Other·March 8, 2022

The following reflects the findings of the California Department of Public Health during the investigation of Facility Reported Incident 758388 §483.10(g)(14) Notification of Changes. 483.10 (g)(14) (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- 483.10(g)(14)(i)(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); 483.10(g)(14)(i)(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) California Code of Regulations, title 22 § 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 11/3/21, at 10:25 AM, the California Department of Public Health conducted an unannounced visit at the facility to investigate a facility reported incident regarding an unknown fracture for Resident 1. Resident 1 was an 81-year-old female, admitted to the facility on 7/19/12 with diagnoses of dementia (impaired decision making and memory), muscle weakness, history of falling, dysphagia (difficulty swallowing), and presence of cardiac arrest. Resident 1 is non-verbal, has contractions to both lower and upper extremities, unable to walk, unable to transfer herself and requires staff assistance with all activities of living (ADLs, includes bathing, grooming, eating, etc.) Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P & P) "Change in a Resident's Condition or Status" when the facility failed to assess and notify Attending Physician (AP), for one of three sampled residents (Resident 1) that a bruise was identified on 10/19/21 to Resident 1's right hip. This resulted in a delay in treatment of the right hip fracture, and potential for pain. During a concurrent interview and record review on 11/3/21, at 10:30 AM, with Director of Nursing (DON), DON reviewed Resident 1's medical records. DON stated on 10/21/21, a bruise on Resident 1's right hip was identified, an x-ray was obtained on 10/23/21 with a result of a right hip fracture. During a concurrent observation and interview, on 11/3/21, at 12:57 PM, with Certified Nursing Assistant (CNA) 1, in Resident 1's room, Resident 1 was observed lying in bed with eyes closed. CNA 1 stated Resident 1 was non-verbal, can't walk, can't transfer herself, is dependent on staff with all ADLs. CNA 1 stated Resident 1 currently had a right hip fracture. During an interview on 11/3/21, at 1:05 PM, with CNA 2, CNA 2 stated she had noticed a bruise on Resident 1's right hip/leg area while giving Resident 1 a shower on 10/19/21 AM shift. CNA 2 stated she verbally informed the Licensed Vocational Nurse (LVN) on duty on 10/19/21 of Resident 1's bruise to right hip/leg area. During an interview on 11/3/21, at 1:30 PM, with CNA 3, CNA 3 stated on 10/20/21 PM shift, she had noticed Resident 1's "right side hip area down to her leg had a dark purple" bruise. CNA 3 stated the facility practice was to immediately notify the on duty LVN of any new skin issues identified. CNA 3 stated she did not report Resident 1's right hip bruise to the on duty LVN on 10/20/21 PM shift because LVN "wasn't nice, was rude. . .. not approachable." During an interview on 11/3/21, at 4:14 PM, with CNA 4, CNA 4 stated she first saw Resident 1's right hip bruise on 10/20/21 PM shift while providing continent care for Resident 1. CNA 4 stated, Resident 1 "has a bruise to right leg hip. . . it was greenish bruise." CNA 4 stated she reported the bruise to the on duty LVN. During an interview on 11/17/21, at 8:43 PM, with LVN 1, LVN 1 stated it was the facility practice for CNAs to report all new skin issues to LVN's. LVN 1 stated LVN's were responsible for assessing new skin issues, assessing for pain, notifying AP, obtaining x-ray if needed, developing care plan, and monitoring the site for signs of worsening. During an interview on 11/18/21, at 7:44 PM, with LVN 2, LVN 2 stated on 10/21/21 NOC (night) shift CNA 5 was providing care to Resident 1 when CNA 5 noticed a "purple" bruise to her hip area. LVN 2 stated no other report was made to her prior to 10/21/21. LVN 2 stated, "That was the first time I saw it [Resident 1's right hip bruise]." During a review of Resident 1's Nurses Notes (NN), dated 10/12/21 thru 10/21/21, the NN dated 10/21/21, at 9:30 PM, indicated, "cna notified nurse of discoloration and swelling to right upper leg. upon check discoloration to cover [sic] upper leg light purple, slight greenish color, and swelling noted. res [Resident 1] had facial grimacing when leg was touched." There was no documented evidence Resident 1 was assessed and AP was notified when Resident 1's right hip/leg area bruise was first identified by CNA 1 on 10/19/21 AM shift. NN notes indicated Resident 1 was assessed and AP was notified of the right bruise two days after the bruise was first identified. During a review of Resident 1's Right Hip x-ray dated 10/23/21, the result indicated a right hip fracture. During a review of the facility "Investigation Report on [Resident 1]" undated, completed by the Administrator, the report included a statement from staff member who provided Resident 1 care from 10/15/21 thru 10/21/21. The report indicated CNA 2 was interviewed and stated she provided Resident 1 care on 10/19/21 and saw a "small bruise on her thigh. Charge nurse was aware and knew of the small bruise. . . "CNA 3 was interviewed and stated she provided Resident 1 care on 10/20/21, "did notice a bruise and reported the bruise to another CNA, does not remember if she let a LVN know, this was her first round before 6 pm." During an interview on 12/1/21, at 10:10 AM, with Director of Staff Development (DSD), DSD stated CNAs were responsible for immediately reporting to LVN's for any new skin issues, including skin tear, bruise, red areas, DSD stated, LVN's "will then do their assessment, complete Change of Condition [COC] form, notify MD [Medical Director], monitor area." During an interview on 12/1/21, at 10:28 AM, with Administrator, DSD, and DON, DON stated CNAs were responsible to notify nurse for any skin issues including skin tear, bruising, redness. DON stated, LVN "will then follow up, do assessment, document finding, fill out COC form, notify MD [Medical Doctor], RP [Responsible Party]." DON stated, LVN "should have followed up" when made aware of Resident 1's bruise to right hip on 10/19/21. During a review of the facility's P&P titled, "Change in a Resident's Condition or Status," dated 5/17, the P&P indicated, "1. The nurse will notify the resident's AP or Physician on call when there has been a(an): b. discovery of injuries of unknown source: d. significant change in the resident's physical/emotional/mental condition; 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted. . ." In violation of the above-cited standards, the facility failed to implement their P & P "Change in a Resident's Condition or Status" when the facility failed to assess and notify AP, for Resident 1 that a bruise was identified on 10/19/21 to Resident 1's right hip. This resulted in a delay in treatment of the right hip fracture, and potential for pain. 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 and led to a Class A citation.