Health inspection·March 18, 2022

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. 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 2/4/2022 the State Survey Agency (SSA) made an unannounced to conduct a recertification survey. 1. The facility failed to report Resident 10's injury of unknown to the SSA, the police, and the Ombudsman Program (residents' advocacy group) as indicated in the facility's Abuse Reporting policy. 2. The facility failed to implement its abuse policy and procedure by failing to investigate Resident 10's injury of unknown. As a result, Resident 10's injury of unknown was not investigated to rule out abuse and placed Resident 10 at risk for further abuse. A review of Resident 10's Admission Record indicated the facility originally admitted the resident on 5/21/2019 with last readmission dated 11/10/2021 with diagnoses including dementia (group conditions characterized by impairment of at least two brain functions, such as memory loss and judgement) and depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 10's initial History and Physical exam completed by the attending physician on 11/29/2021, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 10's Minimum Data Set (MDS - a standardized assessment and care-planning tool), dated 11/14/2021, indicated the resident's cognition (ability to think, understand and reason) was moderately impaired. Resident 10 required limited assistance from staff with bed mobility, locomotion on and off the unit, toilet use and personal hygiene. MDS also indicated resident uses walker and manual wheelchair. A review of Nurse's progress note dated 11/8/2021, indicated resident was found washing his hands in the sink bathroom and noted with small cut on his left forehead with scant to minimal amount of blood. It also indicated that the doctor was notified and ordered to send the resident to the emergency room. A review of Resident 10's Physician's Order dated 11/8/2021, indicated to transfer the resident to General Acute Care Hospital 1 (GACH 1) emergency room (ER) for evaluation due to increase confusion and a left forehead cut. A review of Resident 10's Hospital record dated 11/8/2021, indicated Resident was admitted with laceration on top of his scalp and was lethargic (sluggish, lack of energy). On 2/5/2022 at 10:25 a.m., during an interview, Director of Nursing (DON) stated Resident 10 was found with a cut on his forehead and resident denied falling. DON was unable to provide a documentation that there was an investigation regarding Resident 10's laceration on his forehead. DON further stated that this incident was considered as an injury of unknown and it was not reported to the state survey per policy and procedure. DON also stated that the risk of not investigating the injury of unknown origin for Resident 10 place resident at risk for possible abuse and or injuries. This injury should have been investigated to rule out abuse. On 2/5/2022 at 10:25 a.m., during an interview, Director of Nursing (DON) stated Resident 10 was found with a cut on his forehead and the resident said he did not fall. The DON was unable to provide documentation that there was an investigation regarding Resident 10's laceration on his forehead. The DON confirmed and further stated that this incident was not reported to the state survey per policy and procedure. The DON further stated that the risk of not investigating Resident 10's cut on his forehead placed the resident at risk for fall, possible abuse and or injuries. A review of the facility's policy and procedures titled, "Abuse Prevention Program," dated August 2006, indicated "Facility must ensure that all alleged violation involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, are reported immediately, but no 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 event 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 laws provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures." 1. The facility failed to report Resident 10's injury of unknown to the SSA, the police, and the Ombudsman Program (residents' advocacy group) as indicated in the facility's Abuse Reporting policy. 2. The facility failed to implement its abuse policy and procedure by failing to investigate Resident 10's injury of unknown. As a result, Resident 10's injury of unknown was not investigated to rule out abuse and placed Resident 10 at risk for further abuse. The above violation had a direct relationship to the health, safety, and security of Resident 10.