Other·April 24, 2024

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 3/11/2024, an unannounced visit was made to the facility to conduct a recertification survey. As a result of the investigation, the facility failed to protect Resident 24 who had injuries from unknown source, by failing to: 1. Ensure staff immediately reported Resident 24's injuries of unknown source no later than two hours to the Department of Public Health, Ombudsman, and local law enforcement. 2. Ensure staff investigated Resident 24's injuries of unknown source in accordance with the facility's policy and procedure for resident abuse prevention in the facility. 3. Ensure staff notified Resident 24’s physician and responsible party of Resident 24's injuries of unknown source. As a result, these deficiencies violated Resident 24’s rights and had the potential to compromise Resident 24's safety. A review of Resident 24's Admission Record indicated the facility admitted Resident 24, an 87-year-old female on 4/24/23 and readmitted the resident on 12/10/23 with diagnoses that included dementia and chronic kidney disease. During an observation on 3/12/24 at 8:45 a.m., Resident 24 was sitting in a wheelchair while in Resident 24's room. Resident 24's right side of the forehead had dark red purple skin discoloration with a head bump approximately the size of a quarter coin. Resident 24 also had dark purple skin discoloration below Resident 24’s both eyes, approximately four inches in size on each side. Resident 24 was non-communicative. During an interview on 3/12/24 at 8:48 a.m., Resident 24's roommate stated it had been several days that Resident 24 had bruises below both eyes and bruises with a bump on the forehead. Resident 24's roommate stated she did not witness a fall incident for Resident 24 while Resident 24 was in the room. Resident 24's roommate stated she did not know how Resident 24 got the bruises and bump on the forehead. During an interview on 3/12/24 at 12:23 p.m., Resident 24's Family Member 1 (FM 1) stated it was during FM 2 and FM 3's visit to Resident 24 on 1/25/24 at around 10:30 a.m., that the bruises below both eyes and bump on the head were observed by the family members. FM 1 stated he was not aware of Resident 24's bruises and bump on the head until FM 1 was informed by FM 2 and FM 3 during a face time video call with Resident 24 when FM 2 and FM 3 visited on 1/25/24. FM 1 stated FM 1 did not know for how long Resident 24 had the injuries while in the facility. FM 1 stated staff only said, "Fall" to FM 2 and FM 3 when they asked what happened to Resident 24. FM 1 stated he spoke to the Director of Nursing (DON) on the phone in the morning of 1/25/24, after FM 1 made the face time video call to Resident 24, and FM 1 asked the DON about Resident 24's injuries. FM 1 stated the DON did not give specific information if Resident 24 had an actual fall or any incident that might have caused the bruises below both eyes and bump on the head. During an interview on 3/12/24 at 2:50 p.m., Certified Nursing Assistant 2 (CNA 2) stated CNA 2 was assigned to Resident 24 today (3/12/24) and yesterday (3/11/24). CNA 2 stated CNA 2 was aware of Resident 24's bruises below both eyes and the bump with bruises on the right forehead area about more than a month ago. CNA 2 stated CNA 2 did not know how Resident 24 got the injuries. CNA 2 stated CNA 2 reported to the morning shift (7 AM-3 PM) female charge nurse about the bruises and the bump on Resident 24's head. CNA 2 stated CNA 2 did not remember the name or face of the female charge nurse. CNA 2 stated CNA 2 did not know if the female charge nurse was still working in the facility. During a concurrent interview and record review on 3/12/24 at 3:29 p.m., Licensed Vocational Nurse 2 (LVN 2) stated LVN 2 saw Resident 24 already had bruises below both eyes and bump with bruises on the forehead when LVN 2 started to work full time at the facility approximately a month ago in February 2024. LVN 2 stated LVN 2 did not know how Resident 24 got the injuries. LVN 2 stated Resident 24's medical record did not contain information regarding an incident or a fall that resulted in bruises below both eyes and bruises with a bump on the forehead. There was no documented evidence in Resident 24’s clinical record that the physician and responsible party were notified of Resident 24's injuries since 1/25/24, when FM 2 and FM 3 visited Resident 24. During an interview with the Administrator and DON on 3/14/24 at 3:40 p.m., the Administrator stated he started working in the facility on 3/12/24 and had no knowledge of Resident 24's injuries. The DON stated she was not aware of Resident 24's bruises and bump on the forehead because it was not reported by the staff to the DON. The DON stated Resident 24's injuries were not investigated and reported to DPH, Ombudsman, law enforcement, the physician, and responsible party since 1/25/24, when FM 2 and FM 3 informed the staff of Resident 24's injuries. The DON stated Resident 24's bruises and bump on the forehead were injuries of unknown source that needed to be reported within two hours to DPH, Ombudsman, and local law enforcement but the facility failed to do so. The DON further stated immediate reporting within two hours would ensure the residents were protected from abuse and/or further abuse in the facility. A review of the facility's Policy and Procedures (P&P) titled, "Abuse Reporting and Prevention" dated 1/2023 indicated injuries of unknown sources are to be reported within two hours to DPH, Ombudsman, and local law enforcement to ensure that resident rights are protected by providing a method of investigation and reporting of alleged violations. The facility failed to protect Resident 24 who had injuries from unknown source, by failing to: 1. Ensure staff immediately reported Resident 24's injuries of unknown source no later than two hours to the Department of Public Health, Ombudsman, and local law enforcement. 2. Ensure staff investigated Resident 24's injuries of unknown source in accordance with the facility's policy and procedure for resident abuse prevention in the facility. 3. Ensure staff notified Resident 24’s physician and responsible party of Resident 24's injuries of unknown source. As a result, these deficiencies violated Resident 24’s rights and had the potential to compromise Resident 24's safety. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 24.