Health inspection·September 6, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to identify an injury of unknown origin as possible abuse for one resident (Resident 1), and failed to report the allegation of abuse to the California Department of Public Health. Residents Affected - Few As a result, the facility failed to initiate their abuse policy and procedure related to an injury of unknown origin and placed Resident 1 at risk for further abuse. This failure also placed other residents at risk for abuse and delayed the abuse investigation proces. Findings: Resident 1's record was reviewed. The Record of admission indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Alzheimer ' s disease (a disease which destroys memory and other important mental functions), vascular dementia with behavioral disturbance (a disorder that causes problems with personality and behavior), and hearing loss. According to Resident 1 ' s MDS (an assessment tool), her BIMS (used to assess cognition) indicated Resident 1 was rarely or never understood. On 8/15/24 at 10:32 A.M., a joint observation and interview was conducted in Resident 1 ' s bedroom. Resident 1 was observed laying on her back in bed. Resident 1 had dark purple discoloration surrounding her right eye. Certified Nursing Assistant (CNA) 1 stated staff thinks Resident 1 had a fall, which created the facial bruise, but nobody witnessed it. CNA 1 stated Resident 1 always wore her hair down and a large hat which covered her face. Resident 1 was wearing a black baseball cap, and her hair was down and there was bruising on her face visible from the doorway. CNA 1 was sitting in a chair at Resident 1 ' s bedside. CNA 1 stated she was assigned to stay with Resident 1 and was doing supervision with assistance . which meant always being with Resident 1. CNA 1 stated she is unsure how Resident 1 sustained the injury. CNA 1 stated .it ' s hard to take care of her . and Resident 1 is hard of hearing. CNA 1 stated Resident 1 had aggressive behaviors. She doesn ' t understand that we are only trying to help .[Resident 1] she walks facing down and won ' t let you touch her (Resident 1) and will push you or punch you . On 8/15/24 at 10:56 A.M., Resident 1 was observed waking up. Resident 1 was awake and stated, done here we are eating. Resident 1 said other words that were unintelligible. On 8/15/24 at 11 A.M., an interview was conducted with Licensed Nurse (LN). LN 1 stated on 8/3/24 around 8:30 A.M., Resident 1 was eating breakfast in the dining room. LN 1 stated CNA 2 noticed the bruise on Resident 1 ' s face, then informed LN 1. LN 1 stated staff was not certain when Resident 1 was injured because it was often difficult to see her face. LN 1 stated Resident 1 always wore her Page 1 of 2 055008 055008 09/06/2024 Edgemoor Hospital 655 Park Center Drive Santee, CA 92071

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hair down and a large hat which covered her face. LN 1 stated Resident 1 had dementia and was unable to tell staff how she got the bruise. LN 1 stated when staff attempts to remove her hat to provide care, Resident 1 .gets aggressive and tries to hit staff . and .she screams and yells . LN 1 stated staff also found two dime sized bruises on Resident 1 ' s left forearm. LN 1 stated the cause of the bruises was unknown and stated .we have possible conclusions, but we really don ' t know how it happened .it was probably a fall, but we don ' t know for sure . LN 1 stated if a resident has an injury with an undetermined cause we would tell the administrator because it could be abuse. On 8/15/24 at 12:36 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated an in-service titled Abuse Reporting and Falls was given to staff after [Resident 1] had the bruise . The DSD stated the QA nurse reviewed the incident report and asked the DSD to provide the abuse in-service training based on the incident report. The DSD stated she considered the bruise to be possible abuse because they could not determine how Resident 1 acquired the bruise. The DSD further stated if you see an injury of unknown origin, it needs to be reported. The DSD stated if an injury of unknown origin is not reported their safety gets compromised .it ' s a serious offense . We are supposed to keep them (residents) safe. The DSD stated the facility did not report the injury and we did not keep them safe. The DSD stated the Administrator (Admin) was the facility ' s abuse coordinator. On 8/15/24 at 2:08 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the Interdisciplinary Team (IDT- team consisting of members from different disciplines) concluded, based on Resident 1 ' s history, that the resident had a .possible fall . The DON stated Resident 1 is a vulnerable resident with dementia. The DON stated, .people with dementia are more prone to be victimized .they cannot talk . The DON stated the possible fall was unwitnessed and the resident was not seen on the ground or assisted up from the ground by staff. On 8/15/24 at 2:32 P.M., an interview was conducted with the Administrator (ADM) via telephone. The ADM stated on 8/3/24, Resident 1 was sent to the Emergency Department for evaluation of the bruise. The ADM stated the ombudsman informed the facility that the hospital reported the bruise to the state agency. The ADM stated Resident 1 ' s bruise was not reported to the state agency by the facility. The ADM stated, police were not notified because it was reported by the hospital and .We did not deem it suspicious in nature for abuse reporting . A review of the Facility ' s undated reference document titled Injuries of Unknown Origin indicated, Bruises were more likely to indicate abuse when found in the following areas: Head/neck .Abusive bruising was often found on more than one plane of the body .both the inner and outer sides of the arm . Policy & Procedure titled Abuse & Criminal Activity Identification, Screening, Prevention, Response, Reporting and Investigating, dated 3/15/24, indicated, all (facility) employees and other workers will comply with mandated reporting requirements . and .it is the policy of (the facility) to assure that every staff member and contractor fully understands their responsibility, as mandated reporters under California law, 42 CFR 483.12 055008 Page 2 of 2