Health inspection·January 11, 2024

F609 Freedom from Abuse, Neglect, and Exploitation §483.12(c) (1) (4) 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.

F610 Freedom from Abuse, Neglect, and Exploitation §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §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. Title 22 § 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 12/04/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident neglect and accident. The facility failed to implement their policy regarding investigating and reporting of residents' injuries and to submit a conclusion report of investigation within five days to CDPH for Resident 1. Resident 1 was noted on the floor, found with a cut on left upper cheek and was bleeding profusely (to a great degree; in large amounts) and then transferred to General Acute Care Hospital (GACH 1) on 1/15/2023. As a result, there was a delay of an onsite inspection by the SSA to ensure the residents' injuries were investigated which can also lead to a delay in prevention of further injury and abuse for Resident 1. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on 1/9/2023 with diagnosis including Parkinson's disease (a disorder in the brain that affects movement, often including tremors), quadriplegia (paralysis of all four limbs [arms/legs]), difficulty in walking and muscle weakness. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 1/14/2023, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were severely impaired and required extensive assistance to total dependence from staffs for activities of daily livings (ADLs- transfer, walk in room and corridor, locomotion on and off unit, dressing, eating, toilet use and personal hygiene). The MDS also indicated, Resident 1 was not steady in moving from seated to standing position, walking, and surface-to-surface transfer. A review of Resident 1's Situation Background Assessment Recommendation (SBAR - a written or verbal communication tool used to provide essential and concise information, usually during crucial situations), dated 1/15/2023, indicated, "Resident was noted on the floor with a cut on his left upper cheek and bleeding profusely..." A review of Resident 1's Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) meeting, dated 1/16/2023 indicated, Licensed Vocational Nurse 2 (LVN 2)' statement indicated, "found Resident (1) on the floor by the door at around 5 p.m., noted lying on the floor on his left cheek and bleeding... noted there way a cut on his left upper cheek... Paramedics (a healthcare professional trained in the medical model, whose main role has historically been to respond to emergency calls for medical help outside of a hospital) came and took over... took resident (1) to GACH 1... LVN 2 continued to verbalized that when he did his routine rounds, patient (Resident 1) was all in bed... the only movement he was doing was moving his fingers... and that's why I'm (LVN 2) really surprised why this patient (Resident 1) ended up on the floor and by the doorway." A review of the facility's policy and procedures (P&P) titled, "Investigating Resident Injuries", with reviewed date of 10/19/2023 indicated, "All resident injuries are investigated... If an incident/accident is suspected, a nurse or nurse supervisor completes the facility-approved accident/incident form... If the nursing and medical assessment determined an "injury of unknown source", the investigation will follow the protocols set forth in our facility's established abuse investigation guidelines... "Injury of unknown source" is defined that meets both of the following conditions: A. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and B. The injury is suspicious because of the extent of the injury; or the location of the injury; or the number of injuries observed at one particular point in time; or the incidence of injuries over time." A review of the facility's P&P titled, "Abuse Investigation and Reporting", with reviewed date of 10/19/2023 indicated, "All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of abuse investigation will also be reported... The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings within five (5) working days of the occurrence of the incident." During an interview with Director of Nursing Interim (DONI), on 12/5/2023 at 3:52 p.m., the DONI stated, according to the SBAR and IDT notes, Resident 1 was found in bed and with injury and was transferred to GACH as facility staffs were unable to stop the bleeding. DONI stated, no one witnessed how Resident 1 ended up on the floor away from the bed and with injury and this should have been thoroughly investigated and reported to the State Agency. The facility failed to implement their policy regarding investigating and reporting of residents' injuries and to submit a conclusion report of investigation within five days to CDPH for Resident 1. Resident 1 was noted on the floor, found with a cut on left upper cheek and was bleeding profusely and then transferred to GACH 1 on 1/15/2023. As a result, there was a delay of an onsite inspection by the SSA to ensure the residents' injuries were investigated which can also lead to a delay in prevention of further injury and abuse for Resident 1. The above violation had a direct relationship to the health, safety, and security of Resident 1.