Health inspection·November 26, 2024

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 10/11/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident about injury of unknown origin and a complaint about resident abuse. The facility failed to implement its policy 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 an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) involving Resident 1, within 24 hours, which occurred on 10/9/2024. As a result, there was a delay for an onsite inspection by CDPH to ensure the safety of Resident 1 and other residents and had the potential to result in unidentified abuse. During a review of Resident 1’s Admission Record indicated the facility originally admitted Resident 1 on 3/21/2023 and readmitted on 3/1/2024 with diagnoses that included end stage renal (the kidney) disease (ESRD - irreversible kidney failure) and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool) dated 9/10/2024 indicated that Resident 1 was rarely understood by others and rarely understands others. The MDS further indicated that Resident 1’s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired and needed maximum assistance from staff with oral hygiene, upper body dressing, personal hygiene and bed mobility (movement). The MDS indicated Resident 1 was dependent on staff with toileting hygiene, showering, lower body dressing, and transferring. During a review of Resident 1’s Skin Evaluation dated 10/9/2024 timed at 11:14 a.m., indicated, Resident 1’s left eyelid brow was noted with purplish skin discoloration (any change in natural skin tone) and dry scab (a hard, dried blood clot that can form over a cut or broken skin to stop bleeding and protect the tissues underneath from germs) on Resident 1’s nose bridge. Resident 1’s physician was notified and received new orders for monitoring. During a review of Resident 1’s Change in Condition (COC – when there is a sudden change in a resident’s health) Evaluation form dated 10/9/2024 timed at 1:00 p.m., indicated Resident 1 had a dry scab on the nose bridge (length: one centimeter [cm - a metric unit used to measure length] and width: 0.2 cm [1 x 0.2]), below the left eyelid brown discoloration (one cm by one cm [1 x 1]), and yellow skin discoloration on the forehead (measurement not indicated). During a review of the Transmission Result Verification Report (sent by the facility to the SSA) dated 10/10/2024 indicated that the facility reported the alleged physical abuse to the SSA via the facsimile (known as fax - the telephonic transmission of scanned-in printed material) on 10/10/2024 at 12:39 p.m. (more than 24 hours after receipt of the report from facility staff). During a concurrent interview and record review on 10/11/2024 at 1:18 p.m., with Registered Nurse 1 (RN 1), RN 1 reviewed Resident 1’s COC Evaluation form dated 10/9/2024. RN 1 stated she (RN 1) received the report regarding Resident 1’s skin conditions noted on the resident’s face including a dry scab on the nose bridge, a discoloration under left eyebrow, and faded discoloration (light yellowish to bluish color) on Resident 1’s forehead from Certified Nursing Assistant 2 (CNA 2) on 10/9/2024 between 8:30 a.m. to 9:00 a.m. RN 1 stated Resident 1 was not able to describe what happened. RN 1 stated she (RN 1) then reported Resident 1’s skin COC to the Director of Nursing (DON) on 10/9/2024 at around 9:00 a.m. RN 1 stated she (RN 1) informed Resident 1’s family and notified Resident 1’s physician as well. During a concurrent interview and record review on 10/11/2024 at 3:30 p.m., with the DON, the DON reviewed the Transmission Result Verification Report (sent by the facility to the SSA) dated 10/10/2024 timed at 12:39 p.m. The DON stated that the facility initiated the investigation immediately in the morning of 10/9/2024 upon receiving the report regarding Resident 1’s skin conditions on the face. The DON stated that she (DON) did not think that the changes in Resident 1’s face was a result of physical abuse, so the facility did not report within two (2) hours of receipt of the report from facility staff. The DON stated the facility reported to the SSA on the following day, 10/10/2024, at 12:39 p.m., but it should have been reported within two (2) hours since Resident 1 was not able to explain how he (Resident 1) obtained the injuries on his (Resident 1’s) face and there was no witness to the incident. During a review of the facility’s P&P titled, “Reporting Alleged Violations of Abuse, neglect (failure to provide adequate care or services), exploitation (taking advantage of a resident), or mistreatment” last reviewed on 12/2023, indicated, “If there is an allegation or suspicion of abuse, the facility will make a report to the appropriate agencies as designated by State and Federal laws…. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and the misappropriation of resident property, are reported immediately but: Not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or result in the serious bodily injury.” The facility failed to implement 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 an allegation of physical abuse involving Resident 1, within 24 hours, which occurred on 10/9/2024. As a result, there was a delay for an onsite inspection by CDPH to ensure the safety of Resident 1 and 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.