Health inspection·December 15, 2023

42 CFR §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. 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. On 10/27/2023 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about quality of care. The facility failed to ensure the implementation of its policies and procedures (P&P) to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by not reporting to CDPH two incidents of injuries of unknown origin (injury resulting without knowing how it happened) to Resident 1, which occurred on 3/5/2023 and 7/22/2023. As a result, there was a delay for an onsite inspection by CDPH to ensure the safety of the other residents and had the potential to result in unidentified abuse. 1. A review of Resident 1’s Admission Record, dated 10/27/2023, indicated the resident was originally admitted on 2/16/2023 and readmitted on 4/22/2023 with diagnoses hemiplegia (a condition that causes inability to move half of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (area of dead tissue in the brain caused by blocked and/or narrowed arteries that carry blood and oxygen to the brain) affecting the right dominant side, and unspecified dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage caused by problems with supply of blood to the brain). A review of Resident 1’s Minimum Data Set (MDS- a standardized assessment and screening tool) dated 4/29/2023, indicated Resident 1 had ability to usually understand others and usually be understood. A record review of Resident 1’s Change of Condition/Interact Assessment Form (COC- a documentation to show when there is a physical or mental change in the resident that requires further action by the facility), dated 3/25/2023, timed at 10:00 a.m. indicated Resident 1 had an abrasion (an injury caused by something rubbing or scraping against the skin) to the mid back and right lateral (to the side of or away from the body) lower ribs with skin redness and discoloration (change of skin color from how it usually appears). A record review of Resident 1’s Physician’s Orders, dated 3/25/2023, timed at 7:19 p.m. indicated a STAT (immediate) X-radiation (x-ray-creation of pictures of the inside of the body), of thoracic (chest area of the body between neck and abdomen) and lumbar (lower back area) spine (backbone); right rib for complain of pain in lower back and right rib cage area. A record review of Resident 1’s x-ray report dated 3/25/2023, indicated that Resident 1 had acute (of abrupt onset) fractures (broken bone) of the right lateral eighth, ninth, and tenth ribs. During an interview and concurrent record review on 10/30/2023 at 5:55 p.m. with the Director of Nursing (DON), Resident 1’s COC dated 3/25/2023 was reviewed. The DON stated that Resident 1 was discovered to have multiple rib fractures but nobody from the facility knew how the resident got those injuries. The DON stated that Resident 1 was not a reliable source of how the incident happened due to his dementia and that he could not remember what happened. The DON verified that Resident 1’s x-ray report dated 3/25/2023 indicating multiple fractures to the resident’s ribs were new significant injuries. The DON stated that due to its unknown origin, the fractured ribs were injuries of unknown origin. When asked if the DON reported this incident with injuries of unknown origin to CDPH, DON stated no. 2. A record review of Resident 1’s COC/Interact Assessment Form, dated 7/22/2023, timed at 11:00 a.m. indicated Resident 1 complained of back pain and claims that he had a fall. A record review of Resident 1’s Physician’s Orders, dated 7/22/2023, timed at 12:55 p.m. indicated to transfer Resident 1 to the General Acute Care Hospital (GACH) for further evaluation due to complain of back pain. A record review of Resident 1’s GACH records, dated 7/23/2023, indicated a computed tomography (CT – diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body. It shows detailed images of any part of the body, including the bones, muscles, fat, organs and blood vessels.) of the bones indicated a displaced (pieces of the bone moved so much that a gap formed around the bone where it broke) right scapular (shoulder blade bone) tip fracture, minimally displaced (when the bone cracks part or all the way through but maintains alignment) right lateral fourth to seventh and tenth rib fractures, nondisplaced posterior (back or behind) right sixth and eight rib fractures. During an interview and concurrent record review on 10/30/2023 at 6:55 p.m. with the DON, Resident 1’s COC dated 7/22/2023 was reviewed. The DON stated that Resident 1 was transferred to the GACH for further evaluation and was found to have fractures to the right shoulder blade and right ribs. The DON stated she did not know how this injury happened and that it was an injury of unknown origin. The DON stated that she did not report this incident to CDPH. When asked who is responsible to report injuries of unknown origin, the DON stated she would report them. When asked if these injuries of unknown origin should have been reported to CDPH, the DON stated yes. During an interview on 11/1/2023 at 5:55 p.m. with the Administrator (ADM), the ADM stated that it is the facility’s policy to report any injury of unknown origin with significant injuries to the State agency as mandated reporters. The ADM stated he was not informed by the DON regarding the incidents at the time of the injuries and was not aware that the incidents were not reported to CDH. A review of the facility’s P&P titled, “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating” revised 9/2022, indicates that injury of unknown source must be reported immediately (immediately defined as two [2] hours of an allegation involving abuse or resulting in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury) to the state agency. The facility failed to ensure the implementation of its P&P to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by not reporting to CDPH two incidents of injuries of unknown origin to Resident 1, which occurred on 3/5/2023 and 7/22/2023. As a result, there was a delay for an onsite inspection by CDPH to ensure the safety of the other residents and had the potential to result in unidentified abuse. The above violations had a direct relationship to the health, safety, or security of Resident 1.