Health inspection·February 5, 2025

§483.10(g)(14) Notification of Changes (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention. (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). §483.12(b) The facility must develop and implement written policies and procedures that: §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 (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 1/13/2025, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) was bleeding from several body wounds because of a rough towel that was used on Resident 1 and Resident 1's Responsible Party (RP 1) was not informed of Resident 1's injuries. On 1/16/2025 the CDPH received a Facility Reported Incident (FRI) that Resident 1 had sustained a non-displaced fracture (a broken bone where the bone pieces remain in their original position) of the right humerus (the bone of the upper arm or forelimb, forming joints at the shoulder and the elbow) due to a fall. On 1/14/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation and FRI. Upon investigation, CDPH determined Resident 1 had an unwitnessed fall on 1/11/2025 resulting in multiple skin tears to his body. The facility failed to: 1. Ensure Resident 1's physician was notified following Resident 1's unwitnessed fall in order to obtain instructions for care and monitoring Resident 1. 2. Ensure RP 1 was notified following Resident 1's unwitnessed fall and multiple injuries to his body. 3. Ensure Resident 1 was assessed and monitored with documentation of Resident 1's unwitnessed fall and progressive health status in order to update the physician of Resident 1's status. 4. Ensure Resident 1's unwitnessed fall and care were endorsed to the oncoming shift (7 a.m. - 3 p.m.) following Resident 1's unwitnessed fall and subsequent injuries on 1/11/2025 during the 11 p.m. - 7 a.m. shift. 5. Resident 1's injury of unknown origin for was reported to the CDPH when Resident 1 sustained multiple skin tears on his body following a fall on 1/11/3035. 6. Ensure the nursing staff followed their policy and procedure (P/P) titled "Change of Condition Notification" revised on 4/1/2015, that indicated the licensed nurse will notify the resident's physician and legal representative or an appropriate family member when there is a change in resident's condition including when there was: a. An incident/accident involving the resident, b. An accident involving the resident which results in an injury and has the potential for requiring physician intervention. c. Significant change in the residents' physical, mental or psychosocial status such as deterioration of health, mental or psychosocial status, life threatening conditions and/or clinical complications. The P/P indicated "The Licensed Nurse will notify the family/surrogate decision makers of any changes in the residents' condition as soon as possible. The Licensed Nurse will document the time the attending physician was notified and the method by which physician was contacted, the response time, and whether or not orders were received, the time the family/responsible person was notified." 7. Ensure staff followed the facility's r P/P, titled "Abuse Prevention and Management" revised on 5/30/2024, that indicated the facility will promptly report to the appropriate government agencies concerns of abuse, mistreatment, neglect and injuries of unknown origin as required by law. As a result of these deficient practices, there was a delay in Resident 1's care following his unwitnessed fall with injuries on 1/11/20225, due to Licensed Vocational Nurse 2's (LVN 2) failure to assess and monitor the resident, and report to Resident 1's physician that Resident 1 had an unwitnessed fall and sustained injuries. Resident 1 was subsequently transferred to an General Acute Care Hospital (GACH) on 1/13/2025, were he was assessed with multiple bruises in different healing stages to both arms, swelling to the right foot, skin abrasions (a skin injury when the skin rubs off) with bruising and coagulated blood (a process that prevents excessive bleeding when a blood vessel is injured) to his right shoulder, right bicep (a large muscle in the upper arm), right elbow and right knee. When the facility was made aware of Resident 1's injuries, the facility failed to report the unknown injuries to the CDPH. These deficient practices had the potential for more serious injuries to be unknown by the resident's physician which could result in Resident 1's possible death and the inability of the CDPH to effectively investigate Resident 1's injuries. A review of Resident 1's Admission Record (Face sheet) indicated Resident 1 was an 81 year old male, who was initially admitted to the facility on 11/1/2023 and readmitted on 10/25/2024 with diagnosis including atrial fibrillation ([Afib] a heart condition that causes an irregular heartbeat), cirrhosis of the liver (a type of liver damage where the healthy cells are replaced by scar tissue and the liver is not able to perform its vital functions for the body to function normally), right lung malignant neoplasm (a form of cancer that spreads into or invades nearby tissues) and pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/30/2024, indicated Resident 1 had periods of disorientation and was not able to make consistent and reasonable decisions and required a two-person assist to complete his activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), and was incontinent (loss of control) of bladder and bowel functions. A review of Resident 1's History and Physical (H&P) dated 11/4/2024, indicated Resident 1 was able to make his needs known but could not make medical decisions. A review of Resident 1's Order Summary Report (Physician's orders), indicated Resident 1 had the following orders: 1. On 11/7/2024 - Apixaban (a medication used to treat blood clots and prevent stroke with side effects of bleeding) 5.0 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) one tablet two times a day for Afib. 2. On 11/7/2024 - Aspirin (a medication used as to provide relief from pain and swelling and prevention of blood clots in the body with side effects of bleeding ) 81 mg chewable one tablet daily for cerebrovascular accident prophylaxis (stroke prevention). A review of Resident 1's Care Plan related to the potential/actual impairment to skin integrity due to fragile skin, incontinence and limited mobility, dated 11/2/2023, indicated Resident 1 was to have no complications related to skin injury with interventions including following the facility protocols for treatment of injury and to monitor/document location, size and treatment of skin injury and report abnormalities to the primary care physician. A review of Resident 1's Care Plan on anticoagulant (drugs used to reduce the body's ability to form blood clots such as apixaban)/anti platelet (drugs such as aspirin which stop the blood cells from sticking together to form a clot ) therapy related to Afib, and at risk for bleeding dated 6/14/2024 indicated the goal for Resident 1 was to be free from discomfort or adverse reactions to the anticoagulant' use with interventions including inspecting Resident 1's skin and report abnormalities to the nurse. A review of Resident 1's SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) and Change of Condition (COC) Charting and Skilled Documentation dated 1/11/2025 and timed at 8:10 a.m., indicated Resident 1 was found with skin tears to the following areas of his body: 1. Right elbow 0.5 centimeters ([cm] metric unit of measurement, used for medication dosage and/or amount) by 0.5 cm 2. Right thigh 1.0 cm by 1.0 cm 3. Left lower leg 0.5 cm by 0.5 cm 4. Right shoulder 0.5 cm by 0.5 cm. A review of Resident 1's Health Status Note dated 1/11/2025 and timed at 8:10 a.m., indicated Resident 1 was observed with skin tears on his right shoulder which measured 0.5 cm by 0.5 cm, his right elbow measured 0.5 cm by 0.5 cm, right leg/thigh measured 1.0 cm by 1.0 cm, and his left below the knee measured 0.5 cm by 0.5 cm. The Health Status Noted indicated Resident 1 reported the towel used by a certified nursing assistant (CNA) 2 to clean him during the night shift was rough and caused his bleeding. A review of Resident 1's SBAR dated 1/13/2025 and timed at 12:13 p.m., indicated Resident 1 had a fall incident and on 1/13/2025, the primary care physician recommended Resident 1 be sent to a GACH for a computerized tomography scan ([CT] a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) of the head. A review of Resident 1's Health Status Note dated 1/13/2025 and timed at 12:13 p.m., indicated Resident 1 had an alleged fall on 1/11/20205 at 5 a.m., based on a written statement by CNA 2 who was assigned to care for Resident 1 on that shift (11 p.m. - 7 a.m.). The Health Status Note indicated Resident 1 sustained multiple discolorations and skin tears to his right shoulder measuring 0.5 cm by 0.5 cm, his right elbow measuring 0.5 cm by 0.5 cm, his right leg/thigh measuring 1.0 cm by 1.0 cm, and his left below the knee measuring 0.5 cm by 0.5 cm. A review of Resident 1's Order Summary Report date 1/13/2025, indicated to transfer Resident 1 to a GACH after an alleged unwitnessed fall. A review of GACH's Emergency Department (ED) Documentation dated 1/14/2025 and timed at 4:12 a.m., indicated Resident 1 presented to the GACH lethargic (a state of being drowsy and dull, listless, and unenergetic, indifferent and lazy, sluggish and inactive), with multiple bruises in different healing stages to both his arms, swelling to the right foot, skin abrasion with bruising and coagulated blood to the right shoulder, the right bicep, right elbow and right knee after an unwitnessed fall. During a telephone interview on 1/13/2025 at 3:26 p.m., Resident 1's RP 1 stated on 1/11/2025 at 11 a.m., he visited Resident 1 at the facility and was told by LVN 3 that Resident 1 was bleeding from multiple skin tears on his body. RP 1 stated LVN 3 did not know how Resident 1 sustained the skin tears and she did not receive a report from the nurses on 11 p.m. to 7 a.m. shift that Resident 1 had a COC. RP 1 stated Resident 1 told him and LVN 3 that the towel used on him was hard and rough and caused burning to his skin. RP 1 stated on 1/13/2025 at 11 a.m., he visited Resident 1 again and was told Resident 1 had an alleged fall on 1/11/2025 at 5 a.m., and he (Resident 1) would be transferred to a GACH for further evaluation and tests. RP 1 stated staff did not inform him of Resident 1's injury or fall that occurred on 1/11/2025 at 5 a.m., until he arrived at the facility (1/11/2025 at 11 a.m.). During an interview on 1/14/2025 at 11:10 p.m., CNA 2 stated on 1/10/2025 during the 11 p.m. to 7 a.m. shift, she noticed Resident 1 was moving a lot in bed at the beginning of the shift and she informed LVN 2 about Resident 1's restlessness. CNA 2 stated Resident 1's legs were dangling off the side of the bed, and she had to reposition him several times. CNA 2 stated around 5 a.m., on 1/11/2024, she was passing by Resident 1's room and saw Resident 1 lying on floor face up by the right side of his bed. CNA 2 stated Resident 1 had a bowel movement on the floor, and she informed LVN 2 of Resident 1's situation. CNA 2 stated she and LVN 2 placed Resident 1 back in bed, she cleaned him up and saw a minimal amount of blood on the floor but she did not notice any wounds on Resident 1. CNA 2 stated LVN 2 took over Resident 1's care after she (CNA 2) was finished cleaning Resident 1 up. CNA 2 stated since LVN 2 was aware of Resident 1's incident, she left at the end of her shift and did not inform the incoming nurses of Resident 1's fall incident because she thought LVN 2 would report what happened. During a telephone interview on 1/15/2025 at 11:55 a.m., LVN 2 stated on 1/10/2025 during the early part of the 11 p.m. to 7 a.m. shift CNA 2 informed her that Resident 1 was restless in bed. LVN 2 stated when she checked on Resident 1, he was pulling off his oxygen tubing. LVN 2 stated she assisted Resident 1 to reposition in bed and reminded him to keep his oxygen tubing in place. LVN 2 stated at 5 a.m. on 1/11/2025, CNA 2 informed her that Resident 1 was lying on the floor on the right side of his bed. LVN 2 stated Resident 1 did not look like he was in distress or pain, therefore, she did not check his vital signs ([v/s] the measurements of the body's essential functions, such as temperature, breathing rate, pulse, blood pressure and level of pain) nor did she do a full assessment including a neuro check on Resident 1. LVN 2 stated she assessed Resident 1's skin after CNA 2 completed Resident 1's incontinence care and stated she observed a small amount of bleeding to Resident 1's right upper arm and left it open to air, because the area looked like an old wound that possibly reopened after the fall. LVN 2 stated she did not feel like Resident 1 had fallen since Resident 1 was always on a low bed, so she did not call Resident 1's physician or RP 1 regarding the incident. LVN 2 stated she did not document the incident or Resident 1's status in his medical record and she did not endorse any information to the oncoming shift (7 a.m. -3 p.m.) because she did not feel like Resident 1 had a COC. LVN 2 stated she should have called Resident 1's physician and RP 1 so the physician could decide on what interventions the resident needed, and transfer Resident 1 to the GACH for further care and evaluation as necessary. LVN 2 stated documenting in the resident's medical record during a COC was important to ensure the resident's health progress and assessments were recorded and the resident's condition was communicated to the healthcare team. During a telephone interview on 1/15/2025 at 12:32 p.m., LVN 3 stated during her initial resident rounds on 1/11/2025 at 8 a.m., and upon assessment of Resident 1, she noted Resident 1 had multiple skin tears on his body. LVN 3 stated she was not informed by the previous shift of Resident 1's skin tears or possible COC and there was no documentation in Resident 1's me