Health inspection·August 25, 2024

CFR §483.12(b) The facility must develop and implement written policies and procedures that: CFR §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 7/3/2024 the California Department of Health (CDPH) received a complaint alleging a resident (Resident 1), sustained a hip fracture (a break in the bone) and the facility was unable to provide an explanation about how it happened. On 7/5/2024 at 8 a.m., CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation, CDPH determined Resident 1 sustained an injury of unknown origin (a fracture to her right distal femur [the area of the leg and/or thigh just above the knee joint]. The facility failed to: 1. Ensure an injury of unknown origin was reported to CDPH when Resident 1 sustained a fracture of the distal right femur. 2. Ensure the facility’s policy and procedure (P/P), titled “Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating,” indicating all reports of resident abuse, including the injuries of unknown origin must be reported to local, state, and federal agencies, as required by current regulations, was followed. As a result of this deficient practice, CDPH was unable to investigate Resident 1’s femur fracture in a timely manner and it had the potential for facts related to Resident 1’s injury to be forgotten by staff. A review of Resident 1’s Admission Record indicated Resident 1, an 84-year-old female, was initially admitted to the facility on 12/27/2022 and readmitted on 6/29/2024, with diagnoses including Vascular Dementia (problems with reasoning, planning judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain), contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), of the left and right knees and contractures of multiple sites. A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 6/22/2024, indicated Resident 1’s cognitive skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required a two plus person physical assist to complete her activities of daily living ([ADLs] task such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating) and was incontinent (involuntary voiding of urine and stool) of bladder and bowel functions. A review of Resident 1’s History and Physical Examination (H&P) dated 7/2/2024, indicated Resident 1 did not have the capacity to understand and make treatment decisions. A review of Resident 1’s Situation Background Assessment Recommendation ([SBAR] a form of communication between members of a health care team) and Change of Condition (COC) Communication Form dated 7/2/2024 and timed at 8:15 a.m., the SBAR and COC indicated Resident 1 had swelling to her right lateral (away from the middle of the side of the body, or the outer side of) thigh, with yellowish/greenish discoloration to the right knee. The SBAR and COC indicated Resident 1’s physician ordered an X-ray (a procedure used to generate images of tissues and structures inside the body) of the right pelvis (the area of the body that contain the hip bones and other organs below the stomach) and the right knee on 7/2/2024. A review of Resident 1’s Radiology (X-ray report) Results dated 7/2/2024 and timed at 10:35 a.m., the X-ray report indicated Resident 1 had a distal femur fracture with medial (towards the middle or center of the body) displacement (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) and angulation (the distal portion of the bone points off in a different directions) of the distal fracture fragment (a broken piece of a bone). During an interview on 7/5/2024 at 3:34 p.m., the Director of Nursing (DON) stated Resident 1’s physician indicated Resident 1’s injury could be pathological (caused by a disease rather than injury). The DON stated he did not think this injury was unusual when he did an internal investigation because Resident 1 had no reported fall, and he could not find how the fracture occurred. Therefore, he (DON) did not think a report was needed to be submitted to CDPH. During an interview on 7/5/2024 at 4:13 p.m., the Administrator (ADM) stated Resident 1's physician found that Resident 1's fracture was pathological, and he (ADM) did not believe an investigation was needed because Resident 1 had multiple comorbidities, a history of fractures and no reported falls. The ADM stated the facility should have reported to CDPH when Resident 1 sustained an injury (femur fracture) of unknown origin. A review of the facility’s P/P titled, “Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating,” revised 9/2022, indicated all reports of resident abuse, including the injuries of unknown origin must be reported to local, state, and federal agencies, as required by current regulations. The facility failed to: 1. Ensure an injury of unknown origin was reported to CDPH when Resident 1 sustained a fracture of the distal right femur. 2. Ensure the facility’s policy and procedure (P/P), titled “Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating,” indicating all reports of resident abuse, including the injuries of unknown origin must be reported to local, state, and federal agencies, as required by current regulations, was followed. As a result of this deficient practice, CDPH was unable to investigate Resident 1’s femur fracture in a timely manner and it had the potential for facts related to Resident 1’s injury to be forgotten by staff. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.