Other·May 23, 2024

22 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. 22 CCR § 72527. Patient's Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. 22 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. 22 CCR § 72541 Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. HSC 1418.91 (a) A long-term health care facility shall report all incident of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) Failure to comply with the requirements of this section shall be a class "B" violation. On 4/4/2024, the California Department of Public Health (CDPH) received a complaint indicating Resident 1 had a fracture (broken bone) on the right leg. On 4/5/2024, the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1). Implement its policy and procedure (P&P) titled, "Incident & Accident Management Policy", which indicated to report to the CDPH unusual occurrence which threatens the welfare, safety, or health of the patients, within 24 hours, when Resident 1 sustained fracture on the right thigh on 7/12/2023. This violation delayed the investigation by the CDPH. A review of Resident 1's admission record indicated Resident 1 was a 79-year-old female, admitted to the facility on 4/17/2023. Resident 1's diagnoses included dementia (impairment of memory and abstract thinking), age-related osteoporosis (deterioration in bone mass and micro-architecture, with increasing risk to fragility fractures), and unilateral primary osteoarthritis of right knee, degenerative joint disease, result of wear and tear and progressive loss of articular cartilage). A review of Resident 1's Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 3/26/2024, indicated Resident 1 could understand and be understood by others. The MDS indicated Resident 1 was dependent with activities of daily living (ADLs) such as dressing, toilet use, shower, lower body dressing, outing on/taking off footwear. The MDS indicated Resident 1 required substantial/maximum (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) assistance with personal hygiene, upper body dressing. The MDS indicated Resident 1 was dependent with transfer (moving between surfaces to and from bed, chair, and wheelchair) and substantial /maximal assistance with bed mobility (how resident moves from lying to turning side to side). A review of Resident 1's x-ray (process of taking pictures of tissues and structures inside the body for diagnosis and treatment) result dated 7/12/2023, indicated a displaced fracture on the right femur (thigh). During an interview on 4/5/2024 at 11:27 a.m., Resident 1 stated, approximately one year ago, the Certified Nurse Assistant (CNA) helped me to go to the wheelchair and moved my knee harder and, I think it broke. During an interview on 4/11/2024 at 1:40 p.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 1's fracture was not reported to the CDPH because the facility knew how it happened. The ADON stated, incidents in which a resident sustained a fracture, should be reported to the CDPH. During an interview on 4/11/2024 at 1:54 p.m. with the Administrator (ADM), the ADM stated Resident 1 had osteoporosis and that could have caused the fracture The ADM stated Resident 1's right leg fracture was not reported to CDPH because the facility knew what happened. The ADM stated any unusual occurrence should be reported to CDPH and investigated within 24 hours. A review of the facility's policies and procedure (P&P) titled, "Incident & Accident Management Policy", dated 10/2011, indicated, incidents are events when injuries sustained by a resident, or any happening that is not consistent with the routine care of a resident, had caused injury. The P&P indicated, the facility must meet Title 22 CCR (California Code of Regulation) Section 72541, Unusual Occurrence Reporting Requirements, which included to report to the local health office and the Department, unusual occurrence which threatened the welfare, safety, or health of the patients, within 24 hours. The facility failed to: 1). Implement its policy and procedure (P&P) titled, "Incident & Accident Management Policy", which indicated to report to CDPH unusual occurrence which threatened the welfare, safety, or health of the patients, within 24 hours, when Resident 1 sustained fracture on the right thigh. This violation delayed the investigation by the CDPH. This violation presented a direct relationship to the health, safety, security, or welfare of Resident 1.