Health inspection·October 29, 2024

Health And Safety Code Section 1424 (d) Class "A "violations are violations which the State Department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Title. 22, §72527 (a)(10) - Patients' Rights Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. The Department determined during the investigation of a complaint, that the facility failed to ensure Resident 1 was not subjected to abuse. The facility failed to ensure its Abuse/Injuries of Unknown Origin policies and procedures were implemented. As a result of these failures, Resident 1 was found with injuries of unknown origin, abrasion to right shoulder and bruises to the chin and on the left cheek. On 05/13/2024, the Department received a complaint from Resident 1's family member indicating Resident 1 was found with a wide band aid and when removed, exposed an abrasion measuring 3 inches, with the skin peeled off. The resident was also noted to have bruises to the chin and left cheek. When Resident 1's family inquired about the cause of the injuries, the resident and the facility did not know the causes or sources of the injuries. A review of Resident 1's "History & Physical (H&P)" dated 5/9/24, indicated, Resident 1 was admitted to the facility with diagnoses including: Acute Post-hemorrhagic anemia (a condition in which a person quickly loses a large volume of blood), Gastrointestinal bleeding (bleeding disorder of the digestive tract), cholelithiasis (stones in the gall bladder), diabetes (uncontrolled sugar level in the blood), and unspecified dementia (an impairment of cognition without a specific diagnosis). A review of the facility's P&P titled, "Abuse Prevention Program," dated 12/2022, indicated, "To promote an environment free from any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment. Type of Abuse: ... 7. "Injury of unknown source " ... VI. A The facility shall respond to the abuse allegation (s) immediately by protecting the alleged victim and integrity of the investigation. b. The facility shall examine the alleged victim for any physical signs of injury, including but not limited to psychological, and psychosocial effect ...." A review of the facility's policy and procedure (P&P) titled, "Abuse Prevention Program" dated 12/01/2022 listed seven types of abuse, including "Injuries of Unknown Source." The policy indicated Injuries of Unknown Source is an injury that met both the following conditions: A. The source of the injury was not observed by any person, or the source of the injury, B. is suspicious because of the extent of the injury, the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma), the number of injuries observed at one particular point in time, or the incidence of injuries over time. During an observation on 5/16/24 at 3:06 p.m., Resident 1 was observed in a room, in bed, awake, responsive, and covered with a blanket from neck to lower extremities. Resident 1 was observed with reddish, purplish skin discoloration under the chin, about the size of a quarter and greenish yellowish skin discoloration on the left cheek. During an interview on 5/16/24 at 3:06 p.m. with Resident 1 and family member (FM1), FM1 verbalized on 5/9/24 around 9 a.m., while at the facility's dining area with Resident 1 and Responsible Party (RP), RP and FM1 noticed a bandage on resident's right shoulder area. Resident 1 was not able to recall any accidents, falls, injuries or trauma to any part of her body. During a phone interview on 5/16/24 at 6:45 p.m., the RP indicated on 5/9/24 around 9 a.m., the RP and FM1 noted a bandage on the resident's right shoulder. The RP asked the administrator (ADM) what happened to (Resident 1) since the RP and the family received no notification of a fall or an incident occurring. Per RP, the ADM stated he was not "clinical" but will ask the Director of Staff Development (DSD) to talk to the RP. The RP indicated on 5/9/24, besides the right shoulder skin abrasion, Resident 1 was also noted to have skin bruises on the chin and on the left cheek and no one from the facility seemed to know what happened or even noticed the skin abrasion until it was brought up to their attention by the RP to the facility staff. During an interview on 5/16/24 at 3:50 p.m., with the Director of Nursing (DON) and the facility ADM, the ADM verbalized being approached by Resident 1's RP on 5/9/24 around 10 a.m., inquiring about what happened to Resident 1's right shoulder with bandage. The ADM verbalized he was not "clinical" and referred the RP to the DSD. The ADM then informed the DON about RP's concerns. The DON verbalized on 5/9/24 (unable to recall what time), sometime in the morning, spoke to Resident 1's RP about the resident's skin issues. According to the DON, the DSD found Resident 1 on 5/9/24 with an abrasion on the right shoulder and applied a band aid/bandage on the area. The DON was not able to produce any documentation by the DSD regarding the resident's skin condition. A review of the admission "Progress Notes (PN)," dated 5/7/24, at 8:58 p.m. indicated, Resident 1 was awake, alert, and oriented x 3 (three), able to verbalize needs, with skin intact, and no complaints of pain. A review of the Physical Therapy (PT) treatment encounter notes on 5/9/24, signed by the therapist at 5:40 p.m. indicated, Resident 1 requires moderate assistance from sitting to standing and maximum assistance to moderate assistance with transfer. A review of Resident 1's documentation for change of condition (SBAR - Situation Background Appearance Review and Notify) dated 5/9/24, at 11 a.m., authored by the DON indicated, Resident 1's RP and physician was notified of the left shoulder abrasion and pain condition. During an interview on 5/16/24 at 5:51 p.m., Licensed Nurse (LN2), stated on 5/9/24 (unable to recall what time) Resident 1's RP and FM2 asked when and where the resident sustained the skin changes on the right shoulder, chin area and left cheek. LN2 stated, she responded to FM2 she was not aware of any skin changes as nothing was endorsed by the outgoing shift (night and morning shift). LN2 reviewed Resident 1'sclinical record with the FM2 in attendance, and review of the night shift nursing documentation indicated, there was no documentation regarding skin changes/abrasions/discoloration. LN2 was not able to locate any further documentation about a change of condition, change in skin assessment, or documentation from other nursing staff, DSD, or DON. The facility failed to ensure Resident 1 was not subjected to abuse. The facility failed to ensure its Abuse/Injuries of Unknown Origin policies and procedures were implemented. As a result of these failures, Resident 1 was found with injuries of unknown origin, including abrasion measuring 3 inches to right shoulder and bruises to the chin and on the left cheek. These failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.