Other·March 25, 2022

F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(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. §483.12(c)(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.

F610: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(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. On 1/20/2022, the California Department of Public Health (CDPH - or State Survey Agency [SSA]) made an unannounced visit to the facility to investigate a complaint about resident abuse The facility failed to report Resident 1's bruise to the forehead of unknown origin to the SSA, the police, and the Ombudsman Program (residents' advocacy group) and failed to thoroughly investigate the source of the injury as per the facility's abuse policy. As a result, there was a delay of the investigation by the different agencies to rule out abuse placing Resident 1 at risk for further abuse. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident on 12/1/2021 with diagnoses including cutaneous (localized in the skin) abscess of the abdominal wall (pocket of pus located in the wall of the stomach), end stage renal disease (kidneys do not function on a permanent basis), and anemia (low level of healthy red blood cells to carry oxygen to the body's tissues). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment care-planning tool), dated 12/05/2021, indicated the resident had difficulty remembering, communicating, and comprehending. Resident 1 needed extensive assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's Situation - Background -Assessment - Recommendation form (SBAR - is a technique that can be used to facilitate prompt and appropriate communication between the healthcare team members), dated 12/13/2021 indicated a Registered Nurse (RN) assessed the resident to have a black/bluish ecchymosis (a bruise, discoloration of the skin resulting from bleeding underneath) measuring 1.5 centimeters (cm) in length by 1.5 cm in width on the forehead. The cause of the injury was not indicated. On 2/15/2022 at 12:28 p.m., during an interview with the Director of Nursing (DON) and concurrent review of Resident 1's SBAR and nursing notes, DON stated when the bruising was assessed and the cause was unknown, the RN should have completed an incident report and investigate. On 02/15/2022 at 1:08 p.m., during an interview, DON stated there was no documentation of an incident report or investigation of Resident 1's forehead bruising. DON stated they did not try to find out what happened and how the resident sustained the injury. A review of the facility's policy and procedures titled, "Abuse Investigation and Reporting," revised 7/2017, indicated injuries of an unknown source be reported by facility Administrator, or his/her designee, to the SSA, the local State Ombudsman, and law enforcement officials. The report will be made immediately and no later than two hours. Injuries of unknown source shall be thoroughly investigated by facility management. The facility failed to report Resident 1's bruise to the forehead of unknown origin to the SSA, the police, and the Ombudsman Program and failed to thoroughly investigate the source of the injury as per the facility's abuse policy. As a result, there was a delay of the investigation by the different agencies to rule out abuse placing Resident 1 at risk for further abuse. The above violations had a direct relationship to the health, safety, and security of Resident 1.