Health inspection·December 6, 2024

§483.12(c) Reporting of Alleged Violations 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. 22CCR §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. HSC 1418.91 (a) Abuse Reporting (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. On 10/11/2024 at 5:05 p.m., the California Department of Public Health (CDPH) received a complaint with an allegation of yellow and purple bruising on Resident 1’s wrist. On 10/29/2024, the (CDPH) conducted an unannounced visit to the facility to investigate a complaint. The facility failed to: 1. Report an allegation of abuse involving Resident 1 to CDPH within two (2) hours, as indicated in the facility’s policy and procedure (P&P), titled, “Abuse and Mistreatment of Residents.” As a result, Resident 1 was placed at risk for further abuse and delayed investigation by CDPH. Findings: A review of Resident 1’s Face Sheet (front page of the chart that contains a summary of basic information about the resident), indicated Resident 1 was admitted to the facility on 7/12/2023 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), dysphagia (difficulty swallowing) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). A review of Resident 1’s Minimum Data Set ([MDS resident assessment tool), indicated Resident 1’s cognitive skills (thinking skills) were severely impaired. The MDS indicated Resident 1 was dependent on staff with toileting hygiene, showering, and upper/lower body dressing. A review of Resident 1’s Progress Notes dated 8/2/2024, indicated there was no documentation regarding Family Member 2’s (FM2) report of Resident 1’s left wrist skin discoloration. A review of Resident 1’s medical record did not indicate there was a Situation, Background, Assessment, Recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents) assessment for 8/2/2024, regarding a change in condition for Resident 1’s left wrist skin discoloration. A review of Resident 1’s SBAR, dated 8/3/2024, indicated Resident 1 had yellowish-green skin discoloration on his left wrist. A review of Resident 1’s Fax Transmission Abuse Report dated 8/3/2024 at 1:57 p.m., indicated the facility faxed a “Report of Suspected Dependent Adult/Elder Abuse” ([SOC 341] documentation of information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult) form to CDPH, on 8/3/2024 (no time indicated) regarding an allegation of abuse to Resident 1, which occurred on 8/2/2024. During an interview on 8/7/2024 at 8:37 a.m., FM 2 stated FM 1 saw Resident 1 on 7/30/2024 (time not specified) and noticed Resident 1 had a yellow bruise (skin discoloration) on the left wrist. FM2 stated, on 8/2/2024 when she (FM2) visited Resident 1, Resident 1’s left wrist had purplish and yellowish skin discoloration, “like someone held the wrist tight.” During an interview on 8/7/2024 at 11:25 a.m., Licensed Vocational Nurse (LVN 4) stated she heard FM2 reported Resident 1 had a yellowish skin discoloration on 8/2/2024 on the left wrist. LVN 4 stated, on 8/3/2024, Resident 1’s left thumb to the wrist, was observed with a purplish skin discoloration. During an interview, on 10/24/24, at 3:08 p.m., LVN 1 stated Resident 1’s wife called on 8/2/2024 (time unspecified) and reported Resident 1 had left wrist skin discoloration. LVN 1 stated, if a resident was observed with a skin discoloration (bruise), the abuse coordinator should be notified within two hours. LVN 1 stated the resident would be assessed for pain, the resident’s physician would be notified and a SBAR form would be completed as soon as bruises were observed. LVN 1 stated a bruise of unknown origin was an unusual occurrence and should be considered as a result of a potential abuse and reported to CDPH. LVN 1 stated, if the bruise was not reported to CDPH, it placed Resident1 at risk for further abuse. During an interview, on 10/29/24 at 12:00 pm., the Director of Nursing (DON), stated licensed staff informed her on 8/3/2024 (time unspecified) that Resident 1’s wife called the facility on 8/2/2024 (time unspecified) and reported Resident 1 had a left wrist skin discoloration. The DON stated Resident 1’s left wrist skin discoloration was reported to the Administrator on 8/3/2024. The DON stated the risk of not reporting abuse allegations in a timely manner could result in a potential for further abuse. During a review of the facility’s undated P&P, titled “Abuse and Mistreatment of Residents”, the P&P indicated the facility should report allegations of abuse to the CDPH within two hours. The facility failed to: 1. Report an allegation of abuse involving Resident 1 CDPH within two (2) hours, as indicated in the facility’s policy and procedure (P&P), titled “Abuse and Mistreatment of Residents.” As a result, Resident 1 was placed at risk for further abuse and delayed investigation by CDPH. This violation jointly, separately, or in any combination, presented a direct or immediate relationship to the health, safety, security and/or welfare of Resident 1.