Health inspection·January 10, 2024

F600 Free from Abuse and Neglect Section 483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Section 483.12(a) The facility must- Section 483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. On 6/1/23 at 10:30 a.m., an unannounced visit was conducted to investigate a facility reported incident regarding Resident 1 who had an unexplained event at the facility which resulted in fractures of both bones of Resident 1's left lower leg. The Department determined the facility failed to protect the health and safety of Resident 1 by not establishing a safe environment and by neglecting to adequately assess, report and treat significant pain and injury. These failures led to Resident 1 experiencing unnecessary pain and necessitated transfer of Resident 1 twice to a higher level of care. Resident 1 was admitted to the facility for custodial care in the winter of 2013 with diagnoses which included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities), osteoarthritis (a joint disease that occurs when the cartilage at the ends of bones deteriorates), and chronic pain syndrome (pain lasting 3-6 months or longer associated with depression and anxiety). Resident 1 was dependent on staff for care and was not able to walk or transfer self without staff assistance. Resident 1's "Minimum Data Set [MDS- a standardized assessment tool that measures health status in nursing home residents], dated 4/30/23, indicated that Resident 1 had a "Brief Interview for Mental Status- BIMS," score of 2 (The BIMS test determines how well a resident is functioning cognitively- thinking or conscious mental processes) with scores ranging from 0-15. A score of 2 indicates a severe cognitive impairment). On 5/23/23, CNA 1 indicated she had noticed "a little swelling" to Resident 1's left ankle and had reported it to LN 1. CNA 2 indicated she had observed Resident 1's left lower leg on 5/25/23 "at change of shift." CNA 2 indicated that Resident 1's left lower leg was swollen and bruised and "purple and green color." CNA 1 indicated she had again reported the bruising and pain to LN 1 on 5/26/23. LN 3 indicated that she assessed Resident 1's left lower leg on 5/26/23, "early in her shift" (night shift) after "overhearing the CNAs" discussing Residents 1's leg. LN 3 indicated Resident 1's left lower leg appeared bruised, "purple and blue, mostly around the lower leg and ankle." LN 3 further indicated she did not notify the Administrator (ADM) or the DON of her assessment. LN 2 indicated she was made aware "about 9:30 p.m.," on 5/26/23, of swelling to Resident 1's left lower leg. LN 2 indicated she did not assess Residents 1's left lower leg until the following day. On 5/27/23, at the start of her shift (about 3 p.m.). LN 2 further indicated Resident 1's left lower leg appeared "bruised purple and pink" and "deformed above the ankle." CNA 1 further indicated that on 5/27/23, while providing care to Resident 1, she noticed Resident 1's left lower leg was bruised and painful to touch or move. CNA 1 indicated the bruises were yellow and purple, "mostly purple close to the ankle." CNA 1 indicated she had reported the bruising and pain to LN 1. On 5/27/23, at 4:20 a.m., on Resident 1's Progress Note, Licensed Nurse 3 (LN 3) documented "Resident noted with swollen, discolored, blue in color and painful left ankle." At 5:24 p.m. that same day, in a Progress Note dated 5/27/23 at 10:05 p.m., LN 2 documented "x-ray has been done conclusion: acute fracture of the left distal tibia and fibula" (both bones of the lower leg). Later, at 10:30 p.m. a progress note indicated that "resident was yelling during routine care." LN 2 further documented "left ankle was swollen, discoloration and was painful when touched or moved." On 5/27/23, at "10:28 p.m.," the ADM was notified by LN 2 that Resident 1's x-ray results reflected fractures of the left lower tibia and fibula (both bones of the lower leg) and that Resident 1 needed to be transported to the emergency department. Resident 1 was taken to the Emergency Department (ED) at approximately 1:30 a.m. with complaints of pain in her left ankle. The Emergency Department Record (EDR) indicated "left lower leg extensive bruising with yellowing of bruising, swelling present." Further record review indicated, "Pt here with angulated distal tib/fib [tibia/fibula] fracture likely days old, based on coloring of bruising. Xray's confirm fracture with mild angulation and reduced in ED... Do have concerns about timeliness of care and fact that wound looks old and progressive bruising..." Resident 1's "Procedure Note" dated 5/28/23 at 4:01 a.m., indicated Resident 1 received Procedural Sedation (a procedure with sedation) in order to reduce and stabilize the fractures. A splint was applied to provide pain reduction and healing of the left lower leg fractures. Resident 1 was discharged back to the facility. On 6/1/23 at 11:45 a.m., Resident 1 was observed lying in bed awake, alert and verbally responsive. Her left lower leg appeared yellow from her knee to her toes, as well as areas around the heel and ankle appeared purple in color, the left lower leg appeared swollen with a possible deformity around the middle calf area extending to the ankle. Resident 1 was moaning and speaking in her native language as well as in English. Upon further observation Resident 1 continued to moan and had tears present on her face. The splint appeared to be laying in the wheelchair near Resident 1's bed. At 11:55 a.m. on 6/1/23, LN 1 indicated Resident 1 refused to wear the splint provided by the GACH. LN 1 indicated he was aware that Resident 1 was having pain and that he had not notified the physician of Resident 1's pain or her refusal to wear the ordered splint on her lower left leg. A check-in with LN1 on 6/1/23 at 2 p.m. revealed LN 1 had not medicated Resident 1 for her continued pain. During a subsequent interview and observation on 6/1/23 at 2:05 p.m., Resident 1 was moaning and crying while moving about in her bed and the splint remained on the wheelchair. The DON was summoned to the bedside, at which time the DON indicated he believed Resident 1 was in "severe pain" and rated it as "10/10" on the pain scale (the pain scale is a tool health care providers use to assess a patient's level of pain based on a scale of 0-10, zero representing no pain while ten represents the worst imaginable pain). Resident 1 was subsequently transported via ambulance to the emergency department at 3:05 p.m., on 6/1/23 due to her 10/10 pain. At 7:38 P.M., an ED progress note indicated Resident 1 returned with complaints of increasing pain and swelling of the left lower leg. The previously applied splint was not in place on Resident 1's left lower leg. In a repeat x-ray exam of Resident 1's left lower leg it was indicated that the left lower leg fracture was "again angulated" (the two ends of the bones are at an angle to each other). Resident 1 again received procedural sedation in order to reduce and stabilize the leg. A splint was applied to Resident 1's left lower leg and Resident 1 was discharged from the General Acute Care Hospital (GACH) following the procedure and returned to the facility. During an interview on 6/14/23 at 1 p.m., with the Emergency Department Physician (EDP), the EDP indicated he had cared for Resident 1 in the early morning hours of 5/28/23 for complaints of left leg pain. Upon examination EDP indicated Resident 1 appeared to be "miserable" and she had a "makeshift" support on her left lower leg that was "wrapped too tight." Upon removal of the support, the EDP indicated Resident 1's left lower leg was swollen with yellow bruises from her knee to her toes. EDP further indicated he ordered an x-ray to confirm the previous x-ray at which time he diagnosed an "angulated (the two ends of the broken bones are at an angle to each other) fracture of the left lower tibia and fibula." During a review of an undated facilities policy and procedure (P&P) titled, "Pain Management" the P&P indicated, "the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice..." During a review of the undated document titled, "Nursing Practice Act Rules and Regulations," the document indicated, "Article 2. Scope of Regulation 2275 (b). The practice of nursing within the scope meaning of this chapter means those functions, including basic health care, that helps people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof...including but not limited to, the administration of medications and therapeutic agents, necessary to implement treatment, disease prevention, or rehabilitative regiment... ordered by and within the scope of licensure of a physician..." (Nursing Practice Act Rules and Regulations Issued by Board of Registered Nursing 1997 State of California Department of Consumer Affairs. Pp.5). Therefore, the Department determined the facility failed to protect the health and safety of Resident 1 by not establishing a safe environment and by neglecting to adequately assess, report and treat significant pain and injury. These failures led to Resident 1 experiencing unnecessary pain and necessitated transfer of Resident 1 twice to a higher level of care. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.