Other·August 15, 2023

The Orchards Post Acute Complaint: 847025 Event ID: N5Z011 Date of Violation: 6/22/23 Class B Citation Surveyor: Mallory Stone, HFEN Supervisor: Shieryl Paringit, HFES Bakersfield District Office The following reflects the findings of the California department of Public Health during the investigation of complaint 847025. Health & 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 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 6/23/23, an unannounced visit was conducted at the facility to investigate a complaint regarding alleged abuse towards Resident 1. Resident 1 was a 79-year-old female resident, admitted to the facility on 6/10/2023. She had a diagnosis of left femur fracture (a break in the thigh bone), Hemiplegia (paralysis) and hemiparesis (weakness or inability to move one side of the body) following nontraumatic subarachnoid hemorrhage (bleeding in the space below one of the thin layers that cover the brain) , brain mass (a growth of abnormal cells in the brain), repeated falls, obstructive and reflux uropathy (urine is unable to drain through the urinary tract). Based on interview and record review, the facility failed to report an allegation of abuse within 24 hours to the California Department of Public Health (CDPH) for one of three sampled residents (Resident 1). This failure resulted in delayed investigation of the suspected abuse and potential for continued abuse towards Resident 1. Findings: During a concurrent observation and interview on 6/23/23 at 9:00 a.m. with Resident 1, in room 103C, Resident 1 was observed lying in bed with white bed sheet covering up to chest. Resident 1 was groomed, well kept, and positioned slightly to her right side, with the left arm propped on a pillow. Resident 1 is awake and alert. Resident 1 stated the doctor from yesterday made the facility aware of the bruising and called the police department. Resident 1 stated the bruising was from a recent car accident, and that she is very sore when she is turned and repositioned in bed. During an interview on 6/23/23 at 9:45 a.m. with DON, DON stated, "The resident [1] went to a doctor's appointment yesterday 6/22/23, and the doctor's office called the police to report a suspected abuse. The resident [1] made a comment that she had to do what they tell her, or she get in trouble. The resident [1] had a stroke [occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts] and is [cognitively] impaired. I don't think she is understanding what is being told." During a review of Resident 1's "Minimum Data Set" (MDS-assessment tool), dated 7/6/23, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS) score was 13 (a score of 13-15 suggests a resident is cognitively intact). Resident 1's MDS Section E (behavioral symptoms) dated 7/6/23 was reviewed. The MDS indicated, Resident 1 did not exhibit physical or verbal behaviors directed at others, did not exhibit other behavioral symptoms not directed at others, did not exhibit behaviors related to rejection of care or wandering. During a follow up interview on 7/6/23 at 2:48 p.m. with DON, DON stated the BPD (Bakersfield Police Department) came (on 6/23/23) to the facility to investigate an allegation of abuse, but she (DON) never reported the allegation of abuse to the CDPH. When asked if she was supposed to report allegations of abuse, DON stated, "Yes, when there is an abuse allegation." DON stated, "I honestly did not think of reporting because the BPD said there was nothing there...I didn't even think about it." During a review of the facility's "Alleged Abuse Investigation", dated 7/6/23, the "Alleged Abuse Investigation" indicated, "Resident [1] reported to the physician's office that the nursing staff told her "She needs to comply or else". They submitted a report of alleged abuse and BPD came to the facility to investigate the allegation. Per BPD, the physician's office did not see any s/s of abuse but reported it due to the statement." During a review of the facility's policy and procedure (P&P) titled, "Abuse Investigation and Reporting", dated 7/2017, the P&P indicated, "All alleged violations involving abuse 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. An alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involved abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND had not resulted in serious bodily injury." In violation of the above cited, the facility failed to report an abuse allegation timely to the CDPH. This failure resulted in a delay of the investigation and potential for continued abuse towards Resident 1. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and constitutes a class "B" citation.