Health inspection·January 29, 2025

42 CFR §483.12 (c) Freedom from Abuse, Neglect, and Exploitation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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 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 12/16/2024 the California Department of Public Health (CDPH) received a complaint indicating Resident 1, who was physically immobile (incapable of moving) was transferred to the General Acute Care Hospital (GACH) with several unexplained bruises. On 12/30/2024, the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1.Implement its abuse Policy and Procedure (P&P) titled, “Abuse, Neglect, Exploitation and Misappropriation- Reporting and Investigating” which indicated injuries of unknown source would be reported to the State Licensing/Certification Agency within two hours, when Resident 1 developed new, multiple skin discolorations and bruising (collection of blood underneath the skin that is caused by an injury) to the left cheek and chin. This failure delayed the investigation by the CDPH. Resident 1 was a 35-year-old male, admitted to the facility on 9/10/2024 and readmitted on 12/21/2024. Resident 1’s diagnoses included respiratory failure with hypoxia (a condition where there is not enough oxygen in the blood), hepatic encephalopathy (brain dysfunction due to liver dysfunction that can cause issues with thinking and mobility) and coagulation defect (a condition that affects the ability to control bleeding). A review of Resident 1’s Minimum Data Set ([MDS], a resident assessment tool), dated 10/20/2024, indicated Resident 1 did not speak, was rarely/never able to make his needs known and was rarely/never able to understand verbal content. The MDS indicated Resident 1 was totally dependent on staff for Activities of Daily Living (ADLs) such as oral hygiene, toileting hygiene, personal hygiene, dressing and bed mobility (ability to roll from lying on back to left and right side, and return to lying on back on the bed). A review of Resident 1’s History and Physical (H&P) dated 12/21/2024 indicated Resident 1 did not have the ability to understand and make decisions. A review of Resident 1’s SBAR Communication Form ([Situation, Background, Assessment, Recommendation] a communication tool used by healthcare workers when there is a change in condition among the residents) dated 12/4/2024, indicated Resident 1 was observed with light brown skin discoloration to the left cheek. A review of Resident 1’s SBAR dated 12/9/2024, the SBAR indicated, Resident 1 was noted with multiple discolorations to the left shoulder, right shoulder, left thigh and right elbow. A review of Resident 1’s Progress Note dated 12/12/2024, the Progress Note indicated Resident 1 had bruising on the resident’s left lower chin. During a concurrent interview and record review on 12/30/2024 at 2:50 p.m. with Registered Nurse (RN) 1, Resident 1’s SBAR Communication Form, Progress Notes and H&P were reviewed. RN 1 stated Resident 1’s cheek discoloration was a bruise, measured 3 cm. x 3 cm. and grew twice as large later (size unknown). RN 1 stated the physician ordered to conduct neuro checks for Resident 1 out of concern for mentation changes since facial bruising could have been caused by trauma to the resident’s head. RN 1 stated Resident 1’s facial skin discolorations and bruising were considered injuries of unknown source and should have been reported to the State Agency Immediately. During an interview on 12/30/2024 at 3:45 p.m. with the Administrator (Admin), the Admin stated Resident 1’s skin discolorations and bruises were not reported to the State Agency because they were attributed to the resident’s condition. The Admin stated staff did not know how the bruises occurred or developed and should have been reported to the State Agency and investigated instead of attributing the bruise to medical condition. A review of the facility’s P&P titled, “Investigating Injuries” dated 12/2016, indicated an injury of unknown source was an injury that was not observed by any person, the source of injury could not be explained by the resident, and the injury was suspicious due to the injury’s extent, location, quantity, or incidents over time. A review of the facility’s P&P titled, “Abuse, Neglect, Exploitation and Misappropriation- Reporting and Investigating,” dated 7/2022, indicated the facility will report resident abuse (including injuries of unknown origin) to local, state, and federal agencies (as required by current regulations). The P&P indicated if injury of unknown source is suspected, the suspicion must be reported immediately (within two hours of an allegation involving abuse or within 24 hours of allegation that does not involve abuse) to the Administrator and to other officials according to state law. The facility failed to: 1.Implement its P&P titled, “Abuse, Neglect, Exploitation and Misappropriation- Reporting and Investigating” which indicated injuries of unknown source would be reported to the State Licensing/Certification Agency within two hours when Resident 1 developed new, multiple skin discolorations and bruising to the left cheek and chin. This failure delayed the investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of residents.