Other·May 2, 2024

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. 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. H &S § 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. 22 CCR § 72315 Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 22CCR §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. 22 CCR § 72527 Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. 22CCR §72541 - Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. On 2/29/2024, the California Department of Public Health (CDPH) received a complaint and a facility reported incident (FRI) indicating Resident 1 had an unexplained right humerus (upper arm bone) and right shoulder fracture (broken bone). On 3/14/2024, the CDPH conducted an investigation at the facility. The facility failed to: 1. Report to the CDPH within 24 hours, when Resident 1 sustained a baseball-size (a regulation baseball is 9 to 9.25 inches in circumference) bruise (an injury appearing as an area of discolored skin on the body, caused by a blow or impact) on her right upper arm and a right upper arm fracture. 2. Implement its Administrative Manual titled, "Elder/ Dependent Abuse," which indicated to report any allegations of abuse or that results in serious bodily injury, to the State Survey agency, immediately but not later than two hours. These violations delayed the investigation by the CDPH. Findings: A review of Resident 1's Admission Record indicated Resident 1 was originally admitted to the facility on 8/1/2014 and readmitted on 3/28/2023. Resident 1's diagnoses included quadriplegia (paralysis of all four limbs), contracture of right hand, and aphasia (inability to communicate). A review of Resident 1's History and Physical (H&P), dated 10/23/2023 indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 1/1/2024, indicated Resident 1 had functional limitation in range of motion, impairment on both upper and lower extremities. The MDS indicated Resident 1 required two or more persons to assist with mobility (including rolling form left to right, sit to lying, lying to sitting position and with transfer from bed to chair, chair to bed and with tub/ shower transfer) and had contractures of muscles in multiple sites. A review of the Change in condition (COC) form, dated 2/28/2024 at 2:44 p.m., indicated Certified Nurse Assistant (CNA 2) notified Licensed Vocational Nurse (LVN) 1 that Resident 1 had a right upper arm discoloration. A review of Resident 1's x-ray (a test used to generate images of tissues and structures inside the body) report from the facility dated 2/28/2024, indicated Resident 1 acute obliquely (slant) oriented non-displaced (did not move out of alignment) fracture or surgical neck of humerus. During an interview with Director of Nursing (DON) on 3/26/2024 at 2:35 p.m., the DON stated on 2/28/2024 at approximately 3:00 pm., Licensed Vocational Nurse (LVN 1) informed him Resident 1 had a fracture. The DON stated the facility notified the CDPH on 2/29/2024, around 3:00 p.m. The DON stated the injury of unknow origin was not reported within 2 hours per the facility's policy. The DON stated not reporting abuse in a timely manner could have led to a delayed investigation by the CDPH. A review of the facility's "Administrative Manual titled, "Elder/ Dependent Abuse," dated 11/19/22, indicated to report any allegations of abuse or that results in serious bodily injury, to the State Survey agency, immediately but not later than two hours, The facility failed to: 1. Report to the CDPH within 24 hours, when Resident 1 sustained a baseball-size (a regulation baseball is 9 to 9.25 inches in circumference) bruise (an injury appearing as an area of discolored skin on the body, caused by a blow or impact) on her right upper arm and a right upper arm fracture 2. Implement its Administrative Manual titled, "Elder/ Dependent Abuse," which indicated to report any allegations of abuse or that results in serious bodily injury, to the State Survey agency, immediately but not later than two hours. These violations delayed the investigation by the CDPH. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.