Other·December 14, 2023

F609 §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 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. §483.12(c)(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. 22 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. 22 CCR §72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. On 10/30/2023, an unannounced visit was made to the facility to conduct the Recertification survey. The facility failed to report serious bodily injury to the state survey agency (SSA) within 24 hours for Resident 18 and Resident 87. The facility failed to report: -Resident 18, an 88-year-old confused female, who sustained a left clavicle fracture (broken bone) after a fall on 8/22/2023. -Resident 87, an 80-year-old confused female who on 8/19/2023, had left wrist swelling and was then transferred to a general acute care hospital (GACH) and diagnosed with a wrist fracture (broken bone). Five days after the wrist fracture, on 8/24/2023, Resident 87 fell in her room and was unable to relate how she fell. As a result, there was a delay in onsite inspection from the SSA and caused an increased risk of injuries or potential abuse to Resident 18 and Resident 87. a. A review of Resident 18's admission record indicated the facility originally admitted Resident 18 on 11/29/2018 and readmitted her on 5/31/2023, with diagnoses including dementia (loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), encephalopathy (a disease damaged the functions of the brain) and difficulty walking. A review of Resident 18's Fall Risk Assessment dated 5/31/2023 at 7:48 PM, indicated Resident 18 had a score of 18 which indicated she was at risk for fall. A review of the admission Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 6/5/2023 indicated Resident 18 sometimes understood and had a BIMS score of 6 which indicated severely cognitively impaired. The MDS indicated Resident 18 required extensive assistance with one-person physical assist for transfer and was totally dependent upon staff when moving to or from distant areas within the facility. A review of Resident 18's care plan initiated 6/1/2023 indicated the resident was a Risk for Fall/Injury including a history of falling, unsteady gate, and dementia. The care plan goal indicated to provide preventative intervention to minimize injury potential. The care plan interventions included to assist with transfer and ambulation as needed, encourage the resident to call for assistance, and place the call light within easy reach. According to a review of Resident 18's History and Physical, dated 6/9/2023, the resident did not have the capacity to understand and make decisions. A review of Resident 18's Morris Fall Screen dated 8/22/2023 at 12 PM (the day of the fall), indicated a score of 14 which indicated a high risk for fall. A review of the Nursing Progress Note, dated 8/22/2023 at 12:22 PM, indicated Resident 18 was found on the floor in a sitting position. Resident 18 verbalized with gestures that she lost her balance and slipped from the toilet. She bumped her head and shoulder on the edge of the toilet. The nursing progress note also indicated Resident 18 had one centimeter by 0.5-centimeter (cm - a unit of measure) abrasion, and a bump on the left side of her head. The resident's left shoulder was red, ice pack was applied to the affected area and 650 milligrams (mg) of Tylenol was given for her pain. The note also indicated Resident 18's physician was notified at 11:40 AM and ordered a stat x-ray. A review of the Situation, Background, Assessment, Recommendation (SBAR) Communication form (a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident), dated 8/22/2023 at 11:40 AM, indicated Resident 18 attempted to walk despite having an unsteady gait and refusing assistance. The SBAR indicated Resident 18 fell on the left side of the body, with assistance from a Licensed Vocational Nurse (LVN). A review of Resident 18's X-ray report dated 8/22/2023 indicated the resident's left clavicle was fractured. A review of Resident 18's Care Plan initiated 8/22/2023 indicated the resident had an alteration in musculoskeletal status related to fracture of the left clavicle due to a fall. A goal of the care plan was the resident's wound would heal and progress without complications. The care plan interventions included to encourage / supervise / assist the resident with the use of the arm sling as recommended and to monitor for fatigue. Plan activities during optimal times when pain and stiffness was abated. According to a review of Resident 18's Physician's Orders, dated 8/22/2023 at 9:42 PM, the facility was to apply a left arm sling to Resident 18 at all times and the resident had a new diagnosis of acute nondisplaced distal left clavicle fracture. A review of the interdisciplinary team (IDT, - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) conference note, dated 8/23/2023, indicated Resident 18 had an unwitnessed fall on 8/22/2023 at 11:30 AM inside of the resident's bathroom. A review of the Physician's Orders, dated 8/25/2023, indicated Resident 18 was to have an appointment with an orthopedic surgeon for follow up. During an interview on 10/31/2023 at 1:44 PM, RN 1 stated Resident 18 sustained an abrasion on her head and was bleeding from the fall on 8/22/2023. RN 1 stated Resident 18 complained of left shoulder pain, and she received an x-ray of the left shoulder. Results of the x-ray was a left clavicle (collar bone) fracture (break). RN 1 stated Resident 18 was not sent to the hospital at that time. The doctor ordered an orthopedic consultation. During an interview on 11/1/2023 at 1:30 PM, the Director of Nursing (DON) stated Resident 18's fall on 8/22/2023 was not reported to the SSA. The DON stated the SSA was not notified of Resident 18's clavicle fracture. The DON further stated we do not have to report major injures if we know how it happened. During an interview on 11/2/2023 at 1:24 PM, the DON stated Resident 18's clavicle fracture was a major injury. The DON further stated unusual occurrences were reported because an injury with an unknown cause may be due to abuse. The DON further stated unusual occurrences were reported within 24 hours because there was a risk of abuse or danger to the resident. b. A review of Resident 87's admission record indicated the facility admitted the resident to the facility on 8/4/2023 and readmitted her on 8/20/2023 with diagnoses including encephalopathy (disease of the brain manifested by an altered mental state sometimes accompanied by physical changes), muscle weakness and diabetes mellitus (high blood sugar). A review of Resident 87's Care Plan, initiated 8/5/2023, indicated the resident was a fall risk due to unsteady gait, delirium, and encephalopathy. The care plan goal was to provide preventive interventions to minimize injury potential. The care plan interventions indicted to assist with transfer and ambulation as needed, assistive devices as needed (no indication of the specific device), and to encourage resident to call for assistance. A review of Resident 87's Care Plan, initiated 8/5/2023, indicated the resident had cognitive loss as evidenced by short term memory impairment, long term memory impairment, poor memory recall, problem making herself understood and a problem understanding others. The care plan interventions included to use short simple sentences and ask yes or no questions. According to a review of Resident 87's History and Physical, dated 8/7/2023, the resident did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 8/11/2023, indicated Resident 87 was disoriented to year month and day. The resident required extensive assistance one-person physical assist with bed mobility, transfer, dressing, eating, personal hygiene and bathing. The MDS indicated Resident 87 was totally dependent upon staff for toileting and moving between location in her room and throughout the facility. A review of the SBAR Communication Form, dated 8/19/2023, indicated Resident 87 had left wrist swelling and was suspected of having a fracture. The SBAR indicated the physician recommended to transfer Resident 87 to the General Acute Care Hospital (GACH) Emergency Room (ER). A review of the Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form, dated 8/19/2023 at 10:30 PM, indicated Resident 87 was transferred to GACH due to suspected left wrist fracture and that the resident was not alert. A review of the GACH X-ray report, dated 8/20/2023 at 3:38 AM, indicated Resident 87 had fractures of her radius (one of the two bones that make up the forearm) and ulnar (the longer of the two bones in your forearm. It helps you move your arm, wrist, and hand). A review of the Physician's Orders, dated 8/20/2023, indicated Resident 87 was to have an orthopedic appointment in the next few days for a follow up for a left distal fracture and the facility was to administer two 500 milligram (mg) tablets (total of 1000 mg) of Tylenol Extra Strength (ES) to Resident 87 twice a day for pain on left wrist due to left distal radius fracture for 14 days. According to a review of the Nurse's Note, dated 8/20/2023, Resident 87 returned from the GACH with a new diagnosis of left distal radius fracture and that the resident had a splint to her left arm. A review of the IDT note dated 8/22/2023, indicated the team met to review Resident 87's wrist fracture incident. The IDT note indicated the resident was alert and confused with poor safety awareness at her baseline. The IDT note indicated the recommendations for the resident included to move the resident closer to the nurses’ station, continue to keep left splint, monitor for any complications, and to assist the resident to the restroom per her request. A review of the Nurse's Progress Note, dated 8/24/2023, indicated around 5:50 PM, Resident 87's roommate called out and Resident 87 was found on the floor lying on her right side. The Nurse's Progress Note indicated a quote by Resident 87 as saying, "I was eating dinner, but I don't remember why I am on the floor now." The progress note indicated the nurse found redness on Resident 87's right shoulder measuring 1 cm by 1 cm and an ice pack was applied to the area. A review of the facility census dated 8/24/2023 indicated Resident 87 and Resident 18 were roommates. During an interview on 11/1/2023 at 11:08 AM, Certified Nursing Assistant 4 (CNA 4) stated Resident 87 was very confused when she was admitted to the facility and the resident tried to get out of bed on her own. CNA 4 further stated Resident 87 continued to complain of wrist pain. During an interview on 11/1/2023 at 1:08 PM, Registered Nurse 1 (RN 1) stated we just found swelling on 8/19/2023, so we took an x-ray of Resident 87, and she went to the hospital. RN 1 stated the GACH indicated Resident 87 had a fracture and she returned with a cast. RN 1 further stated on 8/24/2023 Resident 87 fell. She was found on the floor next to her bed and the resident indicated she did not remember anything. During an interview on 11/1/2023 at 1:19 PM, the DON stated Resident 87's fall was not reported to the SSA because Resident 87's fall was witnessed by her roommate (who had dementia). On 11/2/2023 at 9:37 AM, during an interview the Minimum Data Set Coordinator (MDSC) stated Resident 18 was Resident 87's roommate when Resident 87 fell on 8/24/2023. MDSC stated at that time Resident 18's BIMS (Brief Interview for Mental Status - used to assess cognitive status in elderly residents) score was 5 (moderately impaired -decisions poor; cues/supervision required), on 6/5/2023 her score was 5, and on 9/4/2023 her BIMS score remained a 5. The MDSC further stated Resident 18 knew her name but did not know the year and had to be cued to remember situations. During a concurrent observation and interview on 11/2/2023 at 10:21 AM, in Resident 87's room, Resident 87 was observed lying in bed with a brace on her left wrist. When asked how the resident broke her wrist, Resident 87 stated she lost her balance and hit her wrist on the wall. Resident 87 stated her wrist hurts but did not require pain medication. Resident 87 further stated she did not remember her fall on 8/24/2023. During an interview on 11/2/2023 at 10:34 AM, RN 1 stated unwitnessed falls were reported because, "We don't know what happened." During an interview on 11/2/2023 at 1:15 PM, the DON stated he did not report Resident 87's fall because it was witnessed by Resident 18 and did not report Resident 87's wrist fracture because Resident 87 (who was unable to understand and make decisions) was able to state what happened. The DON further stated, he only reports falls with major injury, "When we don't know what happened." A review of the facility's policy and procedure titled, "Unusual Occurrence," dated 12/19/2022, indicated the facility will report an unusual occurrence to the Department of Public Health (DPH) within 24 hours of occurrence. It also indicated reporting to DPH will be made by telephone and confirmed in writing within 24 hours of occurrence. Unusual occurrences shall be reported by telephone to appropriate agencies as required by current law and/or regulations within 24 hours of such incident or as otherwise required by federal and state regulations. It further indicated the State of California Department of Public Health distributed a list of unusual occurrences in January 1996 and the list was not all inclusive and was not intended to replace good judgement. A review of the facility's policy and procedure titled, "Abuse, Neglect and Exploitation," dated revised 12/19/2022 indicated the facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, to the state survey agency and other officials in accordance with state law. Investigation of Alleged Abuse, Neglect and Exploitation. The policy indicated an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: Investigating different types of alleged violations. Focusing the investigation on determining if a