Health inspection·October 10, 2024

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. (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) The following citation was written as a result of an unannounced visit to the facility on 10/1/24 for a Standard Abbreviated Survey. As a result of the investigation, The California Department of Public Health (CDPH) determined that the facility failed to report an incident of an injury of unknown origin for one of three sampled residents (Resident 1) as required by the regulations. This failure resulted in a delay in the abuse investigation process and decreased the facility's potential to protect patients from physical and psychosocial harm. Findings: During a review of Resident 1's admission records, the records indicated Resident 1 was admitted January 2020 with diagnoses that included dementia (memory loss), history of falling, and osteoporosis (bones become weak and brittle). Resident 1's Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had severe cognitive impairment and did not exhibit physical and verbal behaviors towards self and other people. During a review of Resident 1's "SBAR [Situation, Background, Assessment, Recommendation] Communication Form," dated 9/1/24, the form indicated Resident 1 had a fall on 9/1/24. The notes further indicated, "With small scrape to left knee and red mark to back of head left side. Denies pain upon assessment." During a review of Resident 1's neurological checklist, dated 9/4/24, the checklist indicated, "Yes" was marked for the question, "Movement and sensation intact in right arm?" During a review of Resident 1's nurse's progress notes, dated 9/20/24, the notes indicated, "Resident upon assessment, noticed right wrist swelling. Painful to the touch, no ROM [range of motion] to the site...No swelling noted elsewhere. Cannot recall what happened...x ray [imaging that creates pictures of the inside of the body] ordered and wrist wrap in place..." During a review of Resident 1's change of condition notes, dated 9/20/24, the notes indicated, "...swelling noted to Right Wrist with subtle discoloration noted...When asked of pain status, resident stated that it hurts a lot. Resident currently a poor historian to cause of swelling to Right Wrist; has dx [diagnosis]: dementia. Limited ROM to Right Wrist, ROM reduces from baseline." During a review of Resident 1's "SBAR Communication Form," dated 9/20/24, the form indicated under "Pain Evaluation" that the resident had pain and that the pain is new. The form further indicated, "Resident has swelling to the right wrist. Swelling noted to the site...No recollection of injury...New order for wrist x ray and ace wrap [elastic bandage] to the site..." During a review of Resident 1's "Radiology [medical specialty that uses imaging to diagnose diseases] Report," dated 9/20/24, the report indicated, "Results: There is a fracture [break in a bone] involving the distal ulnar shaft [one of the two bones of the forearm] with displacement [ends of broken bone are no longer aligned]. There is associated soft tissue swelling." During a review of Resident 1's nurse's progress notes, dated 9/20/24, the notes indicated, "Resident had x-ray done to her right wrist during the start of the shift d/t [due to] complains of pain and swelling. Result is a fracture involving the distal ulnar shaft with displacement. DON [Director of Nursing] informed [name of doctor], per [doctor] send resident to ER [emergency room]...Resident sent out at about 1800 [6 p.m.]." During a review of Resident 1's hospital after visit summary, dated 9/21/24, the summary indicated, "Reason for Visit...Wrist pain...Diagnosis...Closed fracture [bone breaks but the skin remains intact] of right ulna, unspecified fracture morphology [study of the bone surface features]." During a concurrent observation and interview on 10/1/24 at 12:37 p.m. with Resident 1 in her room, Resident 1 was observed alert, calm, lying on bed, head of bed elevated with both upper side rails up, and had a splint on her right arm covering the wrist to the elbow. Resident 1 smiled when spoken to but did not answer questions verbally. When asked what happened to her arm, Resident 1 did not answer. During an interview on 10/1/24 at 12:41 p.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated, "...she had a swollen wrist, and it was broken, we don't know what happened." During an interview on 10/1/24 at 12:52 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated, "...I fixed her blanket and I saw her wrist was swollen, I went to get ice, we told the NP [Nurse Practitioner], and had Xray done...Until now she can't give me a clear explanation of what happened." During an interview on 10/1/24 t 1:04 p.m. with LN 2, LN 2 stated, "When [LN 1] lifted the blanket, she saw the swelling. We asked [Resident 1] what happened but was not able to tell...I know to the touch it was really painful, we notified NP and ordered Xray...We don't know how it happened...Until this day, I have no idea how it happened...I haven't seen her hurt herself...It could be abuse if you don't know what it is...it should have been reported...we really don't know what happened so there's a possibility that abuse might have happened." During a concurrent interview and record review on 10/1/24 at 3:12 p.m. with the Social Services Director (SSD), the SSD verified Resident 1 had an Xray that showed a wrist fracture and that the cause was unknown. The SSD stated, "Staff didn't note any changes in behavior leading to the wrist fracture. I believe that if abuse is suspected, it should be reportable in 2 hours...It should have been reported...Many problems if not reported, safety of the resident, the risk is still there, we could have done a more thorough investigation. Yes, it caused a delay in the investigation." During an interview on 10/1/24 at 3:31 p.m. with the DON, the DON stated, "We sent her to the hospital because she had ulnar fracture. We spoke with different nurses...we've been investigating on the cause...She had a fall on 9/1/24...I'm leading that it's because of the trauma from the fall...with my investigation, I'm not considering abuse. If something that you suspect as abuse, we report it...but because she had a fall...I don't consider it as an abuse because of her behaviors and osteoporosis and based on my interactions with her, that's why we didn't report it...If there's a possibility of abuse, I will report it immediately, because it is an abuse and we are mandated reporter. If not reported, it can delay the investigation." During an interview on 10/1/24 at 3:58 p.m. with the Administrator (ADM), the ADM stated, "The nurses noticed the swelling on her arm. I was notified when the nurses found the swelling, we sent her up to the hospital for evaluation...Xray revealed a fracture. Immediately, I started an investigation, the investigation is still ongoing. Prior to that, she had a fall, and I couldn't quite conclude anything, that's why I wanted to do a more thorough investigation. With injuries, it's obviously a serious matter...with my investigation, I wanted to conclude if there was anything that would lead to abuse, that's why the investigation is still ongoing and haven't found out the cause. If I concluded that it was an injury of unknown origin, then I would definitely report it. I guess my thought is if abuse is unsubstantiated, or not for pathological reason, I would consider that as unknown origin and submit the report. We still don't know if it's pathological or not. Obviously with the resident status, I think there's a lot of variables to that. If I suspected it at all, I would submit the report...If I think abuse is involved, that's something that I would think would compromise resident's safety, but I haven't had that conclusion." During a review of the facility's policy and procedure (P&P) titled "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," dated 2001, the P&P indicated, "All reports of resident abuse (including injuries of unknown origin)...are reported to local, state and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported...1. If resident abuse, neglect...or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law...3. "Immediately" is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury, or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury." This failure resulted in a delay in the abuse investigation process and decreased the facility's potential to protect patients from physical and psychosocial harm. Therefore, the Department determined the facility failed to report an incident of an injury of unknown origin for one of three sampled residents (Resident 1) as required by the regulations. This violation had a direct or immediate relationship to the health, safety, or security of long-term care clients.