Health inspection·May 15, 2024

42 CFR §483.12 (c) Freedom from Abuse, Neglect, and Exploitation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. 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. H&S § 1418.91 (a) A long-term health care facility shall report all incidents of alleged or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class “B” violation. On 3/22/2024 the California Department of Public Health (CDPH) received two complaints and one Facility Reported Incident indicating on 3/12/2024, Resident 1 sustained a fracture (broken bone) of unknown origin. On 3/22/2024, the CDPH conducted an unannounced visit at the facility. The facility failed to report an injury of unknown origin to the CDPH within two hours, for Resident 1. As a result, there was a delay in the investigation by the CDPH. Resident 1 was a 92-year-old female, admitted to the facility on 10/31/2023 with diagnoses including dementia (a disorder that affected memory and other mental functions) and legal blindness. A review of Resident 1’s History and Physical (H&P) dated 11/3/2023 indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set ([MDS], a standardized care assessment and care screening tool), dated 2/1/2024, indicated Resident 1 was dependent on staff activities of daily living (ADLs) such as personal hygiene, lower body dressing, transfer (moving between surfaces to and from bed, chair and wheelchair), and bed mobility (how resident moved from lying to turning side to side). A review of Resident 1’s Situation, Background, Assessment, and Recommendation ([SBAR] tool for communication between staff) Communication Form dated 3/11/2024, the SBAR indicated, Resident 1 complained of a right knee pain and was not able to recall when the pain started. The SBAR indicated an unnamed Certified Nurse Assistant (CNA) found the resident with both legs dangling and noted with slight swelling to the resident’s right knee. During a review of Resident 1’s Radiology (imaging technology used to diagnose diseases and guide treatment) Results dated 3/12/2024 indicated Resident 1 had an acute (sudden onset) medial supracondylar fracture of the distal femur (when the thigh bone is broken at the knee). During a review of Resident 1’s SBAR Communication Form dated 3/12/2024, the SBAR indicated Resident 1’s right knee radiograph ([Xray]-medical imaging that create pictures of the bones and tissue) report indicated abnormal findings (acute medial supracondylar fracture of the distal femur). The SBAR indicated the physician was notified and orders were obtained to transfer Resident 1 to the general acute care hospital (GACH). The SBAR indicated the Director of Nursing (DON) was made aware. During an interview on 4/12/2024 at 11:34 a.m., the DON stated Resident 1’s fracture was considered an injury of unknown origin and should have been reported to the CDPH immediately or within two hours. The DON stated the incident was not reported to the CDPH within two hours. The DON stated it was important to ensure injuries of unknown origin were reported to the CDPH timely to ensure the incident was investigated and for the resident’s safety. A review of the facility’s P&P titled, “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating” dated 4/2021 indicated all reports of abuse, including injuries of unknown origin, neglect, exploitation or theft of resident’s property were reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The P&P indicated if resident abuse, neglect or injury of unknown source was suspected, the suspicion must be reported immediately to the administrator and to other officials according to the state law. Immediately is defined as: within two hours of all allegations which involved abuse or resulted in serious bodily injury; or within 24 hours of an allegation that did not involve abuse or result in serious bodily injury. The P&P indicated the facility Administrator, or the individual making the allegations immediately reports his or her suspicion to the State licensing/certification agency responsible for surveying/licensing the facility. The facility failed to report an injury of unknown origin to the CDPH within two hours for Resident 1. As a result, there was a delay in the investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.