Health inspection·November 8, 2024

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (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 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 10/4/2024, the California Department of Public Health (CDPH) received a complaint indicating Resident 1 had bruises on her right underarm down to the hip area. On 10/9/2024 at 10:30 a.m., the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1). Report Resident 1's left breast/ rib cage/ chest area bruises on 9/5/2024, to the CDPH, as indicated in the policy and procedure (P&P) titled, "Unusual Occurrence Reporting," which indicated the facility must report injury of unknown origin, to the CDPH within two hours. As a result, there was a delay in the investigation by the CDPH. Resident 1 was an 85-year-old female, admitted to the facility on 11/17/2021, with diagnoses including adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), unspecified protein-calorie malnutrition (lack of sufficient energy or protein to meet the body's metabolic demands), and type 2 diabetes (DM-abnormal blood sugar levels). A review of Resident 1's History and Physical (H&P) dated 6/22/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/13/2024, indicated Resident 1's cognitive skills were severely impaired. The MDS indicated Resident 1 required substantial/ maximum assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene. The MDS indicated Resident 1 required partial to moderate assistance with eating and oral hygiene. The MDS indicated Resident 1 was dependent with transfer from chair to bed. A review of Resident 1's Situation, Background, Assessment, and Recommendation ([SBAR] a structured way to communicate to the care team about a resident's change in condition) dated 9/5/2024 at 10:15 a.m., indicated Resident 1 had a skin discoloration (site not specified) and a 6/10 pain level (a numerical pain scale used in a facility with 0 no pain, 1-3 mild pain, 4-6 moderate pain, 7-8 severe pain, 9-10 worst pain possible) on the left breast/ rib cage/ chest area. A review of Resident 1's Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) notes dated 9/6/2024, indicated Resident 1 had bluish purplish discoloration on the left breast and left rib cage while care was provided by a staff (not identified). During a concurrent interview and record review on 10/9/2024 at 3:45 p.m. with the Director of Nursing (DON), Resident 1's progress notes dated 9/5/2024 was reviewed. The DON stated Resident 1's progress notes did not indicate the facility reported the bruise on Resident 1's left breast and rib cage area to the CDPH. The DON stated the bruise on the left breast and rib cage area were considered an injury of unknown origin and should have been reported to the CDPH within 2 hours. A review of the facility's undated P&P titled, "Unusual Occurrence Reporting," indicated resident abuse including injuries of unknown origin, should be reported to the state licensing/ certification agency responsible for surveying/ licensing the facility within two hours of the allegation or that resulted in serious bodily injury. The P&P indicated verbal or written notices must be submitted to the agency via special carrier, fax, email or by telephone. The facility failed to: 1). Report Resident 1's left breast/ rib cage/ chest area bruises on 9/5/2024, to the CDPH, as indicated in the P&P titled, "Unusual Occurrence Reporting," which indicated the facility must report via special carrier, fax, email or by telephone, resident injuries of unknown origin, to the CDPH within two hours. As a result, there was a delay in the investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.