Other·September 27, 2024

REGULATION VIOLATION § HSC 1418.91(a) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. On 5/27/22 at 4:31 p.m., an unannounced visit was conducted at the facility to investigate a complaint related to Resident 1's bruise on her left lower eye. The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH), when the facility did not follow its policy to notify CDPH of a concern for abuse after Resident 1 suffered a bruised left eye from an unknown source and local police visited the facility to check-in on Resident 1's safety and welfare. This failure did not ensure Resident 1's right to be free from abuse. Findings: During a clinical record review for Resident 1, the Face Sheet (a one-page summary of important information about a resident) indicated Resident 1 was a 102-year-old female who was admitted on 3/26/2019 with diagnoses including Congestive Heart Failure (heart doesn't pump blood as well as it should), Dementia (memory disorder) and Alzheimer's disease (type of dementia that causes problems with memory, thinking and behavior). During a clinical record review for Resident 1, the Minimum Data Set (MDS, a health status screening and assessment tool), dated 7/18/22, indicated Resident 1 had "severely impaired" cognitive ability and "never/rarely made decisions" regarding her tasks for daily life. The MDS indicated Resident 1 had a short-term and long-term "memory problem". During a clinical record review for Resident 1, a licensed nurse's Progress Note dated 5/27/22, at 11:09 a.m., indicated CNA A (Certified Nurse Assistant) had reported to Resident 1's morning nurse a new development of ecchymosis (bruise) to Resident 1's left eye. The progress note indicated on Resident 1 appeared in no distress or fear. The progress note indicated Resident 1 had a tendency to propel herself in wheelchair and would intermittently nap during the day while wearing her glasses. The progress note indicated Resident 1's daughter and doctor had been notified of the new bruise. During an observation and concurrent interview with Resident 1 and Resident 1's Responsible Party (RP) on 5/27/22, at 4:57 p.m., at the front parking lot, Resident 1 was wearing a big, square framed eyeglass. She had a dark purplish discoloration under her left lower eye, starting from the eye's inner corner, and diffused pinkish red discoloration on the outer corner under her left eye. Resident appeared comfortable; no signs of discomfort observed. Resident 1's daughter stated the morning nurse informed her that Resident 1 sustained a bruise on her eye. She stated she arrived at the facility around 10:00 a.m. on 5/27/22 and found Resident 1 "shaken". Resident 1's daughter stated Resident 1 told her she was "hit." When asked Resident 1 how she got the bruise on her left lower eye, Resident 1 did not respond. Then, Resident 1's daughter asked the resident if she was hit, but Resident 1 stated, "no." When Resident 1 was asked if she felt safe, Resident 1 nodded her head affirmatively. Resident 1's daughter stated she had called the police to investigate Resident 1's injury. During an interview with DON (Director of Nursing) B on 5/27/22, at 5:06 p.m., DON B stated the morning nurse informed her on 5/27/22 that Resident 1 had a bruise on her left eye. DON B stated the investigation about the origin of the bruise was ongoing and she planned to talk to the resident's night nurse as well as the CNA to find out how Resident 1 obtained the bruise on her left eye. During a concurrent interview and record review with Administrator C on 6/02/22, at 2:53 p.m., Administrator C verified the Facility policy and procedure titled, "Resident Right, Abuse: Prevention of and Prohibition Against" indicated that bruises, skin tears, and injuries of unknown sources are possible indicators of abuse. Administrator C also verified the policy and procedure indicated that the facility would report allegations of abuse or neglect to appropriate state or Federal agencies, as indicated by policy and applicable regulation. When Administrator C was asked if he reported this concern of abuse or neglect to the state department, he stated, "No, because there was no willful intention to hurt the resident." He stated that on receipt of an allegation or report of abuse, the facility would initiate an investigation into the allegation according to its policy. Regarding Resident 1's injury, Administrator C stated the facility-initiated investigation, though the facility's interdisciplinary team determined there was no need to report the allegation the state agency. Administrator C stated they have an internal document on which staff documented the summary of the facility investigation of what had happened. During an interview with DON B on 7/28/22, at 1:57 p.m., DON B stated a police officer showed up in the afternoon on 5/27/2022 to the facility to conduct a "wellness check" (also known as welfare check, is when visit a person's residence to make sure they are okay) for Resident 1 following a report of a bruise from Resident 1's daughter. Facility policy and procedure titled "Resident Rights, Abuse: Prevention and Prohibition Against," revised 01/2021, indicated "bruises, skin tears and injuries of unknown source" are possible indicators of abuse. The policy and procedure also indicated "all allegations of abuse ... will be promptly and thoroughly investigated by the Administrator or his/her designee." The policy and procedure additionally indicated that "allegations of abuse ...will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes ...." This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.