Health inspection·December 29, 2022

F609 CFR §483.12 (c) 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 patient 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. T22 Section 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 11/17/2022, an unannounced visit was made to the facility to conduct an annual Recertification Survey. The facility failed to ensure Patient 5, with an injury of unknown origin was reported to the State Survey Agency timely (within two hours). Patient 5 had vaginal bleeding and a vaginal tear on her labia (folds of skin around the vaginal opening) on 11/9/2022 from an unknown cause. This violation resulted in the delay of investigation by the State Survey Agency and determination of the cause of Patient 5's injury, including the possibility of physical abuse. A review of Patient 5's admission record indicated the patient was a 72 years old female, who was admitted to the facility on 10/30/2021, with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems) with acute exacerbation (a sudden worsening of the symptoms), epilepsy (result of abnormal electrical brain activity or seizure) and schizoaffective disorder (a mental illness that affect a person's thoughts, mood, and behavior). A review of Patient 5's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/26/2022, indicated Patient 5 had the ability to sometimes make self-understood and had the ability to usually understand others. The MDS indicated Patient 5 was totally dependent on staff for bed mobility, transfer to and from bed, locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing. The MDS indicated Patient 5 required extensive assistance from staff for eating. A review of Patient 5's Situation Background Appearance Request (SBAR, facility's communication and progress note for changes in condition) form, dated 11/9/2022, indicated at 10:10 AM, a Certified Nursing Assistant (CNA) reported that the patient had blood in her diaper when they changed her. The SBAR indicated Licensed Vocational Nurse 3 (LVN 3) assessed Patient 5 and noted bleeding from her vaginal area. At 10:30 AM, LVN 3 called and notified Patient 5's attending physician and the attending physician gave an order for a vaginal consult and laboratory test for Complete Blood Count (CBC, a test that counts the cells that make up a person's blood: red blood cells, white blood cells, and platelets) and Comprehensive Metabolic Panel (CMP, a test that measures 14 components found in the blood including sugars, minerals, electrolytes, enzymes, and waste products, to provide an overall picture of the body's chemical balance and metabolism). A review of Patient 5's Nurses Notes dated 11/9/2022 indicated that CNA 1 reported there was blood on Patient 5's adult brief. The notes indicated Patient 5's vaginal area was checked and a small tear or scratch on the labial area was noted, which possibly where the fresh blood came from. The note was entered and signed by the DON. A review of Patient 5's Physician's Order dated 11/9/2022 indicated for staff to cleanse the patient's vaginal tear or scratch with NS (Normal saline), pat dry, and apply Bacitracin ointment (a triple antibiotic ointment) q (every) shift for 21 days. A review of Patient 5's care plan dated 11/9/2022, indicated the patient was noted with vaginal bleeding during adult brief change and a small tear/scratch on her vaginal/labia. The care plan indicated patient's risk factors were fragile skin/tissue related to advance age. The care plan interventions included to provide Gynecology (area of medicine that involves the treatment of women's diseases, especially those of the reproductive organs) consult as ordered and to apply treatment as ordered. During an interview with Licensed Vocational Nurse 3 on 11/17/2022 at 8:04 AM, LVN 3 stated the bleeding came from a cut on Patient 5's labial area. LVN 3 stated he does not know the cause of the cut and it was the Director of Nursing (DON) who assessed Patient 5's skin tear. During an interview with the Director of Nursing (DON) on 11/17/22 at 9:30 AM, the DON stated CNA 1 reported Patient 5 had moderate amount of blood on her adult brief during adult brief change on 11/9/2022. The DON stated Patient 5's vaginal area was checked and found abrasion/scratch on labial area with very minimal to no bleeding. The DON stated he assessed Patient 5's injury and does not know the cause of the injury but "assumed the tear was from the towel that CNA 1 used to clean the patient's sticky stool". The DON stated they did not report the injury to the State Survey Agency. During an interview with CNA 1 on 11/17/22 at 2:23 PM, CNA 1, stated she cleaned Patient 5's stool with a wet towel. CNA 1 stated she reported to the charge nurse about the blood on Patient 5's adult brief that was mixed with her stool before she cleaned the patient. CNA 1 stated there was blood on Patient 5's adult brief even before she cleaned the patient. A review of the facility's undated policy and procedure, titled "Patient Abuse and Prevention," indicated for the facility to ensure reporting of all alleged and/or substantiated violations to the state agency and all other agencies as required. The policy indicated for the facility to report incident by calling the DHS (Department of Health Services) no later than two hours if the alleged violation involves abuse or results in serious injury or no later than 24 hours if the violation does not involve abuse and does not result in serious bodily injury. The policy further indicated for the facility Administrator, who is the duly appointed Abuse Prevention Coordinator, to report findings of investigation to the Department within five working days of the incident. The facility failed to ensure Patient 5, with an injury of unknown origin was reported to the State Survey Agency timely. Patient 5 had vaginal bleeding and a vaginal tear on her labia on 11/9/2022 from an unknown cause. This violation resulted in the delay of investigation by the State Survey Agency and determination of the cause of Patient 5's injury, including the possibility of physical abuse. This violation jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 5.