Health inspection·June 29, 2021

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. F609 In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §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. The facility failed to ensure Nursing Assistant (NA) 1, NA 2, and Certified Nursing Assistant (CNA) 2 reported an alleged injury of unknown origin/source immediately, but not later than two (2) hours to the local, state and federal agencies and thoroughly investigated by facility management. Resident 1 informed FM 2 that someone pinched the resident’s arm. Resident 1’s family member (FM 2) asked NA 1 and another unidentified staff on 5/14/21 about new bruises found in the resident’s bilateral arms. NA 1 did not inform the charge nurse of the patient’s bruises (from unknown source), to initiate an investigation immediately. NA 2 found the bruises on the resident’s arms on 5/18/21 and reported it to CNA 2. CNA 2 did not report the bruises to the charge nurse immediately. Resident 1’s bruises to bilateral arms was reported to the facility administrator on 5/19/21. The administrator reported to the Department of Public Health and Ombudsman (a state official appointed to provide a check on government activity in the interests of the citizen and to oversee the investigation of complaints of improper government activity against the citizen) on 5/19/21 (5 days after it was first observed and known by NA 1). These deficient practices had the potential for the facility to under report alleged injuries of unknown origin, which could lead to failure to investigate alleged injuries of unknown origin that could be a result of abuse or neglect, in a timely manner. Findings: A review of Resident 1's Admission Record, indicated the facility admitted the 82 year old resident on 8/14/2020, with diagnoses including Parkinson's Disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), dementia with Lewy bodies (a brain disorder that leads to a decline in thinking, reasoning and independent function due to abnormal microscopic deposits that damage brain cells over time), attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 3/30/21, indicated the resident had severely impaired cognitive skills (how the brain remembers, thinks, and learns) but sometimes able to communicate. The MDS indicated the patient was assessed requiring extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transferring from bed to chair, locomotion on and off unit, getting dressed, toilet use, and personal hygiene and total assistance (staff provided care 100% of the time) with bathing. A review of Resident 1's Skin Integrity Care Plan, revised on 4/3/21, indicated the resident was at risk for skin breakdown and poor healing related to decreased mobility, fragile skin, incontinence (accidental or involuntary loss of urine from the bladder [urinary incontinence] or bowel motion, feces or wind from the bowel [fecal or bowel incontinence]), mental illness, and advanced dementia. The care plan goal indicated the resident's skin breakdown will be minimized after interventions daily for 90 days. The approaches included to monitor skin integrity daily during care, provide adequate skin care daily, and assist in bed mobility and repositioning as needed. During an interview on 5/18/21 at 3:25 p.m., Family Member (FM) 2 stated she visited Resident 1 on 5/14/21 and noticed new bruises on the resident's right and left arms. FM 2 stated she asked the resident what happened, and the resident told FM 2 someone pinched her. FM 2 stated, that on the same day (5/14/21), she asked NA 1 and another unidentified facility staff (FM 2 unable to recall who) about the resident's bruises. FM 2 stated the unidentified facility staff told her that Resident 1 probably became aggressive during care and hit her arms somewhere. During an observation and concurrent interview on 5/19/21 at 10:06 a.m., Wound Treatment Nurse (TXN) 1 stated Resident 1 had discoloration (bruising) to her bilateral forearms. TXN 1 stated she did not see the discoloration (bruising) the previous day (5/18/21) when she provided the patient's wound treatment. TXN 1 stated Resident 1 probably hit her arms on the side rails. TXN 1 notified the DON of Resident 1’s bruising to both arms, on 5/19/21. During an interview on 5/19/21 at 10:33 a.m., Licensed Vocational Nurse (LVN) 4 stated she did not notice any bruising or discoloration on Resident 1's arms. LVN 4 stated she did not receive any report of bruising, discoloration, or allegation of abuse from any of the staff or family member. During an interview on 5/19/21 at 12:32 p.m., NA 2 stated she was assigned to care for Resident 1 the previous day (5/18/21). NA 2 stated she noticed the discoloration (bruising) to Resident 1’s arm the previous day but could not remember which arm had the discoloration (bruising). NA 2 stated the discoloration (bruising) did not look new, so she did not report it to the charge nurse. NA 2 stated she reported it to her lead CNA (CNA 2) on 5/18/21. During an observation and concurrent interview on 5/20/21 at 8:09 a.m., Resident 1 stated she sustained the right arm bruises from hitting something on the side of her bed. Resident 1 stated the bruises on her left arm was sustained from a female staff (unable to recall who) pinching her. The resident further stated she did not report the pinching to any staff. During an interview on 5/21/21 at 9:05 a.m., CNA 2 stated NA 2 reported Resident 1’s arm discoloration (bruising) to her on 5/18/21. CNA 2 stated she saw the “discoloration” (bruising) on 5/18/21 and it did not look new. CNA 2 stated she did not report the “discoloration” (bruising) to the charge nurse because she thought NA 2 already reported it. During a telephone interview on 5/21/21 at 10:51 a.m., NA 1 stated she was assigned to care for Resident 1 on 5/14/21. NA 1 stated FM 2 was in the facility and visited Resident 1 on 5/14/21. NA 1 stated FM 2 asked her and showed her the discoloration on the resident's arm. NA 1 stated she could not remember which arm had the discoloration (bruising). NA 1 stated she told FM 2 she did not know where the resident’s discoloration (bruising) came from and to ask the charge nurse about it. NA 1 stated she did not report the discoloration (bruising) to the charge nurse herself. During an interview on 5/21/21 at 11:22 a.m., the administrator stated he was the facility's abuse coordinator. The administrator stated any suspicion or allegation of abuse should be reported to him or to any highest role available in the building immediately. The administrator stated any injuries of unknown origin should be first reported to the charge nurse. A change of condition will be initiated, and an investigation will be started. The administrator stated he reported the alleged abuse involving Resident 1 to the Department of Public Health and the Ombudsman on 5/19/21 and started the investigation as soon as he was made aware of it on 5/19/21. During an interview on 5/21/21 at 11:55 a.m., the director of nursing (DON) stated any staff who observed a patient's injury of unknown origin must notify the resident's charge nurse right away. The charge nurse or supervisor will then assess the injury, call the patient's physician, and notify the family. The charge nurse will complete an incident report and notify her. The DON stated she will then conduct a follow-up investigation and will discuss it with the rest of the team during the stand-up meeting. A review of the facility's policy and procedures titled, "Investigating Injuries," revised in 12/2016, indicated the administrator will ensure that all injuries are investigated. The policy indicated the director of nursing services or a designee will assess all injuries and document clinical findings in the clinical record. If an incident/accident is suspected, a nurse or nurse supervisor will complete a facility-approved accident/incident form. The form will be disseminated to the appropriate individuals, for example the administrator and director of nursing services. The investigation will follow the protocols set forth in the facility's established abuse investigation guidelines. A review of the facility's policy and procedures titled, "Abuse Investigation and Reporting," revised in 7/2017, indicated reports of resident abuse, neglect, exploitation, misappropriation of resident property, and/or injuries of unknown source (''abuse'') shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. The policy indicated an alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury; or twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury.