Health inspection·December 30, 2024

CFR § 483.12 - Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. (c) 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. CCR§ 72315 - Nursing Service-Patient Care b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 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. Health and Safety Code 1418.91. (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. On 12/2/2024, the California Department of Public Health (CDPH) received a facility reported incident regarding a resident's (Resident 1) injuries from unknown origin. On 12/4/2024, CDPH conducted an unannounced visit to the facility to investigate a facility reported incident. The facility failed to: 1. Implement its abuse prevention policy and procedure (P&P) titled, "Abuse, Neglect and Exploitation", revised 12/19/2022, by failing to report an unusual occurrence of an acute (sudden and severe onset) right femoral neck fracture (a particular type of hip fracture that occurs at the hip region below the ball-and-socket joint ) and right temporal (side of the head behind the eye between the forehead and the ear) hematoma (a closed wound where blood collects and fills a space inside the body because it can't flow or drain out) of unknown cause to the State Survey Agency CDPH within 24 hours of the occurrence of the injuries of unknown origin for Resident 1. 2. Implement its P&P titled, "Unusual Occurrence", revised 12/19/2022, indicating an unusual occurrence is reported to the Department of Public Health within 24 hours of occurrence. As a result, there was a delay of an onsite investigation by CDPH to ensure injuries of unknown origin were investigated timely to rule out potential physical abuse and lead to a delay in prevention of potentially ongoing injuries of unknown origin. A review of Resident 1's Admission Record, indicated Resident 1 was admitted to the facility on 10/25/2024 with diagnoses including age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) without current pathological (break caused by natural weakness of the bone structure) fracture (broken bone), dementia (a progressive state of decline in mental abilities), and spondylosis (a condition in which there is abnormal wear on the bones of the neck). A review of Resident 1's History and Physical (H&P), dated 3/22/2024, indicated, Resident 1 had fluctuating (rise and fall irregularly) capacity (ability) to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/29/2024, indicated Resident 1 required moderate assistance (Helper does less than half the effort) from one staff for roll left and right, sit to lying, lying to sitting on side of bed, and toilet transfer. A review of Resident 1's Change in Condition (COC) report, dated 11/27/2024, at 2:00 p.m., indicated Licensed Vocational Nurse (LVN 1) noticed reddish-purple skin discoloration on Resident 1's right hip and right side of the forehead. The COC report indicated Resident 1 was unable to recall how she got the injuries. The COC report indicated during assessment, Resident 1's range of motion (ROM - the distance and direction to which a bone joint can be extended) was limited and Resident 1 complained of 10 out of 10 pain on the numeric pain scale (a pain screening tool, commonly used to assess pain severity at that moment in time using a 0-10 scale, with zero meaning "no pain" and 10 meaning "the worst pain imaginable"), especially when being touched. A review of Resident 1's Transfer Form from the facility to the GACH dated 11/27/2024, indicated, Resident 1 was transferred to the GACH on 11/27/2024, at 11:00 a.m. During an interview on 12/4/2024, at 11:30 a.m., Certified Nurse Assistant (CNA1) stated Resident 1 had been refusing breakfast and morning hygiene care since 7:00 a.m. on 11/27/2024. CNA 1 stated, Resident 1 seemed very upset and did not want to get out of bed. CNA 1 stated she notified LVN 1 about it. During an interview on 12/4/2024, at 2:16 p.m., LVN 1 stated between 11:30 p.m. and 12:00 p.m. she went to Resident 1's room and she noted a red-purplish discoloration on Resident 1's right hip and right forehead. LVN 1 stated, Resident 1 complained of 10/10 pain on her right hip. LVN 1 stated, she notified the Director of Nursing (DON), and the DON came to assess Resident 1. LVN 1 stated Resident 1 was transferred to the GACH Emergency Room (ER) on 11/27/2024. During an interview on 12/5/2024, at 3:08 p.m., the DON stated, she was notified of Resident 1's injury on 11/27/2024. The DON stated, the facility's policy indicated, an unusual occurrence should be reported within 24 hours of occurrence. The DON stated she waited until she received Resident 1's medical record confirmation of a fracture from the GACH before reporting to CDPH. During an interview on 12/5/2024, at 5:15 p.m., the Administrator (ADM) stated, the facility policy indicated, an unusual occurrence should be reported within 24 hours of occurrence and Resident1's incident was an injury of unknown origin which was considered an unusual occurrence. The ADM stated, there was no witness that saw how Resident 1 got injured, and no one was able to find the cause of the injuries. The ADM stated, she received the Resident 1's test results of the fractures from the GACH on 12/2/2024. The ADM stated, she did not report the incident to CDPH on 11/27/2024 because she did not get the medical record from the GACH until 12/2/2024. The ADM stated, she could have reported on 11/27/2024, but she was not sure if the pain level of 10 out of 10 and discolorations on right hip would be considered as reportable injuries even though there was possibility of a fracture. The ADM stated it was important to report unusual occurrences in a timely manner to prevent repeated similar incidents of injuries of unknown origin. A review of Resident 1's Emergency Medical Services (EMS) Report, dated 11/27/2024, indicated dispatch received a 911 call on 11/27/2024, at 12:21 p.m., and arrived at the facility at 12:30 p.m. The EMS Report indicated, Resident 1 was in bed and complained of right-side hip pain. Resident 1 had shortening (one leg shorter than the other due to fracture) and external rotation of right leg (the leg rotates outward, away from the rest of your body). A review of Resident 1's GACH ER's Notes, dated, 11/27/2024 and timed at 12:55 p.m., indicated Resident 1 complained of right hip pain and there was a hematoma on the right temporal area. A review of Resident 1's GACH's X-ray (a way for providers to get pictures of the inside of the body) Report, dated 11/27/2024 and timed at 2:03 p.m., indicated Resident 1 had comminuted (bone broken into three or more pieces) moderately displaced right femoral neck fracture (the pieces of the bone moved so much that a gap formed around the fracture) with soft tissue swelling. A review of the facility's P&P titled, "Unusual Occurrence", revised 12/19/2022, the P&P indicated, it is the policy of the facility that an unusual occurrence is reported to the Department of Public Health within 24 hours of occurrence. Policy Interpretation and Implementation: Reporting to the Department of Public Health will be made by telephone and confirmed in writing within 24 hours of occurrence." A review of the facility's P&P titled, "Abuse, Neglect and Exploitation", revised 12/19/2022, the P&P indicated, "Policy Explanation and Compliance Guidelines...IV. Identification of Abuse, Neglect and Exploitation... B. Possible indicators of abuse include, but are not limited to: Physical marks such as bruises, Physical injury of a resident, of unknown source, Sudden or unexplained changes in behaviors and/or activities... V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur... VII. Reporting/Response: A. The facility will have written procedures that include I. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury." The facility failed to: 1. Implement its abuse prevention P&P titled, "Abuse and Exploitation", revised 12/19/2022, by failing to report an unusual occurrence of an acute right femoral neck fractur and right temporal hematoma of unknown cause to the State Survey Agency CDPH within 24 hours of the occurrence of the injuries of unknown origin for Resident 1. 2. Implement its P&P titled, "Unusual Occurrence", revised 12/19/2022, indicating an unusual occurrence is reported to the Department of Public Health within 24 hours of occurrence. As a result, there was a delay of an onsite investigation by CDPH to ensure injuries of unknown origin were investigated timely to rule out potential physical abuse and lead to a delay in prevention of potentially ongoing injuries of unknown origin. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents at the facility.