Health inspection·September 13, 2024

F609 (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §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. §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. § 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 7/17/2024 the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) had a swollen right knee due to an unreported fall. On 7/31/2024, CDPH conducted an unannounced visit to the facility to investigate complaint allegation. Upon investigation, CDPH determined Resident 1 sustained an injury of unknown origin (right femur fracture [break in the thigh bone]). The facility failed to: 1. Ensure an injury of unknown origin was reported to California Department of Public Health (CDPH) in accordance with facility’s policy and procedure titled, “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating.” As a result, Resident 1’s right femur fracture as an injury of unknow origin was not reported to CDPH and thoroughly investigated to rule out potential abuse or neglect in a timely manner. A review of Resident 1’s Admission Record indicated Resident 1, a 78-year-old female, admitted to the facility on 12/26/2022 with diagnoses including anoxic brain damage(irreversible damage to the brain caused by lack of oxygen), cardiac arrest (abrupt loss of heart function), tracheostomy ( opening surgically created in the neck into the windpipe to allow air to fill the lungs), and gastrostomy tube(G-tube, inserted through the wall of the abdomen into the stomach used to give medicines and liquid nutrition). A review of Resident 1’s History and Physical (H&P) dated 6/8/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/14/2024, indicated Resident 1 was dependent on staff with bathing, toileting hygiene, dressing, personal hygiene, bed mobility, and transfer to and from a bed to chair. A review of Resident 1’s Situation, Background, Assessment, Recommendation ([SBAR] used as a communication tool to share information about a resident condition that needs to be addressed) dated 5/29/2024, timed at 10:50 a.m., indicated Resident 1 had a right knee swelling and the physician ordered right knee and right femur X-ray. A review of Resident 1’s SBAR Documentation dated 5/30/2024, timed at 3:50 p.m., indicated Resident 1 had a displaced fracture at the distal femoral diaphysis (break at the thigh bone just above the knee). During an interview on 7/31/2024, at 10:04 a.m., Certified Nursing Assistant (CNA 1) stated Resident 1 required two people assistance when providing care because of the right leg fracture. CNA1 stated prior to 5/29/2024 Resident 1 used to require one person assistance when providing care like repositioning and incontinence (inability to control flow of urine from the bladder and escape of stool from the rectum) care. During an interview on 7/31/2024, at 10:39 a.m., Treatment Nurse (TN 1) stated Resident 1 had no incidence of fall. TN 1 stated a physician order for right knee and right femur X-ray was done on 5/29/2024 due to an observed swelling of the right knee during Resident 1’s care on 5/29/2024. During a concurrent observation and interview on 7/31/2024, at 9:41 a.m., with Registered Nurse Supervisor (RNS 1), TN 1 and Licensed Vocational Nurse (LVN 1), Resident 1 was observed in bed. Resident 1 was unable to follow commands and was nonverbal (unable to speak). Resident 1 was observed with right knee immobilizer (removable device that maintains stability of the knee). When TN 1 and LVN 1 removed knee immobilizer the resident’s right knee and thigh were observed to be more swollen than the left thigh and knee. RNS 1 stated Resident 1 had more swelling on the right knee because of a right femur fracture, as evidenced by the X-ray result on 5/30/2024. During an interview on 7/31/2024, at 2:03 p.m., RNS 1 stated Resident 1 had no incident of fall. RNS 1 stated she instructed CNA (in general) to team up when providing care to Resident 1. RNS 1 stated Resident 1 only gets out of bed during shower with two people assistance for transfer. RNS 1 stated they did not know how Resident 1 sustained right femur fracture and it was an injury of unknown origin, which should have been reported to CDPH to rule out possibilities of abuse or neglect. During an interview on 7/31/2024, at 4:27 p.m., the Assistant Director of Nursing (ADON) stated Resident 1 did not have a fall in the facility. The ADON stated Resident 1’s right femur fracture was an injury of unknow origin because the facility did not know the cause of the fracture. The ADON stated Resident 1’s right femur fracture was considered an injury of unknown origin because Resident 1 suddenly had a swollen knee and fracture in the right femur. The ADON agreed it should have been reported to CDPH to rule out the possibility of abuse or neglect and should have been investigated. During a concurrent interview and record review on 7/31/2024, at 10:57 a.m., the Director of Nursing (DON) stated he did not report Resident 1’s injury to CDPH because he never thought Resident 1’s right femur fracture was due to trauma. After reviewing facility’s policy and procedure for “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating”, the DON agreed Resident 1’s injury should have been reported to CDPH and investigated to rule out potential neglect or abuse. and investigated to rule out potential neglect or abuse. A review of facility’s P &P titled “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating”, indicated “All reports of resident abuse including injuries of unknown origin are reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported and resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion should be reported immediately to the administrator and to other officials according to state law.” The facility failed to: 1. Ensure an injury of unknown origin was reported to California Department of Public Health (CDPH) in accordance with facility’s policy and procedure titled, “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating.” As a result, Resident 1’s right femur fracture as an injury of unknow origin was not reported to CDPH and thoroughly investigated to rule out potential abuse or neglect in a timely manner. These violations had a direct or immediate relationship to the health, safety, or security of patients or residents.