Other·May 19, 2023

F609 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. §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. 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 3/13/2023 the California Department of Public Health (CDPH) received a complaint alleging Resident 1 was "rough handled" during care and sustained a huge gash with bruising to his right arm and the facility did not provide a copy of the investigation as requested by the resident's family member. On 3/14/2023 at 10:15 a.m., an unannounced visit at the facility was conducted to investigate reported allegations. Upon investigation, it was determined Resident 1 suffered a laceration to his right arm during care and a thorough investigation of the alleged incident was not reported to the CDPH. The facility failed to: 1. Ensure the facility reported the allegation of abuse "rough handling" to the CDPH within 24 hours of being made aware of the allegation. 2. Ensure staff followed the facility's policies and procedures (P/P), titled "Abuse Prevention Program," that specified to report any allegations of abuse within timeframes as required by federal requirements. This deficient practice resulted in the licensing agency, CDPH, being unaware of the abuse allegation and a delay in the investigation of an alleged abuse. This deficient practice placed Resident 1 and other residents at risk for continuous abuse occurrence. During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet, indicated, Resident 1 was originally admitted to the facility on 7/14/2022 with diagnoses including hemiplegia (loss of strength in the arm, leg, and sometimes the face on one side of the body), hemiparesis (weakness or the inability to move on one side of the body) and muscle weakness. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/30/2023, the MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 was understood by others and was usually able to understand others. The MDS indicated, Resident 1 required extensive one-person physical assist for bed mobility, transferring, locomotion on and off the unit, dressing, toilet use, and personal hygiene. During a review of Resident 1's Nursing Progress Notes (NPN), dated 1/8/2023 and timed at 8:35 a.m., the NPNs indicated, Resident 1 was noted with a skin tear on his right arm. During a review of Resident 1's Change of Condition (COC), dated 1/8/2023, the COC indicated during Resident 1's care, a Certified Nursing Assistant (CNA 2) noted a skin alteration and reported it to a Licensed Vocational Nurse (LVN 1). LVN 1 assessed Resident 1 and noted a 1.0-centimeter ([cm] a unit of measurement) by 7.0 cm skin tear on Resident 1's right forearm. During a review of Resident 1's Social Worker Progress Notes (SWPN), dated 2/14/2023 and timed at 10:42 a.m., the SWPNs indicated, the Interdisciplinary Team (IDT) members were made aware of Resident 1's wife's concerns. During an interview on 3/14/2023 at 11 a.m., with Resident 1, Resident 1 stated he was mistreated by staff and held up his right arm, however, no visible injuries were observed. During an interview on 3/14/2023 at 11:05 a.m., with Resident 2 (Resident 1's roommate), Resident 2 stated, he did not see what happened because the privacy curtains were drawn but stated, he could hear Resident 1 saying he did not want to be changed. During an interview on 3/14/2023 at 11:17 a.m., with CNA 1, CNA 1 stated, Resident 1 accused him of causing a skin tear on his (Resident 1) right arm while he was providing care to him. CNA 1 stated, when Resident 1 was cleaned, he always tries to fight and maybe he (Resident 1) hit his arm on the side rail. CNA 1 stated he saw the skin tear and reported it to the charge nurse (LVN 2). CNA 1 stated, he was removed from the care of Resident 1. During an interview on 3/14/2023 at 12:58 p.m., with LVN 1, LVN 1 stated, CNA 2 reported to her that Resident 1 had a skin tear on his right forearm. LVN 1 stated she notified Resident 1's family member (FM) and reported the skin tear to Resident 1's physician, the Registered Nurse Supervisor (RNS), the Treatment Nurse (TN), and the Director of Staff Development (DSD). LVN 1 stated, Resident 1's FM requested that CNA 1 be removed from caring for Resident 1. LVN 1 stated she notified the DSD of the FM's request, and the DSD told her she would remove CNA 1 from Resident 1's care and investigate. LVN 1 stated, Resident 1 told her the skin tear happened when CNA 1 turned him. During an interview on 3/14/2023 at 1:15 p.m., with the Social Services Director (SSD), the SSD stated Resident 1's FM contacted her via text about concerns she had regarding CNA 1 handling Resident 1 roughly during care. The SSD stated, during an IDT meeting (1/9/2023) she reported to the Administrator (ADM), the case manager (CM) and the DSD that Resident 1's FM reported CNA 1 roughly handled Resident 1. The SSD stated, the ADM told her they needed to have a meeting with Resident 1's FM. The SSD stated, she tried to arrange a meeting with Resident 1's FM but the FM refused to attend the meeting and kept saying she wanted an investigation conducted and a copy of the investigation. The SSD stated an allegation of rough handling should be reported within two hours if an injury was involved. The SSD stated she did not know why the incident was not reported to the CDPH. During an interview on 3/14/2023, at 1:24 p.m., and a concurrent review of the Nursing Staffing Assignment (NSA) dated 1/2023, the DSD stated, LVN 1 reported to her that Resident 1 had a skin tear (1/8/2023) and Resident 1's FM requested that CNA 1 would not care for Resident 1 (1/8/2023). The DSD stated CNA 1 told her, the skin tear on Resident 1's arm happened during the resident's care when he (CNA 1) pulled or turned Resident 1, and Resident 1 accidently hit the side-rail on his bed. During an interview on 3/14/2023 at 1:39 p.m., with CNA 2, CNA 2 stated he saw the skin tear on Resident 1's right arm and blood on the resident's blanket. CNA 2 stated Resident 1 said the skin tear happened during the night shift. During an interview on 3/14/2023 at 2:40 p.m., with the ADM and the SSD, the ADM stated, he could not remember who reported that Resident 1 had a skin tear on his arm, but he was notified the Monday following the incident (1/9/2023). The SSD stated again that she reported to the ADM during an IDT meeting (1/9/2023) that Resident 1 had a skin tear and that Resident 1's FM reported that Resident 1 was handled roughly by CNA 1. The ADM stated, he did not hear the SSD report the incident during the IDT meeting because he was distracted talking on his phone, if he had heard the report that Resident 1 was handled roughly, he would have reported it to the CDPH. During a review of the facility's policy and procedure (P&P) titled "Abuse Prevention Program," revised 12/2016, the P&P indicated, to report any allegations of abuse within timeframes as required by federal requirements abuse prevention program provides policies and procedures that govern, as a minimum timely and thorough investigations of all reports and allegations of abuse. The facility failed to ensure: 1. Ensure the facility reported the allegation of abuse "rough handling" to the CDPH within 24 hours of being made aware of the allegation. 2. Ensure staff followed the facility's policies and procedures (P/P), titled "Abuse Prevention Program," that specified to report any allegations of abuse within timeframes as required by federal requirements. This deficient practice resulted in the licensing agency, CDPH, being unaware of the abuse allegation and a delay in the investigation of an alleged abuse. This deficient practice placed Resident 1 and other residents at risk for continuous abuse occurrence. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.