Health inspection·May 13, 2024

42 CFR §483.12 Freedom from abuse, neglect, and exploitation. (a) The facility must— (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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. 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 § 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. 22CCR §72541 - Unusual Occurrences 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. The California Department of Public Health (CDPH) received a complaint on 3/19/2024, indicating on 3/17/2024, Certified Nurse Assistant 1 (CNA1) placed Resident 1 at the edge of bed during care, the resident rolled over, fell and sustained a left leg fracture (broken bone). On 4/2/2024 at 11:20 a.m., an unannounced visit was conducted at the facility to investigate the allegation. The facility failed to: 1). Follow its policy and procedure (P/P) titled “Unusual Occurrence Reporting” which indicated, events which affect the health, safety or welfare of residents, employees or visitors will be reported via telephone within twenty-four (24) hours, to the state agency, as require by federal and state regulations. As a result, there was a delay in the investigation by the state agency. A review of Resident 1’s admission record indicated Resident 1 was originally admitted to the facility on 10/8/2013 and readmitted on 3/21/2024. Resident 1’s diagnoses included nondisplaced transverse fracture of the shaft of left tibia and fibula (a break in the lower leg bones across the bone that did not move out of alignment), osteoporosis (a condition in which bones become weak and brittle), and functional quadriplegia (the inability to move the body from the neck down). A review of Resident 1’s History and Physical (H&P), dated 1/28/2024, indicated Resident 1 had 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 1/29/2024, indicated Resident 1 usually understood and was understood by others. The MDS indicated Resident 1 had impairments with range of motion (the extent or limit to which the body can be moved around a joint) on both sides of the upper and lower extremities. The MDS indicated Resident 1 was dependent (helper does all the effort to complete the activity) for all activities of daily living including rolling left and right in bed, personal hygiene, and toileting. A review of Resident 1’s radiology ([x-ray] process of taking pictures to diagnose and treat diseases) report dated 3/17/2024, indicated acute left proximal tibia and fibula (long bone in the lower leg) fracture. A review of Resident 1’s GACH Emergency Physician notes indicated Resident 1 fell out of bed on 3/16/2024, at a skilled nursing facility (SNF), and complained of a left lower leg pain. The notes indicated Resident 1’s x-ray from the SNF indicated the resident had a closed comminuted left tibia and fibula fracture and was transferred to the GACH for further evaluation. The notes indicated Resident 1 had a left lower leg pain when palpated or with any movement. During an interview with the facility’s Assistant Director of Nursing (ADON), on 4/19/2024 at 1:25 p.m., the ADON stated Resident 1’s left lower leg fracture was not reported to the CDPH within 24 hours after the facility’s x-ray report, because the facility needed to obtain another x-ray from the general acute care hospital (GACH) to confirm the resident indeed had a fracture. A review of the facility’s P/P titled “Unusual Occurrence Reporting” dated January 2024, indicated events which affect the health, safety or welfare of residents, employees or visitors will be reported via telephone within twenty-four (24) hours, to the state agency, as require by federal and state regulations. The P/P indicated a written report detailing the incident and actions taken by the facility after the event shall be reported to the state agency within forty-eight (48) hours of reporting the event.