Hi-desert Medical Center D/p Snf

During an interview on August 25, 2025, at 11:32 AM, with the Director of Nursing (DON), the DON stated, the visitor placed his hand on Resident 1's arm and he had been interfering with Resident 1's care.

The DON stated from what the nurse told me [the visitor] was touching [Resident 1] by helping [Resident 1] get in and out of bed. feeding [Resident 1] and taking food off [Resident 1's] tray. [Resident 1] is a diabetic and [Resident 1] has Alzheimer's [a form of dementia] and unable to consent. [CNA1] gave a statement where she observed [the visitor] eating off [Resident 1's plate and touching [Resident 1's] hand and [the visitor] was asked to leave the room.

The DON stated LVN2 tried to get the visitor to leave Resident 1's room on August 15, 2025, and he refused.

The DON stated LVN2 was concerned about Resident 1's safety.

The DON stated she was made aware of LVN2's nursing note that informed of the event on August 20, 2025 (five days after the incident).

The DON stated that everybody was a mandated reporter and should report right away which did not occur.

During an interview on August 25, 2025, at 1:44 PM, with LVN2, LVN2 stated she observed the visitor enter Resident 1's room accompanied by Resident 3 where she had line of sight and I saw [the visitor] lean over [Resident 1]'s bed to try to wake her up.

And I don't know 100% if [the visitor] touched [Resident 1]. I said please don't wake her up.

Then [the visitor] touched [Resident 1]'s meal tray and said to me he was trying to wake her up and help her eat. I told [the visitor] to please leave the room and he was asking why. I said [Resident 1] can't eat anything until blood sugar is checked and told him she needs to sleep and that's when he started (questioning me). I thought [the visitor] had left but he was back, and he apologized for questioning and the way that he spoke to me. I told my charge nurse that day and what happened, and [RN1] said I did the right thing . We went to [Resident 1] on August 20, 2025, to interview [Resident1].

She didn't remember any occurrence of that. LVN2 stated she was told by the DON on August 20, 2025, that she should have reported the incident and should have known. LVN2 confirmed that CDPH was not notified until August 20, 2025 (five days after the incident).

During an interview on August 25, 2025, at 2:02 PM, with the DON, the DON stated, as far as reporting there was a delay of five days.

The DON further stated, at the time of the event, RN1 and LVN2 should report the incident to the DON who was the abuse coordinator and reported it to the Administration at the hospital.

The DON stated that she helped LVN1 filled out the SOC 341 on August 20, 2025.

The DON stated she was notified by the MDS (The Minimum Data Set is a standardized assessment tool that measures health status in nursing home residents) nurse who found LVN2's nursing note, dated August 16, 2025, during record review for Resident 1's plan of care meeting.

During concurrent interview and record review on August 29, 2025, at 3:30 PM, with the DON, the facility's policy and procedure (P&P) titled, RESIDENT ABUSE, NEGLECT PREVENTION, INVESTIGATION AND REPORTING, dated November 21, 2017, was reviewed.

The P&P indicated, .IN THE EVENT OF AN INCIDENT OR ALLEGATION OF ABUSE: Staff Member's Responsibility: .E.

Reporting is the individual responsibility of the mandated reporter. No one may prohibit the filing of a required report .Charge Nurse or Supervisor Responsibility: .F.

All allegations of abuse that DO NOT result in serious bodily injury are reported within 24 hours to the administrator of the facility, the State Survey Agency (CDPH) and the ombudsman in accordance with State law through established procedures.

The DON stated that this P&P was not followed.

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