Health inspection·July 7, 2022

Health and Safety Code Section 1424 (c): Class "AA" violations are violations that meet the criteria for a class "A" violation and that the state department determines to have been a direct proximate cause of death or have been a proximate cause of the death of a patient or resident of a long-term health care facility. Health and Safety Code Section 1424 (d): Class "A" violations are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. Title 42, Federal Code of Regulations, Section 483.25, Subdivision (d) Quality of care is a fundamental principle that applies to all treatment and care provided to facility patients. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. Title 42, Federal Code of Regulations, Section 483.90, Subdivision (i)(5) The facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. (i) Other environmental conditions. The facility must provide a safe, functional, sanitary, and comfortable environment for the residents, staff and the public. The facility must- (5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents. Title 22, California Code of Regulations, Section 72507, Subdivision (b) The facility shall provide designated areas for smoking. Patients shall be permitted to smoke only in designated areas. The designated area shall be under the periodic observation of facility personnel or responsible adults. This does not preclude the designation of the patient rooms as smoking areas. Title 22, California Code of Regulations, Section 72523, Subdivision (a) (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The Department determined, during an investigation of a facility reported incident, that the facility failed to: a) Provide adequate supervision when Resident 1 was outside smoking in the designated smoking area at 7:35 p.m. and wheeled herself across a dimly lit area of the parking lot from the designated smoking area; b) Implement Resident 1's smoking care plan for continuous monitoring of Resident 1's whereabouts during smoking.; and c) Have adequate lighting in the designated smoking area and the parking lot area near the smoking area. These facility failures resulted in Resident 1's wheelchair being hit by a motor vehicle, and Resident 1 being run over by the same motor vehicle, causing critical injuries that resulted in Resident's 1's death within 47 minutes after being hit and run over by the vehicle. On 10/1/21, at 10 p.m. an email was received from Santa Paula Post Acute informing the Department that the facility had an unusual occurrence that day at about 7:40 p.m., and that a resident was hit by a car. Police were called and the matter is currently under investigation. On 10/2/21, at 12:46 a.m., an email was received from Santa Paula Post Acute with an initial letter attached describing the unusual occurrence and that Resident 1 had passed away. Review of Resident 1 clinical records (face sheet) set forth that Resident 1 was a 79 year old female admitted to the facility on 12/14/2009 with diagnoses including unspecified mood disorder (a mental health problem that primarily affects a person's emotional state), other secondary Parkinson ism (symptoms similar to Parkinson's Disease caused by certain medicines), unspecified Alzheimer's Disease (a progressive disease starting from mild memory loss and possibly leading to a loss of the ability to carry on a conversation and respond to the environment), unspecified generalized muscle weakness, dementia in other diseases classified elsewhere with behavioral disturbance (a general term for memory loss and cognitive abilities serious enough to interfere with daily life), nicotine (a stimulant in tobacco products} dependence, cigarettes, uncomplicated, personal history of other mental and behavioral disorders, and unspecified cataracts (clouding of the lens of the eye). Resident 1's History and Physical (H&P) dated 10/6/20, indicated, Resident 1 "does not have the capacity to understand and make decisions." Resident 1's Minimum Data Set (MDS, a comprehensive assessment) dated 7/31/21, set forth that Resident 1 had moderately impaired cognition (mental awareness), and required one­person physical assist with supervision during locomotion off the unit. Resident 1's "Psychiatric Evaluations" dated 5/7/21, 6/8/21, and 9/9/21 indicated, Resident 1 was assessed as "unpredictable and confused, delusional (beliefs that are contradicted by reality or rational argument, and a typical symptom of mental disorder), had impaired/no judgment and insight, and had intermittent irritability around smoking time." Resident 1's "Smoking Assessment" dated 7/31/21, indicated Resident 1 had cognitive loss, smokes six to ten times per day (morning, afternoon, and evening), and refuses use of a smoking apron. The assessment also indicated facility staff will continue to monitor the resident's whereabouts especially during smoking time to ensure safety of the resident. Resident 1's "Smoking Care Plan" initiated 6/2/14 and updated on 7/25/21 indicated "Resident was at risk for safety hazard, injury to self and/or others related to smoking and/or lighting materials. Resident does not use a smoking apron and goes out to smoke when she wants to." The care plan interventions included "Monitor for safe smoking habits and compliance with smoking schedule. Encourage resident to follow safe smoking policy and procedures; smoke only in designated areas ... " During a concurrent observation and interview on 10/4/21, at 9:50 a.m., with the Assistant Administrator (AADM), and Infection Preventionist (IP), in the parking lot next to the original designated smoking area, a visual inspection was completed, pictures were taken, and drawings were depicted of the area where the accident happened. The AADM and IP provided consistent accounts of the sequence of events that transpired on 10/1/21. The AADM and IP stated Resident 1 had finished her smoke break and started to go to the door located on the side of the facility leading to the parking lot and smoking area in her wheelchair. The Receptionist (RECPT) overseeing Resident 1 was at the entrance getting ready to open the door when another resident with a tab alarm attempted to get out of her wheelchair. This triggered the alarm, and RECPT turned her attention to turning the alarm off. Suddenly, Resident 1 veered to her right off the pathway to the side door and into the parking lot. During this time, Certified Nursing Assistant (CNA) 1 was driving into the parking lot to park after CNA 1's lunch break. CNA 1 made a turn and hit Resident 1 in her wheelchair. The impact ejected Resident 1 from the wheelchair. CNA 1's car went over the wheelchair, tilting the car upward. CNA 1 thought it was a flat tire, stopped for a moment, and then proceeded to drive again. CNA 1, not knowing that Resident 1 was in front of her vehicle, accelerated and ran over Resident 1. The car dragged Resident 1's body towards the parking space, where CNA 1 parked the car. Another CNA, (CNA 2), witnessed Resident 1 being run over by CNA 1's car. CNA 2 got out of her car to try to help. CNA 2 alerted CNA 1 as to what had just happened. CNA 1 got out of the car and only then realized she ran over Resident 1. CNA 2 ran inside the facility to get help. Staff came out to help until the ambulance and fire department came along with the police. While being transported to the hospital, Resident 1 passed away. During a review of Resident 1's hospital records, dated 10/1/21, the Emergency Room (ER) physician notes indicated, Resident 1's diagnosis to be Traumatic Cardiac Arrest (is a condition in which the heart has ceased to beat due to blunt or penetrating trauma). Further review indicated, Resident 1 was transported by paramedics with agonal respirations (someone who is not getting enough oxygen and is gasping for air), on the way to the hospital, Resident 1 suffered a cardiac arrest and was dead upon arrival. Time of death was recorded at 8:22 p.m. During an interview on 10/4/21, at 3:23 p.m., Resident 2 stated he was outside by the parking lot talking to a friend on the phone. The sun had already set and it was dark. Resident 2 saw Resident 1 moving from the smoking area towards the parking lot in her wheelchair. Resident 1 kept going into the parking lot, even though a car was turning that direction. The turning car then hit Resident 1, then continued forward to park. CNA 1 got out of the car that hit Resident 1, and CNA 2 was also heading towards the accident. Resident 2 stated he heard a distinct "clunk, clunk" when the accident occurred, and noted that "there is good lighting over the parking area, but the smoking area is dark." During an interview on 10/4/21, at 4:14 p.m., Receptionist (RECPT) stated, Resident 1 "prefers to be left alone to do her business." During Resident l's smoke breaks, RECPT would supervise the resident from inside the entrance door most times and could usually see the Resident 1, and never had issues because it was always just routine. RECPT stated she was trained by another receptionist when it was her first time to take Resident 1 out for a smoke. The training RECPT was provided to monitor a smoking resident was, in essence, "to keep an eye watch on them, and be aware as to where they are going and not to leave the lighter with the resident." RECPT stated that on 10/01/21, around 7:35 p.m., Resident 1 wanted to go to smoke and asked for a cigarette. RECPT stated she took the resident outside, lit her cigarette with a lighter, and took the lighter back inside. RECPT stated she was inside the entrance door, supervising Resident 1 "from a distance" at the time of the incident. RECPT stated Resident 1 then gestured with her hand to let RECPT know she was done smoking. She opened the door, then another resident set off the alarm at the door. RECPT stated "I had to redirect the other resident and when I turned around, I saw Resident 1 on the ground with CNA 1 out of her car and CNA 2 came inside saying, "call 911". RECPT stated she doesn't have to be standing directly with or have proximity to the resident to supervise but checks in on her frequently. During an interview on 10/5/21, at 3:50 p.m., CNA 1 stated on the night of the accident, she was coming back from lunch. She was driving in the parking lot and started to make a turn to park when, "It felt like a flat tire and I kept going and it felt weird, but I kept driving and got into the first space. Then someone came to me and kept telling me it's (Resident 1... it's (Resident 1). I stopped the car and parked, ran out and I saw the resident. I did not see anything, and it felt like a flat tire, or something was under the car." During an interview on 10/5/21, at 10 a.m., CNA 2 stated, she was going to lunch and was about to leave the driveway when she saw the accident happen. CNA 2 stated, "When I saw what was happening, I immediately stopped the car and parked and I ran to CNA 1's car, but it was too late. I saw Resident 1 being run over by the car. I ran inside to ask for help." During an observation on 10/5/21, at 7:30 p.m., at the accident location by the parking lot, a visual inspection was conducted during nighttime. General lighting in the area was observed. There were three sets of lights, two were focused on the parking lot, these lights were bright and illuminated certain areas of the parking lot, and were activated by movement, and one sensor light was focused on the previous smoking area, where Resident 1 smoked. The light by the smoking area was not bright, and when it was off, the area became dark. Observation from a view from the doorway (outside), there was a tree preventing a direct view of the smoking area. Observation inside the doorway, looking through the glass, where RECPT claimed to be located when the incident occurred, the view of the smoking area was obstructed. Observation of the smoking area by the doorway, a person could not be visualized. Measurements of the surrounding area were taken. The edge of the doorway to the table in the smoking area was 60 feet. From the tree at the end of the smoking area, behind the table to the doorway was 70 feet. The facility's Policy and Procedure (P&P), titled, "Smoking Policy - Residents," dated December 2007 indicated in part, "1. Prior to, or upon admission, residents shall be informed about any limitations on smoking, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences ... 7. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine any restrictions on a resident's smoking privileges. 8. Any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 10. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 13c. Anyone who provides smoking supervision to residents shall be advised of any restrictions/concerns and the plan of care related to smoking." Here, RECPT, who was supervising Resident 1 during Resident 1's smoke break in a manner consistent with her training, was did so from a location that had limited visibility of the designated smoking area where Resident 1 was located, was too far away to timely intervene to prevent harm to Resident 1 and created a distraction where use of the facility door prompted another resident to attempt to leave, triggering an alarm. As a result, Resident 1 wheeled herself unimpeded from the designated smoking area through a dimly lit area of the parking lot, where she was struck by a vehicle, which caused critical injuries that led to her death. The facility failed to: a) Provide adequate supervision when Resident 1 was outside smoking in the designated smoking area at 7:35 p.m. and wheeled herself across a dimly lit area of the parking lot from the designated smoking area. b) Implement Resident l's smoking care plan for continuous monitoring of Resident 1's whereabouts during smoking. c) Failed to have adequate lighting in the designated smoking area and the parking lot area near the smoking area. These violations presented imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result and was a direct proximate cause of Resident 1's death.