The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|SONOMA DEVELOPMENTAL CENTER||15000 ARNOLD DRIVE / P O BOX 1493 ELDRIDGE, CA 95431||Nov. 4, 2014|
|VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT||Tag No: A0145|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on staff interview, record review, review of facility documents, and review of facility policies, the facility failed to ensure a patient's right to be free from all forms of alleged abuse when an investigation was not initiated timely due to a delay in the implementation of the GER (General Event Report) policy. Bruises, observed in the genital area, were not reported timely nor was a GER initiated, per policy. This failure had the potential for a delay in the investigative process.
The policy for "General Event Reporting (GER) & Investigation System," effective 8/2014, contained the following: "When an event occurs that has an adverse effect on the safety, care, treatment, and habilitation of a client living at [name of facility] and /or the operation of [name of facility], the staff are required to complete a General Event Report (GER) as soon as they become aware of the incident...It is required that the staff observing an incident; having first knowledge; or, in all cases of abuse, "first suspicion," must initiate the GER and must submit it within 2 hours." The policy contained,"Appendix A," which defined types of incidents/unusual occurrences and included any injury involving the breasts, genitals, or rectal /anal area.
On 10/21/14, review of the GER, dated 9/1/14, indicated Resident 1 was transferred to an outside acute care hospital on [DATE] with symptoms of left hemiparesis (weakness on the left side of the body) and returned to the facility GAC (General Acute Care) hospital on [DATE].
A level 2 entry in the GER indicated, per a conversation with the DON (Director of Nurses) at the outside acute care hospital, bruising to the periarea was documented on the acute care hospital's nursing notes prior to discharge.
On 10/21/14, review of the "Nursing Admission Assessment," dated 8/31/14 at 3:30 p.m., indicated, under the heading,"Skin Condition," "diffused bruises" were documented as being present in the genital area upon return to the facility, as indicated on a diagram of the human body. The exact location and size of the bruising was not documented. The GER indicated that the bruises were not reported upon Resident 1's return to the facility but were reported and documented on the next shift's assessment, as follows: During client care on 8/31/14 at 11:45 p.m.,two bruises in the periarea (genital area) were noted and measured 4 cm x 2 cm (centimeters/unit of measure) and 2 cm x 1.5 cm.
Notifications to the police, administration, and physician were made approximately 9 hours after the bruises were initially noted by the licensed staff that completed the admitting assessment. The GER was initiated on 9/1/14 at 2:53 a.m..
During an interview with licensed staff on 10/30/14 at 2:55 p.m., licensed staff stated that she failed to mention the measurements of the bruise and did not complete a GER. Licensed Staff stated, "I know the protocol now."