Health inspection·May 24, 2024

The following reflects the findings of the California Department of Public Health during the investigation of: Survey Re-licensing/Re-certification JCMD11. Representing the Department, HFEN # 49330. State Citation B was written. C.F.R. §483.12(c)(1) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 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. C.F.R. §483.12(b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95. (4) Establish coordination with the QAPI program required under §483.75. (5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. (ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. On 4/23/2024 at 7:30 A.M., an unannounced visit was conducted at the facility to conduct an annual recertification survey. It was determined that the facility failed to ensure: 1. An injury of unknown origin was reported to the California Department of Public Health (CDPH) after a resident with dementia had bruises to the entire face. 2. Its policy and procedure titled Abuse Investigation and Reporting was implemented. As a result of these failures, the investigation was delayed and placed Resident 1 at further risk for injury. A review of Resident 1's Admission Record indicated the resident was readmitted to the facility on 4/11/2024 with diagnoses that included metabolic encephalopathy (an acute condition of brain dysfunction), violent behavior, dementia (a condition that effects cognitive function.) A review of Resident 1's Minimum Data Set Assessment (MDS - assessment tool), dated 4/17/2024, indicated the resident scored 0 on the brief interview of mental status (BIMS-a score of 0-7 suggests severe cognitive impairment). On 4/23/2024 at 3:29 P.M., an observation was conducted in the hallway of station 3. Resident 1 was observed ambulating in the hallway, accompanied by a staff member. Resident 1 had greenish purple bruises to the whole face, extending to the neck area. A review of Resident 1's Nurses Notes, dated 4/13/24, indicated Resident 1 was noted "...with discoloration to right eye and with slight redness to left eye with noted swelling to entire face...resident then was asked what happened and was unable to give description [sic] or details as to what took place...." The Nurses Note indicated the Director of Nursing (DON), administrator (ADM), and physician were all notified. A review of Resident 1's interdisciplinary team (IDT- a group of healthcare professionals with various areas of expertise) note, dated 4/24/24 at 5:05 P.M., indicated "...on 4/13/24 at around 10 A.M...." Resident 1 was sent to the hospital for further evaluation. Resident 1 returned to the facility on the same day. An investigation was conducted by the facility to determine how Resident 1 sustained the bruises on her face. The IDT note further indicated "...Multiple residents and other staff interviewed. No residents saw or witnessed fall or altercation with peer. No staff witnessed or heard of a fall or altercation with peer.... [Resident 1] requires redirection and her BIM score is 0 (severe impaired cognition) ...resident has no capacity to understand and make decisions...." During an interview with certified nursing assistant (CNA) 23 on 4/24/24 at 3:36 P.M., CNA 23 stated she had cared for Resident 1 in the past. CNA 23 stated Resident 1 ambulated daily without assistance. CNA 23 stated Resident 1 had exhibited combative behavior towards staff and other residents for no reason. CNA 23 stated that if she sees an injury of unknown origin, she would " ...contact (name of the abuse coordinator) the abuse coordinator and tell the charge nurse ...we don't want to neglect her." During a telephone interview with Resident 1's family member on 4/25/2024 at 10:32 A.M., the family member stated that the facility informed him of the bruises on Resident 1's face. The family member stated "[the facility] assumed she had a fall ...nobody saw [the fall]." The family member stated that the facility informed him that an investigation was conducted to determine how Resident 1 sustained the bruises. During an interview conducted with licensed nurse (LN) 21 on 4/25/2024 at 1:14 P.M., LN 21 stated that if a resident had an injury of unknown origin, she would inform the charge nurse and the abuse coordinator "for their safety ..." During an interview with the ADM and the DON on 4/25/2024 at 3:31 P.M., the ADM stated the source of Resident 1's injury was still uncertain. The ADM stated the injury had not been reported to CDPH. The DON and ADM both acknowledged that the facility's abuse investigation and reporting policies had not been implemented. A review of the facility's policy titled Abuse Investigation and Reporting revised July 2017, indicated "All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ("abuse") shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported ...." The P&P further stated "all alleged violations ...including injuries of an unknown source ...will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility ...." In violation of the above cited standards, the facility failed to ensure: 1. An injury of unknown origin was reported to the California Department of Public Health after a resident with dementia had bruises to the entire face. 2. Its policy and procedure titled Abuse Investigation and Reporting was implemented. As a result of these failures, the investigation was delayed and placed Resident 1 at further risk for injury. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.