Other·August 23, 2023

F609 Reporting of Alleged Violations 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. The Department determined the facility failed to report an injury of unknown origin immediately, but not later than 2 hours, when Resident 20 was found to have a left tibia (the shinbone, the larger of the two bones in the lower leg) and fibula fracture (calf bone, the outer and smaller of the two bones in the lower leg between the knee and ankle) per the facility's policy, and Federal law. Based on observation, interview, and record review, the facility failed to report to the Department an injury of unknown origin for 1 of 28 sampled residents (Resident 20) when Resident 20 had a nondisplaced fracture (broken bones that were not moved far enough during the break to be out of alignment) of the left tibia and fibula on 6/29/23. This failure resulted in a delay in the Departments investigation into Resident 20's fractures and had the potential for an occurrence of abuse to go undetected. Findings: A review of Resident 20's "ADMISSION RECORD," indicated Resident 20 was admitted to the facility in mid-2012 with diagnoses which included dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), cerebral infarction (a result of disrupted blood flow of the brain due to problems with blood vessels that supply it, also used with the term stroke), and aphasia (loss of ability to produce or understand language). During a review of Resident 20's Minimum Data Set (MDS, an assessment and care planning tool), dated 5/25/23, the functional status section of the MDS indicated Resident 20 required total dependence to move in bed, total dependence to transfer between surfaces, total dependence in dressing, eating, toileting, and personal hygiene. The functional status section also indicated Resident 20 was not able to walk in the room or in the corridor on the unit 100% (percent) of the time. Further review of the health conditions section of the MDS indicated Resident 20 had no falls since admission. A review of Resident 20's "Nurses Note," dated 6/28/23, indicated Resident 20 was "...noted with 2+ [plus] pitting edema [a swollen part of the body which has a dimple or pit after pressure is applied for a few seconds] to left lower extremity ..." A review of Resident 20's "Nurses Note," dated 6/29/23, indicated Resident 20 was "noted with swelling to left lower extremity. Tech [technician] unable to obtain doppler ultrasound [noninvasive test to help health care provider find out if a condition is reducing or blocking blood flow] ...Notified MD [Medical Doctor] ...send [Resident 20] out for further evaluation and treatment ...to ER [Emergency Room] ..." A review of Resident 20's hospital record titled "[facility name] Patient Education & [and] Visit Summary," dated 6/29/23, indicated, "... [Resident 20] were seen in the emergency department for a broken bone in your left lwoer [sic] leg. [Resident 20] broke both your distal [site located away from a specific area, most often the center of the body] and [sic] tibia and fibula. It is unclear how this happened. As [Resident 20] don't [does not] walk ..." During a review of Resident 20's hospital record titled "Final Report," dated 6/29/23, indicated, " ... [Resident 20] was brought from [facility name] for evaluation of swelling and bruising to the left lower extremity. [Resident 20] has been found to have distal tib-fib [tibia, fibula] fracture that is nondisplaced. [Medical Doctor's name from Emergency Room] called the nursing home and apparently no one was aware of any particular injury ... [Resident 20] has advanced dementia and cannot relay any information ...the ombudsman [patient advocate] is being contacted..." Further review of the "Final Report" indicated an x-ray was done on 6/29/23 which revealed the fracture and, "...osteopenia... [a condition that begins as you lose bone mass, and your bones get weaker]." During a telephone interview on 7/24/23 at 2:59 p.m. Family Member (FM) 2 stated Resident 20 had a broken left tibia and fibula and was unsure how this happened as Resident 20 was confined to the bed. During a concurrent observation and interview on 7/25/23 at 11:09 a.m. with Certified Nursing Assistant (CNA) 2 in Resident 20's room, Resident 20 was observed to have a splint (a strip of rigid material used for supporting and immobilizing a broken bone) on the left lower leg. CNA 2 stated she was unsure how Resident 20 had a broken left leg. During a telephone interview on 7/27/23 at 12:48 p.m. Licensed Nurse (LN) 5 confirmed writing the "Nurses Notes" for Resident 20 dated 6/29/23. LN 5 stated she received a call from the hospital and was told Resident 20 had a fracture. LN 5 also stated she reported this information to the Director of Nursing (DON). LN 5 further mentioned she was unsure how Resident 20 had the fracture as Resident 20 does not get out of bed and had no recent fall or injury. During a concurrent interview and record review on 7/27/23 at 4:33 p.m. with the DON, Resident 20's "Nurses Note," dated 6/28/23 and 6/29/23, Resident 20's hospital records "[facility name] Patient Education & Visit Summary," dated 6/29/23, and Resident 20's hospital record "Final Report," dated 6/29/23 were reviewed. The DON mentioned she was aware of Resident 20's fracture of the left tibia and fibula. The DON further stated Resident 20 had no fall or injury prior to Resident 20's fracture. The DON stated an injury of unknown origin was not knowing the cause of the incident or injury. The DON confirmed there was no documentation of a report to the Department about Resident 20's injury of unknown origin. The DON also stated it should have been reported and the risk of not reporting was that potential abuse may have occurred and to ensure resident safety. A review of an article published by UCLA healthcare titled, "Spontaneous Fractures in Nursing Home Patients," dated 2014, indicated, ..."Spontaneous fractures of the long bones...tibia-fibular...often result from turning or transferring. They occur from either direct force or torque. Two important contributing factors are the decrease in bone mass and bone quality and increased torque during passive transfer. Fractures in the SNF [skilled nursing facility] setting often raise suspicion of abuse..." chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://proceedings.med.ucla.edu/wp-content/uploads/2016/11/Spontaneous-Fractures-in-Nursing-Home-Patients-G.-Chen-M.-Garcia-9.16.2014.pdf During a concurrent interview and record review on 7/27/23 at 5:10 p.m. with the Administrator (ADM), the undated facility's policy titled "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" was reviewed. The P&P indicated, "All reports of resident abuse (including injuries of unknown origin) ...are reported to local, state and federal agencies...and thoroughly investigated by facility management. Findings of all investigations are documented and reported ...If resident abuse ...injury of unknown source is suspected, the suspicion must be reported immediately to...other officials according to state law ...The administrator or the individual making the allegation immediately reports his or her suspicion to the ...state licensing/certification agency responsible for surveying/licensing the facility ... "Immediately" is defined as ...within two hours of an allegation involving abuse or result in serious bodily injury ..." The ADM confirmed that their P&P indicated they need to report an injury of unknown origin. The ADM further stated an injury of unknown origin "is when we don't have any idea at all why there is an injury." When asked if this was reported to the Department, the ADM stated it was not. Therefore, the Department determined the facility failed to report an injury of unknown origin immediately, but not later than 2 hours, when Resident 20 was found to have a left tibia (the shinbone, the larger of the two bones in the lower leg) and fibula fracture (calf bone, the outer and smaller of the two bones in the lower leg between the knee and ankle) per the facility's policy, and Federal law. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.