Health inspection·July 3, 2024

F609 Reporting of Alleged Violations 483.12 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 then 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 f 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. On 6/11/24 at 10:30 a.m., an unannounced visit was conducted at the facility to investigate an allegation of resident safety regarding an injury of unknown origin. The department determined the facility failed to immediately report Resident 1's injury of known origin when Resident 1 was diagnosed with a displaced (pieces of bone moved) radial (the longer of two bones of the forearm) and nondisplaced ulnar (the shorter of two bones of the forearm) fractures (breaks in the bone). This failure increased the potential to impede protection for Resident 1 and decreased the facility's potential to provide Resident 1 with a safe environment. Resident 1 was a 94-year-old female who was admitted to the facility on 5/1/24. Resident 1 had multiple diagnoses which included dementia (impaired ability to remember) without behavior, Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills), unspecified site of disorders of bone density and structure (osteoporosis), history of falls, and muscle weakness. Resident 1's Minimum Data Set (MDS, a standardized comprehensive assessment tool) dated 6/3/24 indicated seven over 15, which revealed moderate cognitive impairment. During an interview on 6/11/24, at 10:57 a.m., with the Director of Nursing (DON), the DON stated on 5/14/24, the Nurse Practitioner (NP) saw the resident due to a complaint of (c/o) pain, and the NP recommended obtaining an x-ray (medical imaging). A review of Resident 1's Practitioner's Progress Notes (PPN) dated 5/14/24, at 4:05 p.m., indicated, "...Pt [patient] seen in [the] room after nursing report she is c/o left forearm pain. Pt with significant tenderness to palpation. She yelps and pulls [her] arm away during the exam. Will obtain x-ray of left forearm." A review of Resident 1's "Radiology Results Report (x-ray)," dated 5/15/24 at 3:52 a.m., indicated, "...LEFT FOREARM...There is evidence of an acute or possibly subacute fracture of the distal radial diaphysis...There is [a] deformity of the distal ulna consistent with [a] distal diaphyseal fracture [wrist fracture] ..." A review of Resident 1's "Daily Documentation (DD)," dated 5/15/24 at 8:35 a.m., indicated at 5:29 a.m., Resident 1 was complaining of pain with a pain level of 6 over 10 (between moderate and severe level). A review of Resident 1's DD dated 5/16/24, at 2:50 a.m., indicated, "Resident noted with pain [8/10] to left arm due to recent fracture..." A review of Resident 1's Interdepartmental Team (IDT) progress notes dated 5/16/24, at 1:33 p.m., indicated, "...IDT to review pt fx. [fracture] of [the] distal end of the L radius. Pt. c/o pain to left arm... was evaluated by NP with rec. [recommendation] for [an] x-ray. X-ray ordered and results indicate fracture to left arm..." A review of Resident 1's PPN dated 5/16/24, at 6:08 p.m., indicated, "...Pt [was] seen in [the] room after x-ray results come back showing a new fracture of left arm..." During an interview on 6/11/24, at 11:20 a.m., the DON confirmed she was aware of Resident 1's left arm fracture and stated, "...Yes, I investigated...did not know the cause of the fracture..." The DON acknowledged that Resident 1's fracture was an injury from an unknown source. During an interview on 6/11/24, at 11:42 a.m., the DON confirmed and stated, "...We didn't report it [Resident 1's fracture] ..." A review of the facility's policy and procedure titled "...Abuse Investigation and Reporting," revised July 2017, indicated, "All reports of resident...mistreatment and/or injuries of unknown source...shall be promptly reported to...state...agencies...All...injuries of unknown source...will be reported immediately...The Administrator, or his/her designee, will provide the appropriate agencies...with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident." Therefore, the department determined the facility failed to immediately report Resident 1's injury of known origin when Resident 1 was diagnosed with a displaced radial and nondisplaced ulnar fractures. This failure increased the potential to impede protection for Resident 1 and decreased the facility's potential to provide Resident 1 with a safe environment. This violation had an immediate relationship to the health, safety, or security of patients or residents.