Health inspection·October 19, 2022

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00782163. Representing the Department, HFEN #39512. State Citation Willful Material Falsification was written. §483.20 Resident Assessment The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. §483.20(b) Comprehensive Assessments §483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychological well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnosis and health conditions. (xi) Dental and nutritional status. (xii) Skin Conditions. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. §483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.) § 72311 - Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. § 72527 - Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (3) To be fully informed by a physician of his or her total health status and to be afforded the opportunity to participate on an immediate and ongoing basis in the total plan of care including the identification of medical, nursing and psychosocial needs and the planning of related services. On 5/9/22, an unannounced visit was conducted to investigate allegations that Resident 1 had not been accurately assessed. A review of Resident 1's face sheet, undated, indicated Resident 1 was admitted on 4/1/22, with a primary diagnosis of subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), and discharged on 4/20/22. The facility failed to accurately complete the resident assessment instrument when the Minimum Data Set (MDS, a resident assessment tool used to guide care) sections on cognitive patterns (an assessment of the resident's attention, orientation and ability to register and recall new information), preferences for customary routine and activities, health conditions/pain assessment interview, and participation in assessment and goal planning were completed by the Minimum Data Set Coordinator (MDSC) without direct observation of Resident 1 or Resident 1's participation. These failures resulted in an inaccurate depiction of Resident 1's mental, physical, and psychosocial condition and care needs due to lack of Resident 1's input to the assessment process and MDSC's fabrication of interview answers. A review of Resident 1's General Acute Care Hospital After Visit Summary (AVS), dated 4/1/22, indicated, "Information on Stroke: You have been diagnosed with a stroke or stroke-like symptoms during your hospitalization. Review the following to reduce your risk of stroke: Symptoms of Stroke: Sudden numbness or weakness of face, arm or leg-especially on one side of the body. Sudden confusion, trouble speaking or understanding. Sudden trouble seeing in one or both eyes. Sudden trouble walking, dizziness, loss of balance or coordination. Sudden severe headache with no known cause." A review of Resident 1's History and Physical, dated 4/2/22, indicated Resident 1 had diagnoses of post subarachnoid hemorrhage, and development of brain cancer after having lung cancer. A review of Resident 1's Admission MDS, dated 4/9/22, indicated the MDS Coordinator (MDSC) completed Sections A through Q and Section S on 6/20/22. The MDS indicated the following section entries for: C: Cognitive patterns, (an assessment of the resident ' s patterns, orientation and ability to register and recall new information). The MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score of 13. D: Mood. The MDS indicated Resident 1 had a Patient Health Questionnaire-9 (PHQ-9, a scoring system used to assess degree of depression. A PHQ-9 score of 0-4 points is an indication of "normal" or minimal depression.) score of zero. F: Preferences for customary routine and activities. The MDS indicated Resident 1's preferences were: Very important: Choosing the clothes to wear; taking care of personal belongings; choosing between a tub bath, shower, bed bath, or sponge bath; having snacks available between meals; choosing own bedtime; having family or close friend involved in discussions about care; being able to use the phone in private; doing favorite activities; going outside to get fresh air when the weather is good. Somewhat important: Having books, newspapers, and magazines to read; listening to music; keeping up with the news; doing things with groups of people; participating in religious services or practices. Not very important: Having a place to lock things up to keep them safe; being around animals such as pets. J: Health conditions/pain management interview. The MDS indicated Resident 1 had no pain. Q: Participation in assessment and goal setting. The MDS indicated Resident 1 and Resident 1's representative had participated in the assessment process. During a concurrent interview and record review, on 7/14/22, at 2:01 p.m., with the Director of Nursing (DON), Resident 1's Admission MDS, dated 4/9/22, was reviewed. The DON stated the Admission MDS did not include the diagnoses of brain cancer or stroke/stroke-like symptoms. During an interview on 7/14/22, at 2:32 p.m., with the MDS Coordinator (MDSC), the MDSC stated he had not documented the problem area diagnoses of brain cancer and stroke/stroke-like symptoms on Resident 1's MDS. During a concurrent interview and record review on 9/15/22, at 10:12 a.m., with the MDSC, Resident 1's Admission MDS, dated 4/9/22, was reviewed. MDSC stated he completed and signed the Admission MDS on 6/20/22, two months after Resident 1's discharge to the acute care hospital. MDSC stated he had not observed or interviewed Resident 1 when he completed Resident 1's Admission MDS since the resident was no longer in the facility. MDSC stated the sections C, D, F, J, and Q, were completed without direct evaluation or participation by Resident 1. MDSC stated for the Admission MDS to provide a clear picture of Resident 1's care needs, the Admission MDS should be completed during Resident 1's first fourteen days in the facility. During a review of the facility's policy and procedure (P&P) titled, "Resident Assessment Instrument (RAI) Process," dated 2001, the P&P indicated, "The Resident Assessment Instrument (RAI) is used at the facility to provide the caregiving staff with ongoing assessment information necessary to develop a resident care plan, to provide the appropriate care and services for each resident, and to modify the care plan and care/services based on the resident's status... The RAI promotes the resident's highest practical level of functioning, concentrating on conditions that affect physical, cognitive, and psychosocial functions...The facility conducts a comprehensive assessment to identify the resident's needs within 14 days after admission...The facility is expected to use resident observation and communication as the primary source of information when completing the MDS. This observation must be in real time... A MDS may never be created retrospectively."