Health inspection·August 16, 2024

§483.12(c) (1) (4) 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)(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. Title 22 California Code of Regulations: § 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 7/2/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident neglect and abuse. The facility failed to follow its policy and procedures titled "Unusual Occurrence Reporting" which indicated the facility will report unusual occurrences by telephone to appropriate agencies within twenty-four hours of such incident as required by federal and state regulations. On 6/14/2024 Resident 1 had an unwitnessed fall and sustained a fracture (broken bone) of the left elbow. This deficient practice resulted in a delay of investigation by the California Department of Public Health (CDPH) and had a potential to place Resident 1 and other residents at risk for abuse. A review of Resident 1's was a 96-year-old male admitted to the facility on 1/18/23 and re-admitted on 6/23/24 with diagnoses including dementia (loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life) and unsteadiness on feet. A review of the Minimum Data Set (MDS- standardized care and health screening tool) dated 4/14/24 indicated Resident 1 had moderately impaired cognitive function. Resident 1 was dependent (helper does all the effort) with shower, needed substantial assistance (helper does more than half the effort) with oral hygiene, toileting hygiene, upper/lower body dressing, putting on/off footwear, personal hygiene, and supervision with eating. A review of Resident 1's Change of Condition (COC, a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) Evaluation dated 6/14/24 at 4:47 p.m., indicated Resident 1 had an unwitnessed fall on 6/14/24 at around 4:46 p.m. The COC indicated Resident 1 was observed on the floor and sustained a hematoma (localized swelling that is filled with blood caused by a break in the blood vessel) and laceration (cut or tear of the skin) 0.2 by 0.5 centimeter (cm, unit of measurement) on the forehead. The COC indicated Resident 1 complained of pain on the left arm. The COC indicated the primary physician was notified and orders received to transfer Resident 1 to the general acute hospital (GACH 1) by the paramedics for further evaluation. A review of Resident 1's Nurses Notes dated 6/14/24 at 11:29 p.m., indicated the GACH 1 informed licensed vocational nurse (LVN 1) that Resident 1's computed tomography (CT scan, procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures inside the body) of the head indicated no bleeding and Xray indicated no fracture. The nurses' notes indicated GACH 1 sent Resident 1 back to the facility on 6/14/24. A review of Resident 1's Skin/Wound Treatment Note dated 6/15/24 at 8:23 a.m., indicated Resident 1's laceration on the forehead had red and purplish discoloration with minimal bleeding. The Notes indicated Resident 1's left arm was swollen, painful to touch and with purplish discoloration. Resident 1 was given Tylenol 650 milligrams (mg., unit of measurement) for pain. Resident 1's primary physician was notified and gave order for a stat (immediately) Xray of the left arm. A review of the Nurses Notes dated 6/15/24 at 2:30 p.m., indicated the GACH 1 informed the facility by telephone that GACH 1 did not obtain Xray of Resident 1's left elbow. A review of the Radiology Results Report dated 6/15/24 at 5:08 p.m., indicated Resident 1 had a left supracondylar distal humerus fracture (a break to the lower part of the bone close to the elbow). A review of Resident 1's Progress Notes dated 6/15/24 at 6:59 p.m., indicated Resident 1 was transferred to GACH 1 on 6/15/24. A review of the Resident 1's Progress Notes dated 6/16/24 at 1:15 a.m., indicated Resident 1 was readmitted to the facility on 6/15/24 at 11:20 p.m. with orders including orthopedic consult (medical specialty concerned with treatment of bones that have not grown correctly or were damaged) and sling (to keep arm stable and supported for proper healing) on the left arm. During an interview and concurrent review on 7/2/24 at 12:20 p.m., Registered Nurse Supervisor (RNS 1) Resident 1's Progress Notes were reviewed. RNS 1 stated on 6/14/24 at about 4:46 p.m. Resident 1 was sitting in his wheelchair and fell. RNS 1 stated Resident 1 sustained a laceration on his forehead. RNS 1 stated GACH 1 obtained a CT scan of the head and Xray of the spine and found no fracture. RNS 1 stated GACH 1 sent Resident 1 back to the facility, and on 6/15/24 Resident 1's elbow was observed swollen, discolored and was the resident was unable to move the left arm. RNS 1 stated the primary physician gave order for a stat x-ray of the left arm and the result indicated Resident 1 had a fracture on the left elbow. During an interview on 7/2/24 at 2:12 p.m., the Director of Nursing (DON) stated the facility did not report to the CDPH when Resident 1 had a fall and sustained a fracture of the left elbow. During an interview on 7/2/24 at 2:54 p.m., the Administrator (ADM), the ADM stated he did not report when Resident 1 had a fall with major injury because the incident was not in the facility's list of reportable incidents. During a review of the facility Policy titled "Unusual Occurrence Reporting" revised on 11/23, indicated as required by federal or state regulations, the facility reports unusual occurrences or other reportable events which affect the health, safety or welfare of the residents, employees, or visitors. The same Policy indicated unusual occurrences shall be reported by telephone to appropriate agencies as required by current law and/or regulations within twenty-four hours of such incident as otherwise required by federal and state regulations. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within 48 hours of reporting the event or as required by federal and state regulations. The facility failed to follow its policy and procedures titled "Unusual Occurrence Reporting" which indicated the facility will report unusual occurrences by telephone to appropriate agencies within twenty-four hours of such incident as required by federal and state regulations. On 6/14/2024 Resident 1 had an unwitnessed fall and sustained a fracture of the left elbow. This deficient practice resulted in a delay of investigation by CDPH and had a potential to place Resident 1 and other residents at risk for abuse. The above violation had a direct relationship to the health, safety, and security of Resident 1.