Other·September 6, 2023

T22 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. F609 §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. An unannounced visit to the facility was conducted on 7/31/2023 at 5:40 PM to investigate an allegation of abuse for Patient 1. A complaint was received by the California Department of Public Health (CDPH) on 7/31/2023, indicating an allegation of abuse that was observed on 7/31/2023. The facility failed to report an allegation of abuse to CDPH and other officials immediately, but not later than two hours for Patient 1, who had a discoloration on the right eye due to unknown source, in accordance with the facility’s policy on "Abuse: Prevention of and Prohibition Against." This deficient practice had the potential for under reporting allegations of abuse, which could lead to failure to investigate alleged abuse, neglect, exploitation or mistreatment, including injuries of unknown source, which could lead to failure to investigate in a timely manner. A review of Patient 1's Admission Record indicated a 74 year old female patient who was admitted to the facility on 2/8/2023 with diagnoses including cognitive social or emotional deficit following cerebral infarction (ischemic stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), aphasia (loss of ability to understand or express speech, caused by brain damage), and dysphagia (impairment in the production of speech resulting from brain disease or damage). A review of Patient 1's History and Physical Examination dated 3/31/2023, indicated Resident 1 had fluctuating ability to make decisions. A review of Patient 1's Minimum Data Set (MDS, an assessment and screen tool) dated 2/3/2023 indicated Patient 1 had severely impaired (never/rarely made decisions) cognitive skills for daily decision making and required extensive assistance (resident involved in activity, staff provide weight-bearing support) for bed mobility and transfer. During a concurrent observation and interview in Patient 1's room on 7/31/2023 at 5:57 PM, Patient 1 was observed with a dark red and purplish discoloration around the right eye. Patient 1 could not verbalize what happened to her right eye upon interview. During an interview with certified nursing assistant (CNA) 1 on 7/31/2023 at 6:03 PM, CNA 1 stated he saw the discoloration on Patient 1's right eye for the first time yesterday when he came to work. CNA 1 stated Patient 1 did not have a bruise on right eye when he saw the patient last four (4) days prior. CNA 1 stated he asked Licensed Vocational Nurse (LVN) 1 about the discoloration and LVN 1 did not know the cause. During a concurrent interview with LVN 2 on 7/31/2023 at 6:31 PM and record review of Patient 1's Change of Condition (COC) nursing progress note dated 7/30/2023 timed at 4:15 AM, the note indicated skin discoloration around the resident’s right eye. LVN 2 stated before the COC, there was no mention of any discoloration to Patient 1's right eye in the progress notes. During an interview with the Assistant Director of Nursing (ADON) on 7/31/2023 at 7 PM, ADON stated she was unsure of what caused the injury and is investigating what caused the discoloration of Patient 1's right eye. The ADON stated she did not think the injury needed to be reported to CDPH and was unsure of the facility's policy for reporting injuries of unknown origin. A review of the facility's policy and procedure titled "Abuse: Prevention of and Prohibition Against," dated 10/2022 indicated new and existing staff topic training will include, but not be limited to: Allegation of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate State or Federal agencies in the applicable timeframes, as per policy and applicable regulations. The facility must ensure that all individuals who are involved in the reporting or investigation process are free from retaliation or reprisal. The policy indicated because some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or has occurred, possible indicators of abuse include, but are not limited to bruises, skin tears and injuries of unknown source. The facility failed to report an allegation of abuse to CDPH and other officials immediately, but not later than two hours for Patient 1, who had a discoloration on the right eye due to unknown source, in accordance with the facility’s policy on "Abuse: Prevention of and Prohibition Against." This deficient practice had the potential for under reporting allegations of abuse, which could lead to failure to investigate alleged abuse, neglect, exploitation or mistreatment, including injuries of unknown source, which could lead to failure to investigate in a timely manner. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.