Health inspection·April 9, 2025

§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 1/31/2025, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) regarding a resident (Resident 1) found on the ground on an exterior patio on 1/23/2025. The Resident was transferred to a hospital via 911 and reported that he sustained a hip fracture (a break in the bone). On 2/14/2024, the CDPH conducted an unannounced visit to the facility to investigate the FRI. Upon investigation the CDPH determined Resident 1 had a previously unwitnessed fall on 3/22/2024 resulting in a left hip fracture that was not reported to the CDPH. The facility failed to: 1. Report an injury of unknown origin when Resident 1 had an unwitnessed fall and sustained a left hip fracture. 2. Follow their Policy and Procedure (P/P), titled, “Abuse - Reporting” dated 8/1/2024, that indicated “the facility shall 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 two hours after an 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 the other officials (including to the State Survey Agency and adult protective services where State law provides or jurisdiction in long-term care facilities). This deficient practice resulted in the inability of the CDPH to investigate Resident 1’s injury in a timely manner and had the potential for information to be lost and/or forgotten. A review of Resident 1’s Admission Record (Face Sheet), indicated Resident 1, an 84-year-old male, was originally admitted to the facility on 3/18/2024 and readmitted on 1/31/2025 with diagnoses including displaced intertrochanteric fracture of right femur (a break in the hip bone), displaced intertrochanteric fracture of the left femur, difficulty walking, and dementia A review of Resident 1’s Minimum Data Set ([MDS] a resident assessment tool) dated 1/10/2025, indicated Resident 1 had severe cognitive impairment, and exhibited wandering behaviors. The MDS indicated Resident 1 used a walker and wheelchair and required supervision/touch assistance with walking more than 10 feet. A review of Resident 1’s Nursing Progress Note dated 3/22/2024 and timed at 8:30 p.m., indicated Resident 1 was found on the floor lying on his back in his restroom and was not able to move from side to side or lift his leg. A review of Resident 1’s Physician’s Order dated 3/22/2024, indicated a STAT (immediate) Xray (a procedure that produces images inside the body to determine injuries) of both hips. A review of Resident 1’s Radiology Interpretation report dated 3/23/2024 and timed at 1:14 p.m., indicated Resident 1 sustained a left hip intertrochanteric fracture with varus deformity (a condition where the distal [away from the center of the body or point of attachment] segment of a bone or joint angles inward [bow leg syndrome] consistent with an acute fracture (a sudden break in a bone caused by traumatic injury), and osteoporosis (weak and brittle bones). A review of Resident 1’s Physician’s Order dated 3/23/2024, indicated to transfer Resident 1 to a General Acute Care Hospital (GACH) due to a left hip fracture and pain related to a fall. A review of the GACH’s Admission Information (Face Sheet), indicated Resident 1 arrived in the emergency room (ER) on 3/23/2025 at 3:01 p.m., for a left hip fracture from an unwitnessed fall. A review of the GACH’s Imaging Report dated 3/23/2024 and timed at 4:50 p.m., indicated Resident 1 sustained a left comminuted intertrochanteric fracture (a severe hip fracture where the bone in the hip region is broken into multiple pieces, with fractured fragments displaced inwards, causing a deformity where ethe upper leg is angled inwards at the hip joint) with varus deformity (a condition where the distal [away from the center of the body or point of attachment] segment of a bone or joint angles inward [bow leg syndrome]. A review of the GACH’s Surgery Information Record, dated 3/24/2024 and timed at 6:22 p.m., indicated Resident 1 had a left hip fracture gamma nail insertion (a surgical procedure to stabilize severe femur fractures). During an interview on 2/18/2025 at 4:32 p.m., Registered Nurse (RN) 2, stated when Resident 1 fell on 3/22/2025 he reported the fracture to the Administrator (ADM) and Registered Nurse (RN) 1, who was the Director of Nursing (DON) at the time. During an interview on 2/19/2025 at 10:14 a.m., RN 1 stated she did not recall anyone reporting Resident 1’s fracture to her on 3/22/2024 but stated Resident 1’s fall and injury should have been reported to the state agency (CDPH). During an interview on 2/18/2025 at 3:20 p.m., the ADM stated he was not aware of Resident 1’s fall and fracture that he sustained on 3/22/2024 and he did not know why Resident 1’s fall and injury had not been reported to him. The ADM stated Resident 1’s unwitnessed fall and injury, should have been reported to him and the state agency (CDPH) within 24 hours of the Xray report. A review of the facility’s P&P titled “Abuse - Reporting” dated 8/1/2024, indicated the facility shall 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 two hours after an 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 the other officials. The facility failed to: 1. Report an injury of unknown origin when Resident 1 had an unwitnessed fall and sustained a left hip fracture. 2. Follow their P/P titled, “Abuse - Reporting” dated 8/1/2024, that indicated the facility shall 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 two hours after an 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 the other officials This deficient practice resulted in the inability of the CDPH to investigate Resident 1’s injury in a timely manner and had the potential for information to be lost and/or forgotten. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.