Health inspection·June 13, 2023

F609 Reporting of Alleged Violations Section 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Section 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. Section 483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. California Health and Safety Code, 1418.91 (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 twenty-four hours. (b) Failure to comply with the requirements of the section shall be a Class B Citation. The following citation is written as a result of complaint #CA00830851. An unannounced visit was made to the facility on 3/16/23, at 9:15 a.m., to investigate an allegation of abuse. The Department determined the facility failed to: Implement State law related to alleged and suspected patient abuse and abuse reporting, when the facility administrator failed to report an allegation of abuse to the Department. Resident 1 was admitted to the facility in the fall of 2022 with respiratory failure (when the lungs cannot get enough oxygen into the blood), dependence on ventilator (a bedside machine with tubes that connect to person's airway), quadriplegia (paralysis of all four limbs), as well as multiple other diagnoses. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 9/22/2022, the MDS indicated the BIMS (Brief Interview for Mental Status an assessment tool), was not completed due to resident's inability to participate. Resident 1 had a severe neurological injury related to cerebral vascular accident (stroke) 5 years ago and required total care in completing Activities of Daily Living (ADLs). During a review of information submitted by Resident 1's Power of Attorney 1 (POA 1), it was noted that Resident 1 was transported to an acute care facility on 10/27/22 related to swelling and bruising of the right shoulder. The emergency department record documented an area of ecchymosis (bruising) on the right shoulder as well as swelling and some deformity. The results of the radiology exam were a torn rotor cuff (tear in the tissues connecting muscle to bone around the shoulder bone) of the right shoulder. During a review of Resident 1's Progress Notes titled, "River Bend Nursing Center Progress Notes," dated 10/27/22, at 4:17 p.m., a staff member, who was later identified as LN 1, notified POA 1 that Resident 1 had "tremendous swelling" of the right shoulder and was being sent to the emergency department for evaluation. During a continued review of Resident 1's Progress Notes, an entry dated 10/27/22, at 4:31 p.m., was made into the medical record, documenting, "RT Shoulder. Bruising and swelling is present. Bruising is yellow in color. R/P along with PMD has been notified and new order was received to send resident to ER for evaluation." Further record review in Resident 1's Progress Notes reflect documentation dated 10/28/22, at 11:41 p.m., by LN 2 that indicated "...skin integrity was of yellow, green, and bluish discoloration 3x3 with no skin tears or lesions." On 10/28/22, at 12:37, review of Resident 1'S Progress notes reflected an entry by LN 1 which indicated, "Discoloration noted to Rt shoulder was bluish-purple in color upon assessment noted on 10/27/22, not yellow in color as previously indicated. Shoulder continues with swelling present at this time. Resident denies pain from. Resident is able to move extremities." During an interview on 3/16/23, at 9:15 a.m. with Administrator 1 (ADM 1), ADM 1 stated he was not aware of an injury or transport of Resident 1 to an acute care facility on 10/27/22. ADM 1 indicated he had just recently taken over the administrator role, and it would have been the former ADM's duty to report the injury to the Department. ADM 1 said he had not done an investigation because he was not aware of the allegation of an injury to Resident 1. ADM 1 further stated that when an abuse allegation occurred, nursing staff report the injury to the Director of Nurses (DON) or the ADM. An investigation is then completed and the allegation is reported to State [Department] by him or his designee. During an interview on 3/28/23, at 4:17 p.m., with POA 1, POA 1 indicated Licensed Nurse 1 (LN) called POA 1, on 10/27/22 "in the afternoon" and indicated Resident 1 had "tremendous" swelling of her right shoulder and was being sent to the emergency department for evaluation. POA 1 stated she was not notified of what emergency department or the outcome of the emergency department visit. POA 1 indicated that when she was emailed by the MSW (facility Social Services person) at River Bend on 10/28/22, she was informed the Resident was sent to the emergency department on 10/15/2022, for replacement of peg tube (feeding tube to deliver nutrition directly to the stomach) and "she was sent back on the same day" (Oct. 15). MSW further stated in her email response that "Resident 1's shoulder was not a new condition." The hospital Medical Doctor 1 (MD 1) stated that due to her history of a dislocated rotator cuff, swelling was present, and it was most likely related to age." POA 1 indicated she received no further information regarding the emergency department visit on 10/27/22, until she was able to obtain the medicals records from the acute facility. During an interview on 4/10/23, at 11:36 a.m., ADM 2 stated he had not been able to locate any record of an abuse report regarding Resident 1 in October of 2022. ADM 2 stated this was prior to his becoming the ADM at the facility and he was not aware of the process followed by the prior ADM for reporting to the State. During a review of a facility policy titled, "Abuse Investigating and Reporting," revised July 2017, the policy indicated, "All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property, will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: The State licensing/certification agency responsible for surveying/licensing the facility...report allegations involving abuse (physical, mental, verbal, sexual,) not later than two (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 provide for jurisdiction in long-term facilities in accordance with State law established procedures." In violation of the above cited standards, the Department determined the facility failed to: Implement State law related to alleged and suspected patient abuse and abuse reporting when the facility administrator failed to report an allegation of abuse to the Department. This violation had a direct or immediate relationship to the health, safety and security of residents.