Health inspection·August 23, 2024

(Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) §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. §72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 6/26/2024, California Department of Public Health (CDPH) received a complaint alleging that a resident (Resident 1) sustained a fractured left elbow and no one at the facility knew how it occurred. On 7/11/2024, at 9:40 a.m., CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation CDPH determined, after Resident 1's Family Member (FM) voiced concerns that Resident 1 appeared to be in pain when her left arm was exercised, an X-ray was ordered. The X-ray results confirmed Resident 1 sustained a nondisplaced fracture (a bone that cracks or breaks but stays in place) to his left elbow, which the facility claimed they had no knowledge of how the fracture occurred. The facility failed to: 1. Report an injury of unknown origin to CDPH and law enforcement within the regulated time frame of two hours, when they became aware of the fracture to Resident 1's left elbow. 2. Ensure staff adhered to the facility's policy and procedure (P/P) titled, "Abuse Investigation and Reporting," that indicated, all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies (as determined by current regulations). This deficient practice resulted in CDPH's inability to investigate Resident 1's left elbow fracture in a timely manner and had the potential for evidence and information to be lost and/or forgotten and other injuries of unknown origin to go unreported by the facility. A review of Resident 1's Admission Record (Face sheet), indicated, Resident 1 was originally admitted to the facility on 2/23/2024 and re-admitted on 4/18/2024 with a diagnosis including epilepsy (a chronic, noncommunicable brain condition that causes people to have repeated seizures [brief episodes of involuntary movement that can affect part or all of the body and can cause loss of consciousness and control of bladder or bowel function]). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/10/2024, indicated Resident 1 was dependent on staff for all activities of daily living ([ADLs] tasks such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating) including bed mobility and transfers. During an interview on 7/11/2024, at 12:05 p.m., Resident 1's FM stated, her and a friend of the family visited Resident 1 on 6/19/2024. The family member stated, the friend of the family was exercising Resident 1's left arm and noticed that Resident 1 could have been in pain because of a frown Resident 1 had on her face. The FM stated she reported this to Licensed Vocational Nurse (LVN 1) and Registered Nurse Supervisor (RNS 1) but neither one of them could find anything wrong with Resident 1's arm. The FM stated Resident 1's physician was present at the facility on 6/19/2024 and assessed Resident 1 but could not find anything wrong with Resident 1's arm either, however, the physician still ordered an X-ray. FM 1 stated the X-ray showed Resident 1 had a left arm fracture. A review of Resident 1's Physician's Order, dated 6/19/2024, indicated to obtain an X-ray of Resident 1's left elbow to rule out pain. A review of Resident 1's X-ray report, dated 6/20/2024, indicated, Resident 1 had an age-indeterminate (the age of the fracture could not be determined or established), nondisplaced fracture at medial (toward the middle or center of the body or closer to the midline) humeral condyle (elbow). During an interview on 7/11/2024, at 2:10 p.m., the Administrator (ADM) stated, Resident 1's fracture was not reported to CDPH because, per the Xray report, Resident 1's fracture was old and therefore not an unusual occurrence. The ADM stated, he was not sure how Resident 1's fracture happened but Resident 1 was transferred to a General Acute Care Hospital (GACH) multiple times, and per Resident 1's physician, the fracture probably happened when the emergency medical technicians (EMTs) transported Resident 1 to the GACH. During an interview on 7/11/2024, at 2:20 p.m., the Director of Nursing (DON) stated Resident 1's fractured arm was not reported to CDPH because the X-ray indicated Resident 1's fracture was "age indeterminate," meaning the fracture was old and Resident 1's physician stated, it probably happened during Resident 1's transfer to the GACH. The DON acknowledged she did not know how Resident 1's fracture happened. A review of the facility's P/P titled, "Abuse Investigation and Reporting," dated 6/2017, indicated, all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as determined by current regulations). The facility failed to: 1. Report an injury of unknown origin to CDPH and law enforcement within the regulated time frame of two hours, when they became aware of the fracture to Resident 1's left elbow. 2. Ensure they adhered to the facility's P/P, titled, "Abuse Investigation and Reporting," that indicated, all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies (as determined by current regulations). This deficient practice resulted in CDPH's inability to investigate Resident 1's left elbow fracture in a timely manner. This deficient practice had the potential for evidence and information to be lost and/or forgotten and other injuries of unknown origin to go unreported by the facility. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.