Health inspection·July 24, 2024

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 42 CFR §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. 22 CCR §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. 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. On 6/5/2024, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) had a faded bruise (occurs when blood vessels break and leaked blood into the skins top layer) on his chin. The complaint alleges the bruise was not there five days prior. On 6/19/2024, the CDPH made an unannounced visit to the facility. The facility failed to: 1. Ensure an allegation of abuse including injuries of unknown source was reported immediately, but not later than 24 hours to the CDPH, the Ombudsman Program (advocates for residents in nursing home) and law enforcement (police) in accordance with the facility's policy and procedure for Resident 1. On 5/31/2024, Certified Nursing Assistant 1 (CNA 1) observed a fading greenish yellowish bruise to Resident 1's left jaw. As a result, there was no investigation conducted to rule out abuse and this placed Resident 1 at risk for further abuse. A review of Resident 1's Record of Admission indicated the facility admitted the 43-year-old male resident on 3/5/2010, with diagnoses that included chronic respiratory failure (condition in which not enough oxygen passes your lungs into your blood), dependence on respirator (a machine that helps you breathe or breathes for you), unspecified (unconfirmed) cerebral palsy (group of conditions that affect movement and posture caused by damage that occurs to the developing brain) and essential hypertension (high blood pressure that is not due to another medical condition). A review of Resident 1's Progress Note (History and Physical), dated 6/3/2024, 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 3/31/2024, indicated Resident 1 was dependent on staff for all activities of daily living (ADL-personal hygiene, bed mobility, dressing, and transfers). The MDS indicated Resident 1 was always incontinent (unable to control) of bowel and bladder functions. A review of Resident 1's Nursing Narrative Notes, dated 6/2/2024 timed at 7:17 a.m., indicated, Resident 1 had a bruise on the left cheek and left side of the forehead endorsed by LVN 4 to RN 3. The Nursing Narrative Notes indicated RN 1 was notified. A review of Resident 1's Physician Order, dated 6/4/2024, indicated to monitor left lower jaw discoloration for significant changes. During an interview on 6/19/2024 at 9:49 a.m., Registered Nurse 1 (RN 1) stated she was the Charge Nurse on 6/4/2024 when Family Member 1 (FM 1) had a concern about Resident 1's left jaw discoloration. RN 1 stated she did not see the discoloration, but she notified the physician. During an interview on 6/19/2024 at 10:25 a.m., the Director of Nursing (DON) stated they did not do an investigation because FM 1 did not notify them. During an interview on 6/19/2024 at 10:41 a.m., Certified Nursing Assistant 1 (CNA 1) stated on 5/31/2024 between 8 a.m., to 11 a.m., she gave a bed bath to Resident 1 and noticed a fading greenish yellowish bruise to Resident 1's left jaw. CNA 1 stated she reported to LVN 2 and LVN 2 informed CNA 1 that it was already reported to RN 4. During a concurrent interview and record review on 6/19/2024 at 11:57 a.m., with the DON, Resident 1's Nurses Narrative Note dated 6/2/204 timed at 7:17 a.m. was reviewed. Resident 1's Nurses Narrative Note indicated Resident 1 had a bruise on the left cheek and left side of the forehead. The DON stated nurses should report to the DON so they can assess the resident and investigate the injury. The DON stated an injury of unknown origin could have resulted from abuse. The DON stated it was not reported to the SSA, Ombudsman and the law enforcement agency. During a concurrent interview and record review on 6/19/2024 at 12:07 p.m., with the DON, facility's policy and procedure (PP) titled, "Reporting of Alleged Abuse, neglect and Involuntary Seclusion," revised on 8/16/2022, was reviewed. The DON stated, the PP indicated, "Injuries of unknown source: an injury should be classified as an injury of unknown source when both the following are met A. The source of injury was not observed by a person, or the source of the injury could not be explained by the resident. And the Injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. All licensed employees are considered Mandated Reporters ... The investigation will be timely and will be given priority. Any authorities that need to be contacted example given, police Department, Ombudsman will be contacted within 24 hours, The Department of Health (SSA) will be contacted within two hours of the initial report. Types of Abuse that must be reported whether alleged or witnessed. 12. Injuries of unknown source". The DON stated it was the facility's policy to report injury of unknown source to the SSA, Ombudsman and Police Department. During an interview on 6/19/2024 at 12:09 p.m., the Administrator (ADM) stated he was not informed of the incident until today, 6/19/2024. The facility failed to ensure an allegation of abuse including injuries of unknown source were reported immediately, but not later than 24 hours to the CDPH, the Ombudsman Program and law enforcement in accordance with the facility's policy and procedure for Resident 1. On 5/31/2024, CNA 1 observed a fading greenish yellowish bruise to Resident 1's left jaw. As a result, there was no investigation conducted to rule out abuse and this placed Resident 1 at risk for further abuse. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.