Other·January 15, 2021

Health and Safety Code, Section 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 24 hours. Health and Safety Code, Section 1418.91 (b) A failure to comply with the requirements of this section shall be a class "B" violation. An unannounced visit was made to the facility on 11/24/20 and 12/16/20 to investigate complaints CA00712208 and CA00714942. The department determined the facility failed to report an injury of unknown source to the California Department of Public Health for one of five sampled residents (Resident 1) when: Resident 1was diagnosed with a right knee fracture. This failure caused a delay in the investigation of the injury of unknown source for Resident 1 to rule out suspected abuse and had the potential to cause harm to residents in the facility. Findings: According to a facility obtained document entitled, Admission Record, Resident 1was admitted to the facility in 2015 with diagnoses including generalized muscle weakness and osteoarthritis (a type of degenerative joint disease where the wearing down of the protective tissue at the ends of bones occurs gradually and worsens over time). Further review of Resident 1's clinical record revealed the following documents: A Resident Care Plan, dated 10/26/20, for "Risk for fracture/Osteoporosis." The plan of care indicated Resident 1 was at risk for spontaneous fracture and functional decline, and was to be handled gently when moving or assisting with position changes. A Nurses Note, dated 11/7/20 at 1:45 p.m., indicated Resident 1 was complaining of pain in the right leg with movement but no redness or bruising was noted. A Nurses Note, dated 11/7/20 at 5:00 p.m., indicated Resident 1's right leg and right knee appeared slightly swollen and the resident was continuing to complain of pain. An untitled note written by a Nurse Practitioner (NP), dated 11/9/20. The note indicated Resident 1 was being seen by the NP for pain in the right leg. The NP's note indicated Resident 1's right knee and right calf exhibited "diffuse swelling/tenderness/erythema[reddening of the skin]/warmthness." The note further indicated the plan was to send Resident 1 to the emergency room for further evaluation of the right leg. A Nurses Note, dated 11/9/20 at 11:30 a.m., indicated Resident 1 was sent to the ED for right knee pain, redness, and swelling. A Nurses Note, dated 11/9/20 at 9:15 p.m. "Late entry," indicated the hospital called to notify the facility Resident 1 had a fracture to the right leg. The note further indicated the Director of Nurses (DON) was informed. In an interview with the DON on 12/16/20 at 10:51 a.m., the DON indicated she left a voicemail message with the SA as soon as the hospital notified the facility of Resident 1's right knee fracture. The DON further stated an SOC341 [a form completed to report suspected abuse] was not completed but a fax was sent to the SA. The DON was unable to indicate what specifically was faxed to the department (SA). Further, the DON indicated an investigation of Resident 1's injury was conducted but was unable to provide documented evidence of an investigation. The DON stated the results of the investigation were not sent to the SA. A facility policy entitled "Abuse - Reporting and Investigations," revised November 2016, was obtained and reviewed. The policy indicated, "The Administrator of designee will notify law enforcement immediately by telephone no later than 2 hours of an initial report of alleged abuse, and/or injuries of unknown source resulting in serious bodily injury." The policy further indicated the LTC (Long Term Care) Ombudsman (an official appointed to advocate for individuals and assist in complaint resolution) and CDPH will be notified within two hours of the initial report by telephone and in writing. Finally, the policy indicated a written report of the results of all abuse investigations and appropriate action taken will be provided to CDPH (California Department of Public Health) Licensing and Certification and other that may be required by state or local laws, within 5 working days of the reported allegation. The department determined the facility failed to report an injury of unknown source to the California Department of Public Health for one of five sampled residents (Resident 1) when: Resident 1 was diagnosed with a right knee fracture. The above violations, jointly, separately or in any combination presented, had a direct or immediate relationship to the health, safety, or security of residents.