Other·May 17, 2023

Health and Safety Code Section 1418.91. (a)(b) (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. (b). A failure to comply with the requirements of this section shall be a class "B" violation. The Department determined during the investigation of a complaint the facility failed to report an allegation of abuse for one resident (Resident 1) not later than 2 hours upon knowledge of the incident. During a review of Resident 1's medical record on 6/9/22, indicated the resident's diagnosis included spinal stenosis (pressure on the spinal cord and the nerves causing low back pain, numbness, and muscle weakness), deformity of right and left foot (abnormal shape or form), generalized weakness, and bipolar disorder (mental disorder that causes unusual shifts in mood). The minimum data set (MDS- assessment), dated 5/3/22, indicated the resident's brief interview for mental status (BIMS score -a test used to get a quick snapshot of functioning cognitively) was 04. (A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). Resident 1 required extensive assistance with two-person physical assist for bed mobility, transfers, toilet use, personal hygiene and did not walk in room or corridor. During an observation and concurrent interview on 6/9/22 at 2:10 p.m., inside Resident 1's room, the resident was laying on the bed with a maroon-colored skin area around the left eye, the area around the right eye was with dark purple discoloration extending to right cheek bone, forehead with bump and slightly elevated skin area with minimal dark yellow discoloration, and right-hand middle and ring fingers were swollen. Resident was asked how she sustained the bruises on her face. Resident 1 responded "I don't want to talk about it now." During an observation and concurrent interview with LN3 on 6/9/22 at 2:15 p.m., LN3 confirmed taking care of Resident 1 on 6/8/22 from 7:00 a.m., to 3:00 p.m. LN3 indicated CNA3 reported to her that [resident name] face was bruised around eyes, cheek, and forehead. LN 3 stated "I came into [resident name] room, saw her face bruised so I went to get another nurse (LN4) to come with me to see [resident name]'s face. [Resident name] was asked how she got those bruises. Resident stated "Someone (a man) was really mad and kept punching me, (a man)... " so I went to report this to the assistant director of nursing (ADON) and Director of Nursing (DON). The DON told me not to worry about it that they (ADON & DON) will take care of it. Resident must have hit herself with the bed rails but ... there is no bed rails. [DON name] called me to tell me that I have a lot of things to do, to stop saying that the resident is saying someone was hitting her because the State will have to be contacted and the State will come after me... I'm supposed to report any possible abuse ... especially because the resident had said someone a man had punched her. Resident had been taken care by a male CNA (CNA4) on 6/7/22 from 3:00 p.m., and on." LN3 indicated Resident 1 had not fallen before and is not strong enough to move by herself or try to get out of bed and no one from the facility had interviewed LN3 and has not heard of any investigation taking place regarding the bruises on the resident's face. The facility's policy and procedure titled "Abuse Prevention, Intervention, Investigation & Crime Reporting Policy, dated 11/2016, in part ..The facility will comply with Section 1150B of the Social Security Act (the Act) as established by Section 6703(b)(3) of the Patient Protection and Affordable Care Act in reference to reporting and reasonable suspicion of crimes committed against a resident of a federally funded long term care facility... 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 caused the allegation involved abuse or result in serious bodily injury or not later than 24 hours if the events that caused the allegation do not involved abuse and do not result 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 facilities ) in accordance with State law.. in part. During a review of the facility's abuse policy and procedure, dated 11/2016, and concurrent interview with the DON and FA on 6/9/22 at 5:45 p.m., the incident of Resident 1's facial bruising and allegation of the resident being hit by "Someone a man had kept on punching or hitting her" was discussed, how it was communicated to the DON and ADON on the morning of 6/8/22 by LN3 and also to the FA. That on 6/8/22 as stated by LN4 around 2:40 p.m., DON and FA went to the resident's room to check the resident's (Resident 1) bruised face and were "investigating". Furthermore, during the record review and interview with the DON and FA it was found out, the facility just faxed over a report to the Department about Resident 1's incident on 6/9/22 more than 24 hours after the resident was noted by staff with fascial bruising and swelling. This facility's failure is a violation of the Health and Safety Code (H&SC) 1418.91 (a)(b) which mandates facilities to report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours and is a Class B Citation.