Other·September 3, 2019

F000 INITIAL COMMENTS

F000 DEFICIENCY) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey regarding investigation of three complaints on 8/27/19. For Complaints CA00650758, CA00650855, and CA00651120, regarding Quality of Care and Treatment, a federal deficiency was identified (see F689). Inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 36623, Health Facilities Evaluator Nurse.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 09/16/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide adequate supervision for one of two residents when Resident 1 was unsupervised in the patio and under the sun. This failure resulted in Resident 1 suffering from heat stroke (serious illness of the body overheating; symptoms include high body 055739 08/27/2019 SALINAS VALLEY POST ACUTE 637 E Romie Ln Salinas, CA 93901 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE temperature, difficulty breathing, and confusion) and second degree burns due to sun exposure. Findings: Review of Resident 1's record indicated he had diagnoses including muscle weakness, cognitive communication deficit, and dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 7/31/19 indicated his cognition was moderately impaired and he required limited assistance and one-person physical assistance while in his wheelchair. Review of Resident 1's Change in Condition Evaluation, dated 8/15/19 indicated he had increased confusion and was "unable to move without assistance, was drowsy, and unable to carry conversation." The Evaluation indicated he had labored breathing, increased temperature, and other abnormal vital signs. It also indicated he had a "cluster of blisters" on his left arm. It indicated there was a doctor's order to send the resident to the hospital. Review of Resident 1's History and Physical from the hospital indicated he had heat stroke with an initial temperature of 104.1 degrees Fahrenheit (F, scale of temperature, normal body temperature is 98.6 degrees F), encephalopathy (disease that affects brain function) "likely from heat stroke" and had blisters on his upper arms. Review of Resident 1's Discharge Summary indicated he had heat stroke and second degree burns from sun exposure. 055739 08/27/2019 SALINAS VALLEY POST ACUTE 637 E Romie Ln Salinas, CA 93901 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE During an interview on 8/21/19 at 10 a.m., Resident 1 stated his arms hurt and he got the injury from sitting in the sun so long. During an interview on 8/21/19 at 10:32 a.m., licensed vocational nurse B (LVN B) stated she was assigned to take care of Resident 1 on 8/15/19 and did not see him outside on the patio. During an interview on 8/21/19 at 12 p.m., the lead respiratory therapist (RT) stated on 8/15/19 she saw the nurse and CNA A trying to wake up Resident 1. The RT stated Resident 1 was breathing fast, had an elevated heart rate, and was warm to the touch. The RT stated they put Resident 1 on oxygen. The RT stated she did not see Resident 1 outside on the patio. During an interview on 8/21/19 at 12:38 p.m., certified nursing assistant A (CNA A) stated another resident (Resident 3) called staff to help Resident 1 on the patio. CNA A stated Resident 1's feet got stuck in the dirt and plants and he could not move his wheelchair. CNA A stated Resident 1 was sweaty and looked exhausted. CNA A stated she pulled his wheelchair out and left the patio to inform the nurse about Resident 1. CNA A stated when she returned to the patio, Resident 1 was not responding. CNA A stated she did not see Resident 1 outside on the patio until Resident 3 called her. During an interview on 8/21/19 at 12:45 p.m., Resident 3 stated she saw Resident 1 on the patio and he looked like he was having trouble breathing. Resident 3 stated she told LVN C about Resident 1 and LVN C said he was OK. Resident 3 stated she saw Resident 1 wheel himself toward the plants in the dirt and get stuck. Resident 3 stated she turned on her call light to get staff to help Resident 1. 055739 08/27/2019 SALINAS VALLEY POST ACUTE 637 E Romie Ln Salinas, CA 93901 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Review of the facility's 4/2017 policy, "Resident Supervision and Monitoring," indicated the residents are supervised under normal circumstances to ensure optimal safety.