated she went to LVN 1 and brought him to the resident's room. CNA 1 stated LVN 1 was irate and told the resideni she was a liar. The resident demonstrated again what he did. CNA 1 stated Resident 1 does not lie, and had told her of a previous incident of LVN 1 kissing her. CNA 1 was asked what she did with the information of the LVN kissing the resident. CNA 1 stated she was not on duty during the time of the kissing occurred, but stated the resident informed her she had reported the incident to the social worker. CNA 1 stated,
*After the incident on October 30, 2009, LVN 1 would call me to go into Resident 1's room with him, because if he went by himself, the resident would scream. CNA 1 stated Resident 1 would become upset every time LVN 1 was around her.

The facility failed to protect Resident 1 and implement its abuse policy and procedure by failing to:

1. Report the allegation of sexual abuse to the oncoming shift, since the allegation occurred at 6 a.m.

2. Notify the Department of Public Health and/or Ombudsman of the abuse allegation timely.

3. Immediately remove LVN 1, during the investigation to keep the resident safe, as indicated in its policy.

The above violation had a direct relationship to the heanh, safety, or security of Resident 1.