Health inspection·August 22, 2024

CFR §483.12 - Freedom From Abuse, Neglect, and Exploitation (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. 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. 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. On 7/8/2024 the California Department of Public Health (CDPH) conducted an annual recertification survey of the facility. During the recertification survey CDPH determined the facility failed to report and investigate an injury of unknown origin for Resident 73. The facility failed to: 1. Report Resident 73's left hip fracture as an injury of unknown source within 2 hours to the appropriate State Agencies, including the Department of Public Health and the local Ombudsman (representatives assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) and conduct the investigation of Resident 73's left hip fracture to rule out potential abuse. On 4/30/2024 Resident 73 was noted to have limited range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move). On 5/8/2024, Resident 73's X-ray (image that creates pictures of the inside of the body) results indicated Resident 73 had a left displaced (bone moved out of its original position) femoral neck (narrow portion of the hip bone) fracture (break in the bone). 2. Follow its policy and procedure titled, "Abuse Prevention" which indicated staff will report injuries of unknown origin so that investigations can be conducted to rule out abuse and file all required documentation. The P&P indicated the facility was required to report all allegations of abuse, including injuries of unknown source, even if there was no reasonable suspicion of abuse within two hours. As a result of these failures Resident 73's left hip fracture of unknown source the CDPH's investigation regarding the circumstances of Resident 73's injury were delayed and placed Resident 73, and other residents with severely impaired cognition at risk for ongoing unrecognized abuse, neglect, or mistreatment. A review of Resident 73's Admission Record indicated the resident, an 81-year-old female's , was originally admitted to the facility on 10/26/2022 and re-admitted on 5/17/2024 with diagnoses including dementia (decline in mental ability severe enough to interfere with daily life), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning), muscle weakness, and left displaced femoral neck fracture. A review of Resident 73's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 1/30/2024, indicated Resident 73 had clear speech, was able to express ideas and wants, clearly understood verbal content, and had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 73 was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) on staff for eating, oral hygiene (ability to use suitable items to clean teeth), toileting, showering/bathing, lower body dressing, and chair/bed-to-chair transfers. A review of Resident 73's Rehab - Joint Mobility Screen (brief assessment of a resident's ROM in both arms and both legs) form, dated 1/30/2024, indicated Resident 73 had the ROM impairment in both legs, including severe ROM limitations (25 percent [%] or less of full ROM) in the left hip, both knees, and both ankles, and moderate ROM limitation (approximately 50% of full ROM) in the right hip. The Joint Mobility Screen form indicated Resident 73 was receiving Restorative Nursing Assistance ([RNA] certified nursing assistance program that helps residents to maintain their function and joint mobility) for passive range of motion ([PROM] a movement of joint through the ROM with no effort from the person) exercises to both legs, five times per week, but was noted to have stiffness in both hips, knees, and the right ankle. A review of Resident 73's Change in Condition ([CIC] major decline or improvement that affects a resident's health or will not resolve without intervention) Evaluation, dated 2/1/2024, indicated Resident 73 did not want to participate in the RNA program. The CIC Evaluation indicated Resident 73's physician was notified and ordered a PT and Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation. Resident 73's CIC Evaluation also indicated Family Member (FM 1) was notified. A review of Resident 73's Change in Condition (CIC Evaluation, dated 4/30/2024, indicated Resident 73 was noted to have changes in ROM in the left hip and left knee, including tight adduction (hips moving toward the body) of both legs with feet crossing and difficulty separating the legs. The CIC Evaluation indicated Resident 73's physician was notified and ordered a physical therapist's (PT) Evaluation. Resident 73's CIC Evaluation also indicated FM 1 was notified. A review of Resident 73's PT Evaluation and Plan of Treatment, dated 5/2/2024, indicated Resident 73 was referred to PT due to changes in ROM in the left hip and left knee. The PT Evaluation indicated Resident 73's ROM in both hips and both knees were impaired, including left hip flexion 0-15 degrees, right hip flexion 0-90 degrees, left knee flexion 0-20 degrees, and right knee flexion 0-90 degrees. The PT Evaluation indicated Resident 73 was in a supine position with the right leg positioned on top of the left leg, noted stiffness to the left leg more than the right leg, and decreased ROM to the left hip and knee. The PT Plan of Treatment included therapeutic exercises, neuromuscular reeducation, and therapeutic activities, four times per week for four weeks. A review of Resident 73's Physical Medicine and Rehab note, dated 5/7/2024, indicated Resident 73 with noted limitations and difficulty with ROM in both legs, including the right leg fixed (immovable) in adduction. The Physical Medicine and Rehab physician (Physiatrist) recommendation included hip and knee X-rays due to difficulty performing ROM to Resident 73's both hips and both knees. A review of Resident 73's physician orders, dated 5/7/2024, indicated an X-ray of the hips one time only for one day. A review of Resident 73's Radiology Results Report, dated 5/8/2024, indicated Resident 73 had an age-indeterminate (unknown length of time), displaced left femoral neck fracture. A review of Resident 73's CIC Evaluation, dated 5/8/2024 at 7:30 p.m., indicated Resident 73's physician was notified of Resident 73's displaced left femoral neck fracture and ordered to administer Naproxen (medication that treats swelling and pain) 375 mg, every 12 hours as needed, an Orthopedic (branch of medicine dealing with the correction or prevention of deformities, disorders, or injuries of the bones and associated soft tissue) specialist referral, a Physiatrist consultation for pain management, and to apply the abduction pillow all times until Resident 73 received an Orthopedic specialist consultation. Resident 73's CIC Evaluation also indicated FM 1 was notified. During a review of Resident 73's Progress Note, dated 5/13/2024 (five days after receiving X-ray results on 5/8/2024), the Progress Note indicated Resident 73's physician assessed Resident 73 while in the facility and ordered for Resident 73 to be transferred to the General Acute Care Hospital (GACH) for evaluation due to left hip pain, tightness in both legs into adduction (the movement of a joint or body part inward toward the midline), and the abnormal X-ray with age-indeterminate displaced left femoral neck fracture. During a review of Resident 73's physician orders, dated 5/13/2024, the physician order indicated to transfer Resident 73 to the GACH emergency room for evaluation and treatment due to left hip pain, tightness in both legs into adduction, and abnormal X-ray with age-indeterminate displaced left femoral neck fracture. During a review of Resident 73's PT Discharge Summary, dated 5/14/2024, the PT Discharge Summary indicated Resident 73 was discharged from PT due to Resident 73's discharge to the hospital. A review of Resident 73's Progress Note dated 5/17/2024 at 5:17 p.m., indicated Resident 73 was re-admitted to the facility with a diagnosis of an old left femoral fracture. During an interview on 7/10/2024 at 5:21 p.m., the Assistant Administrator (AADMIN) stated he received Resident 73's X-ray results on 5/8/2024, which indicated an age-indeterminate left hip fracture. The AADMIN stated Resident 73's left hip fracture was not reported to the Department of Public Health since it was age-indeterminate and was not a new injury. During a telephone interview on 7/10/2024 at 6:13 p.m., FM 1 stated Resident 73 did not have any history of hip fractures prior to residing in the facility. FM 1 stated Resident 73 started crossing one leg over the other in approximately 1/2024 (exact date unknown) and complained of pain whenever Resident 73's legs were uncrossed. FM 1 stated it made sense that Resident 73's X-ray results indicated a left hip fracture because Resident 73 had pain. During an interview on 7/12/2024 at 8:16 a.m., the AADMIN stated any physical injury, including pain, bruising, and a fracture were considered physical harm. The AADMIN stated the facility was required to report physical harm within two hours of knowing about the physical harm. The AADMIN stated if a resident (in general) had physical harm, then the facility would ensure the resident's safety, including sending the resident to the hospital, if necessary, report the physical harm to the Department of Public Health, Ombudsman, local law enforcement, and the resident's responsible party, and then the facility would investigate the incident. During an interview on 7/12/2024 at 8:20 a.m., the AADMIN stated Resident 73's left hip fracture was physical harm with an unknown cause of injury and Resident 73's impaired cognition prevented Resident 73 from explaining how the injury occurred. The AADMIN stated Resident 73's left hip fracture should have been reported within two hours. The AADMIN stated the facility started the investigation on 5/14/2024 (six days after receiving the X-ray results) but did not complete the investigation for Resident 73's left hip fracture of unknown cause. A review of the facility's policy and procedure (P&P) titled, "Abuse Prevention," dated 12/31/2015, indicated the facility ensured the resident's rights were protected by providing a method for prevention, reporting and investigation of any type of alleged abuse. The P&P indicated staff will report injuries of unknown origin so that investigations can be conducted to rule out abuse and file all required documentation. The P&P indicated the facility was required to report all allegations of abuse, including injuries of unknown source, even if there was no reasonable suspicion of abuse within two hours. The P&P indicated the facility will perform an investigation, including interviewing employees, family, and visitors who may have knowledge of the alleged incident. The facility failed to: 1. Report Resident 73's left hip fracture as an injury of unknown source within 2 hours to the appropriate State Agencies, including the Department of Public Health and the local Ombudsman (representatives assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) and conduct the investigation of Resident 73's left hip fracture to rule out potential abuse. On 4/30/2024 Resident 73 was noted to have limited range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move). On 5/8/2024, Resident 73's X-ray (image that creates pictures of the inside of the body) results indicated Resident 73 had a left displaced (bone moved out of its original position) femoral neck (narrow portion of the hip bone) fracture (break in the bone). 2. Follow its policy and procedure titled, "Abuse Prevention" which indicated staff will report injuries of unknown origin so that investigations can be conducted to rule out abuse and file all required documentation. The P&P indicated the facility was required to report all allegations of abuse, including injuries of unknown source, even if there was no reasonable suspicion of abuse within two hours. As a result of these failures Resident 73's left hip fracture of unknown source the CDPH's investigation regarding the circumstances of Resident 73's injury were delayed and placed Resident 73, and other residents with severely impaired cognition at risk for ongoing unrecognized abuse, neglect, or mistreatment. This violation had the direct or immediate relationship to the health, safety, or security of Resident 73.