Health inspection·December 7, 2023

42 CFR §483.12: Freedom from Abuse, Neglect, and Exploitation §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 42 CFR §483.12(b): Freedom from Abuse, Neglect, and Exploitation §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, 22 CR §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 10/24/2023 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident abuse. The facility failed to protect Resident 1's right to be free from physical abuse by a Certified Nursing Attendant (CNA) in accordance with the facility's policy and procedures (P&P) titled "Abuse, Neglect and Exploitation" dated 12/19/2022. As a result, Resident 1 suffered a right femur (bone in the thigh) fracture (cracking or breaking of a bone) on 10/15/2023 and was transferred to a general acute care hospital (GACH) for further evaluation and management on 10/15/2023 at GACH at 5:15 PM. On 10/16/2023 Resident 1 had open reduction internal fixation (ORIF-surgical procedure that puts pieces of a broken bone into place using screws, plates, or rods that are used to hold the broken bone together) to repair the right femur fracture. A review of Resident 1's admission record, indicated Resident 1 was admitted to the facility (skilled nursing facility [SNF]) initially on 11/5/2021 with a readmission to the facility on 10/20/2023 with diagnoses that included cerebral infarction (lack of blood supply to the brain causing damage to the brain) with left sided weakness, bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs and lows), type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), restlessness (the inability to rest or relax as a result), agitation and contracture (a condition of shortening and hardening of muscles or other tissue, often leading to deformity [disfigurement or distortion ]) of the left knee. The admission record did not indicate Resident 1 had osteoporosis (brittle/fragile bones). A review of Resident 1's history and physical dated 11/29/2022, indicated Resident 1 did not have the capacity to understand and make decisions on her own. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 8/11/2023, indicated Resident 1's cognition (a person's mental ability to think, learn, remember, use judgement, and make decisions) is severely impaired. Resident 1 required one person physical assist with bed mobility, transfer, eating, toilet use and personal hygiene. A review of Resident 1's care plans did not reveal Resident 1 had kicking or thrashing behavior. A review of Resident 1's Change of Condition (COC- a deterioration in health, mental status, or psychosocial [mental, emotional, social, and spiritual health] status) form, dated 10/15/2023, indicated that on 10/15/2023 at 4:20 PM, Resident 1 was noted to have a misaligned (having an incorrect position or alignment) right thigh with a fracture was suspected. Resident 1 unable to move the right leg. Resident 1 complained of moderate pain, 4 out of 10 (4/10) pain level, using the numeric pain scale (numeric pain scale of 0 to 10 pain level with "0" as no pain, and score of "10", the highest level of pain). Resident 1 was administered Tylenol (medication given for pain). Resident 1's medical doctor (MD) ordered to transfer Resident 1 to a General Acute Care Hospital (GACH) for higher level of care (further evaluation and management). A review of Resident 1's Transfer Form (facility initiated form to inform the GACH of resident current condition) dated 10/15/2023 at 5:15 PM, indicated Resident 1 transferred to GACH via Emergency Medical Services (EMS-ambulance emergency services or paramedic services that provide urgent pre-hospital treatment and stabilization for serious illness and injuries and transport to definitive care) due to suspected fracture of the right thigh. A review of Resident 1's Emergency Room (ER - department/unit of the GACH for initial assessment and treatment) Physician note, dated 10/15/2023, indicated Resident 1 presented with right leg swelling with significantly deformed right distal femur fracture. The ER notes indicated the mechanism of the fracture was unclear and a concern for possible neglect/elder abuse. The ED notes indicated x-ray (a specialized image of a body part) of the right femur showed Resident 1 had displaced femur fracture, "considering this traumatic (caused by various forces from outside of the body, which can either be blunt or penetrating [sharp]) injury, will do board imaging (expanded pictures of the body) to evaluate for any other traumatic injuries .... Consultation with orthopedic physician (a doctor who specializes in part of the human body that includes your bones, cartilage, ligaments, tendons and connective tissues injuries), x-ray results impression showed moderate to severely displaced comminuted (bone that is broken in at least two places) fracture of the midshaft of the right femur for [Resident 1]. A review of Resident 1's GACH Xray report dated 10/15/2023 at 8:24 PM, indicated Resident 1 had a moderate to severely displaced comminuted extra-articular (outside of the joint) fracture of the mid shaft of the right femur. A review of Resident 1's GACH Operative Report dated 10/16/2023, indicated Resident 1 had a right femur ORIF completed under general anesthesia (a method of medically inducing loss of consciousness that renders a patient unarousable even with painful stimuli) to repair the right femur fracture. A review of Resident 1's GACH Discharge Summary dated 10/20/2023, indicated Resident 1 had right femur ORIF completed on 10/16/2023 and was tolerated well. "Complicated with metabolic encephalopathy (commonly defined as an alteration in consciousness caused due to brain dysfunction) after surgery ...Day of discharge had no significant complaints and agreeable to plan of discharge. [Resident 1] was discharged back to the facility [SNF] on 10/20/2023 . During an interview on 10/24/2023 at 1:45 PM with Resident 1's responsible party (RP) 1, RP 1 stated that she was very involved in her Resident 1's care. RP 1 stated that she visits Resident 1 at the SNF twice a day on most days. RP 1 stated that on 10/15/2023 at 2 PM, she arrived at the facility to be with Resident 1. RP 1 stated she left the facility on 10/15/2023 at around 3 PM. RP 1 stated that on 10/15/2023 at around 4 PM, she received a call from the SNF informing her that Resident 1 was being transferred to GACH following an injury to the right leg. RP 1 stated that she went directly to the GACH ED on 10/15/2023 and met with Resident 1. RP 1 stated that she observed that Resident 1's right thigh had a deformity. RP 1 stated that when she last saw Resident 1 at the SNF on 10/15/2023 at around 3 PM, Resident 1 did not have a deformity of the right thigh. RP 1 stated that she asked Resident 1 what happened to Resident 1's right leg to which Resident 1 said, the "big lady" referring to Certified Nurse Assistant 1 (CNA 1), "hit my leg" while demonstrating a hitting motion with her [Resident 1's] hand. During an interview on 10/24/2023 at 3:15 PM with CNA 2, CNA 2 stated that she was working the day shift (7AM to 3PM) on 10/15/2023 and was assigned to provide care to Resident 1. CNA 2 stated that on 10/15/2023 at around 10:20 AM, she placed Resident 1 in a wheelchair (WC) and then wheeled Resident 1 to the patio area. CNA 2 stated stayed with Resident 1 while Resident 1 drank coffee and ate a cookie. CNA 2 stated that she placed Resident 1 back into bed around 10:45 AM. CNA 2 stated that RP 1 arrived at the SNF at around 2 PM on 10/15/2023 and that RP 1 stayed with Resident 1 until 2:40 PM on the same day. CNA 2 stated she checked on Resident 1 at 2:45 PM to see if Resident 1 needed to be cleaned/provided care prior to CNA 2 ending her shift at 3 PM. CNA 2 stated that she did not observe Resident 1's right leg deformity at any time during her the 7AM to 3PM shift. During an interview on 10/24/2023 at 3:32 PM with LVN 1, LVN 1 stated he worked on 10/15/2023 on 3PM to 11PM shift. LVN 1 stated he was the charge nurse for Resident 1. LVN 1 stated that on 10/15/2023 around 4 PM, he was sitting at the nursing station far from Resident 1's room. LVN 1 stated CNA 1 came and told him that Resident 1 had a "loose leg (not firmly or tightly fixed in place)". LVN 1 stated that he went to Resident 1's room right away and found Resident 1 lying on her back with her head slightly elevated and her right foot was rotated in towards her left leg. LVN 1 stated Resident 1's right thigh, "was curved. Not normal appearing" and called the Registered Nurse Supervisor (RNS). LVN 1 stated he observed a new (clean and unused) incontinent brief (a product designed to help manage urinary or bowel output) at the foot of Resident 1's bed. LVN 1 stated Resident 1 was yelling in pain. LVN 1 stated Resident 1's skin was intact, no bleeding or redness observed. LVN 1 stated RNS came to the bedside of Resident 1. LVN 1 stated that CNA 1 stated that Resident 1 was like that when she entered the room. LVN 1 stated that he asked Resident 1 what happened, and Resident 1 responded that she was in pain. LVN 1 stated that RNS called a medical doctor (MD). LVN 1 stated that he administered Tylenol (medication for pain) to Resident 1 for pain control for 7 out of 10 pain level. LVN 1 stated that EMS arrived and transferred Resident 1 to the GACH. During an interview translated by RP 1 on 10/25/2023 at 11:23 AM, Resident 1 stated the "big lady", referring to CNA 1, came into her room, placed her leg onto the bedrail on the right side of the bed and "hit" her leg. Resident 1 stated that she asked CNA 1 why she was doing this to her. Resident 1 stated that she [Resident 1] did not do anything to CNA 1. During an interview on 10/26/2023 at 1:15 PM with Social Services director (SSD), SSD stated that on 10/16/2023, she followed up with RP 1 and RP 1 told her GACH was going to do surgery on Resident 1. SSD stated RP 1 told her that GACH informed RP 1 that someone in the facility "did this to [Resident 1] and was shocked that the facility did not fire the employee. During an interview on 10/26/2023 at 3:15 PM with RNS, RNS stated that on 10/15/2023, she was working the afternoon (3 PM to 11 PM) shift as the RNS. RNS stated that on 10/15/2023 at around 4:10 PM, she received a call from LVN 1 that something was wrong with Resident 1's right leg. RNS stated she went quickly to Resident 1's room and found LVN 1 and CNA 1 in Resident 1's room. RNS stated that she observed Resident 1 lying on her back with the head of the bed slightly elevated. RNS stated Resident 1 had a right leg deformity. RNS stated Resident 1 stated Resident 1 was in pain at a pain level of 4 /10. RNS 1 stated she contact the MD who ordered for Resident 1 to be transferred to GACH. During an interview on 10/26/2023 at 3:35 PM with CNA 1, CNA 1 stated she was assigned to work on the evening shift (3 PM to 11 PM). CNA 1 stated she arrived late at work on 10/15/2023 at 3:45 PM. CNA 1 stated she her assignment included Resident 1. CNA 1 stated she went to provide care to Resident 1 around 4 PM and when she entered Resident 1's room, she observed Resident 1 lying on her bed without clothes on and had removed her incontinent brief. CNA 1 stated that initially she did not notice any deformity on Resident 1's right leg or if Resident 1 was in pain. CNA 1 stated Resident 1 did not complain of any pain when CNA 1 entered Resident 1's room. CNA 1 stated she went to Resident 1's left side of the bed, turned Resident 1 onto the left side and noticed Resident 1's right leg was "loose". CNA 1 stated that once she noticed Resident 1's right leg was "loose", she went and informed LVN 1. CNA 1 stated she did not remember how long she was in Resident 1's room for. CNA 1 stated that she did not turn Resident 1 to Resident 1 left side. During an interview on 10/26/2023 at 4:05 PM with the Director of Nursing (DON), the DON stated that on 10/15/2023 at around 4 PM, RNS informed him that Resident 1 had an injury of unknown origin to the right leg. The DON stated he right away informed the Administrator (ADM) and Social Services Director (SSD). The DON stated the RNS told him that she received MD's order to transfer Resident 1 to GACH. The DON stated CNA 1 and LVN 1 were suspended until the investigation on how Resident 1 sustained a fracture of the right femur was completed. The DON stated during facility's investigation interview, CNA 1 explained that when she entered the room on 10/15/2023, CNA 1 noticed Resident 1's right leg was misaligned. The DON stated he could not remember if CNA 1 informed him that CNA 1 had attempted to turn Resident 1. The DON stated that the facility was unable to determine how Resident 1 sustained a right femur fracture. During an interview on 10/26/2023 at 4:35 PM with the ADM, the ADM stated that on 10/15/2023 at around 4 PM (unsure of the exact time), the DON informed her that Resident 1 had an injury of unknown origin to the right leg. The ADM stated during facility's investigation all staff involved (CNA 1, CNA 2 and LVN 1) were interviewed. The ADM stated CNA 1 said that when she [CNA 1] entered Resident 1's room, CNA 1 noticed Resident 1's right leg was misaligned (incorrect position). The ADM stated that the ADM and the DON reviewed the facility's inhouse video footage, and that CNA 1 was observed entering room and exiting Resident 1's room on 10/15/2023 at around 4 PM. CNA 1 was observed exiting Resident 1's two to three minutes after entering the Resident 1's room. The ADM stated the facility was unable to determine how Resident 1 sustained a right femur fracture. The ADM stated, "[CNA 1] will no longer be assigned to provide care for [Resident 1]". A review of the facility's P&P titled, "Abuse, Neglect and Exploitation" dated 12/19/2022, indicated, "It is the policy of this facility protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property ...The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written ...Establishing a safe environment ...The facility will have written procedure to assist staff in identifying the different types of abuse ...Possible indicators of abuse include ...Physical injury of a resident, of unknown source ...Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame". As a result, Resident 1 suffered a right femur fracture on 10/15/2023 and was transferred to a GACH for further evaluation and management on 10/15/2023 at GACH at 5:15 PM. On 10/16/2023 Resident 1 had ORIF to repair the right femur fracture. The above violations had direct or immediate relationship to the health, safety, or security for Resident 1.