Other·June 20, 2023

F609 Reporting of Alleged Violations Section 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Section 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. Section 483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Health and Safety Code 148.91 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. The following citation is written as a result of an unannounced visit conducted at the facility on 4/19/23 to investigate complaint CA00835306. The Department determined the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source 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. This failure had the potential to place the resident at risk for further harm. Resident 1 was admitted to the facility on 9/10/19 with diagnoses that included Alzheimer's disease, right below knee amputation and contracture (tightening of muscles that limits mobility) of the left knee. Review of Resident 1's Quarterly Minimum Data Set (MDS-an assessment tool), dated 3/21/23, described him as able to make himself understood and able to understand others. Resident 1's BIMS (a brief screening that aids in detecting cognitive impairment) score was "3" which indicated he had severe cognitive impairment. The MDS described Resident 1 as having no signs or symptoms of delirium or behavioral symptoms. The MDS also described Resident 1 as needing extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. During a review Resident 1's "Nurse's Note," dated 3/29/23 at 2:11 p.m., the note indicated, "Writer informed by the Tx [treatment] nurse of the slowly resolving edema [swelling] to the LLE [left lower extremity]. LLE observed with edema, resident with facial grimacing and verbalization of pain when the left hip and the left knee was touched during assessment. No apparent injury observed...MD [physician] in facility, informed of the findings." During a review of Resident 1's Physician Progress Note, dated 3/29/23 at 6:16 p.m., the progress note indicated, "He ([resident]) was seen today on the request of staff for left lower extremity pain and swelling...He got back from dining room, laying in bed, range of motion of hip and knee elicits significant amount of pain and patient was screaming...No reports of any falls." During a review of Resident 1's "Radiology Report," dated 3/29/23, the report indicated, "There is an acute fracture involving the left proximal tibial [shin bone] metaphysis [the neck portion of a long bone] and fibular neck [lower leg bone] with minimal displacement...Conclusion: Limited exam, though acute appearing left proximal tibial and fibular fractures." Review of a Resident 1's SNF (skilled nursing facility)/NF (nursing facility) Hospital Transfer Form, dated 03/30/23 at 12 a.m., indicated Resident 1 was transferred to the hospital emergency room due to "fracture of tibia/fibula." During a review of an Interdisciplinary team (IDT) note dated 3/31/23 at 11:40 a.m., the note indicated, "IDT met to review resident was reported to have left non displaced comminuted intra-articular proximal tib [tibial] fracture/also an old healing tib/fib [tibial/fibula] fracture. Resident is 93 years old with an end stage dementia and severe osteoarthritis. Resident had left hip fracture upon admission that has healed. Res. [resident] was unable to walk following rehab [rehabilitation] for the left hip fracture d/t [due to] age and cognition. Resident does not appear in pain however pain meds are prescribed. Resident received a splint to lower extremity. IDT recommends insuring Res. keep ortho [orthopedic] F/U [follow up] appointment. Continue pain management as needed, PT [physical therapy] to eval [evaluate] for contracture management. Resident's family aware of POC [plan of care]." During an interview on 4/19/23 at 11:43 a.m., with the Administrator, he was unable to produce any documentation that the facility conducted an investigation of the cause of Resident 1's acute left proximal tibial and fibular fractures. During a telephone interview on 5/16/23 at 2:24 p.m., with the Administrator, when asked if Resident 1's fracture was reported to the Department he stated "No." The Administrator stated they had determined the root cause and that the fractures were "pathological." Review of the facility's policy titled, "Investigating Resident Injuries," revised April 2021, indicated, "All resident injuries are investigated." The policy indicated, "Documentation includes information relevant to risk factors and conditions that could cause or predispose someone to similar signs and symptoms (e.g., receiving anticoagulants, having osteoporosis, having a movement disorder that results in thrashing movement, etc.). a. Descriptions in the medical record must be objective and sufficiently detailed (e.g., dimensions and location of bruises) and should not speculate about causes. 3. If an incident/accident is suspected, a nurse or nurse supervisor completes the facility-approved accident/incident form...7. If the nursing and medical assessment determines an "injury of unknown source" the investigation will follow the protocols set forth in our facility's established abuse investigation guidelines. 8. "Injury of unknown source" is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: (1) the extent of the injury; or (2) the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or (3) the number of injuries observed at one particular point in time..." Review of the facility's policy titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation," revised September 2022, indicated, "All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported." The policy indicated. "If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law." Therefore, the Department determined the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source 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. This failure had the potential to place the resident at risk for further harm.