Health inspection·October 31, 2023

1st revisit The following reflects the findings of the California Department of Public Health during a revisit conducted on 11/16/23 to correct the plan of correction. Representing the Department, HFEN # 33280. § 72311 (a)(1)(B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. § 72523 (a) - Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 10/31/23, the facility received a citation from the Department for failure to provide safe environment of residents who were at risk for suicide. The accepted plan of correction indicated corrective action was effective 11/6/23. This included implementing an environment free of items that could be used to inflict self-harm. During an unannounced revisit survey, call lights with long, loose cords in the rooms of residents identified as being at risk for suicide were observed. Findings: A revisit survey was conducted on 11/16/23, at 9 A.M. The secured unit was toured, which had 37 rooms on three hallways. The tour revealed the resident rooms had call lights that plugged into the wall with long loose cords that reached to the beds. The cords were able to be disconnected from the wall. On 11/16/23, at 9:45 A.M., an interview with the Director of Maintenance, (DM) was conducted. DM stated most of the call light cords were 15 feet long, and some of them were 8 feet long. DM stated the cords needed to be that long in order to reach the resident from where they were plugged in. DM stated the cords were zip tied to the bed, but there was no concern about securing them any further. The facility was asked for a list of residents determined to be at risk for suicide based on assessment risk. Three residents were identified (1, 2, 3). Resident 1 was admitted to the facility on 8/4/22, according to the facility Admission Record. Per Resident 1’s Suicide Risk Screening Tool dated 10/16/23, “…Does resident have history of suicide ideation/suicide threats/suicide attempts? Yes…Does resident have a current/history of suicidal ideation/suicide threats/suicide attempts? Yes”. Per Resident 1’s Care Plan, dated 11/8/23, “Resident is at risk for suicide attempt…verbalizes that she likes suicide…” The care plan interventions did not address providing an environment free of items that could be used to inflict self-harm. Resident 2 was admitted to the facility on 8/3/23, according to the facility Admission Record. Per Resident 2’s Suicide Risk Screening Tool dated 8/29/23, “…Does resident have history of suicide ideation/suicide threats/suicide attempts? Yes…Does resident have a current/history of suicidal ideation/suicide threats/suicide attempts? Yes”. Per Resident 2’s Care Plan, dated 11/8/23, “Resident is at risk for suicide r/t multiple medical condition.” The care plan interventions did not address providing an environment free of items that could be used to inflict self-harm. Resident 3 was admitted to the facility on 8/21/23, according to the facility Admission Record. Per Resident 3’s Suicide Risk Screening Tool dated 8/29/23, “…Does resident have history of suicide ideation/suicide threats/suicide attempts? Yes…”. Per Resident 3’s Care Plan, dated 11/8/23, “Resident is at risk for suicide r/t behavioral problem.” The care plan interventions did not address providing an environment free of items that could be used to inflict self-harm. On 11/16/23, at 10:25 A.M., Resident 1, 2, and 3’s rooms were toured with the Administrator and Director of Nursing. Resident 1’s bedside had an 8-foot call light cord next to the bed. Residents 2 and 3 each had a 15-foot call light cord next to their respective beds. The Administrator and DON acknowledged having loose cords were a risk for residents at risk for suicide. Per the plan of correction dated 10/30/23, “Maintenance will conduct additional measures…to inspect rooms for any hazard materials such as i.e. loose cords, open wire…as part of routine maintenance…” Initial Visit The following reflects the findings of the California Department of Public Health during the investigation of Facility Reported Incident: CA 00857677. Representing the Department, HFEN 39111. State Citation AA was written. 42 C.F.R. § 483.10. Notification of changes. (g)(14) (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s), when there is- (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). 42 CFR § 483.25(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. 42 CFR §483.40 Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. (a) The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with §483.70(e). These competencies and skills sets include, but are not limited to, knowledge of and appropriate training and supervision for: (1) Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, that have been identified in the facility assessment conducted pursuant to §483.70(e), (2) Implementing non-pharmacological interventions. §483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include: §483.70(e)(1) The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident capacity; (ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population. 22 CCR § 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. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. 22 CCR § 72515. Admission of Patients. The licensee shall: (b) Accept and retain only those patients for whom it can provide adequate care. 22 CCR § 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 8/29/23, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a facility reported incident investigation about quality of care, resident assessment, and accidents. The facility failed to ensure Resident 1, who was admitted to the facility with a history of mental disorders (syndromes characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior) and suicidal ideation (SI, thoughts of self-harm or of killing oneself), was provided the necessary behavioral healthcare and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being, and a safe environment with adequate supervision. On 8/24/23, Resident 1, after having verbalized to staff on several occasions that she wanted to kill herself, told certified nursing assistant (CNA) 3 that she would swallow glass. Resident 1 was then left alone in her room with a glass vase which the resident then broke and ingested. The facility failed to: 1. Perform an initial and continuing assessment of Resident 1's history of suicide attempts and suicidal ideation while at the facility. 2. Identify Resident 1's care needs and care plan for Resident 1's mental disorders and history of SI with resident-specific interventions to include providing an environment free of items that could be used to inflict self-harm upon the resident's admission, following the resident's Minimum Data Set Assessment (MDS, a comprehensive assessment), and when the resident's behaviors and symptoms manifested. 3. Notify the physician and/or psychiatrist (physician who specialized in mental disorders) of Resident 1's SI verbalizations and increased frequency of SI, which were a change of condition that was not promptly acted upon by nursing staff. 4. Ensure that Resident 1 received adequate supervision to prevent accidents when nursing staff left Resident 1 alone in her room after she stated that she was going to swallow glass. 5. Ensure that Resident 1's environment remained free of accident hazards when Resident 1 was left alone in her room with a bedside glass flower vase that she could use to ingest glass. 6. Have staff working on the facility's behavioral health unit (BHU, an area of the building that housed residents with cognitive impairment and mental disorders), where Resident 1 resided, with the appropriate training, skill sets, and competencies (measurable pattern of knowledge, skills, abilities, and behaviors, and other characteristics in order to perform occupational functions successfully) to provide care for residents with mental disorders and those experiencing SI. 7. Have a system in place wherein all staff were knowledgeable and capable of responding immediately and efficiently to behavioral emergencies/crisis (when a resident was posing a danger to self and/or others). 8. Update the Facility Assessment (determines what resources are necessary to care for its residents competently during both day-to-day operations and emergencies) to thoroughly assess its BHU and the training and competencies required of staff to provide care to residents with mental disorders, SI, and respond during behavioral emergencies. 9. Only accept and retain residents for whom it could provide care when the facility admitted Resident 1 and they were unable to provide the care and services to residents with a history of SI. 10. Implement numerous policies and procedures, including but not limited to facility policies titled: "Facility Assessment", "Behavioral Health Services", "Change of Condition Notification", "Suicide Threats", and "Admissions Policies." As a result, Resident 1 was sent out to the hospital on 8/24/23 and experienced pain, sustained shards of glass throughout the gastrointestinal tract (GI tract, path where food travels through the body) that cut the organs of the GI tract, developed sepsis (infection in the blood) and died at the hospital on 8/29/23. A review of Resident 1's facility Admission Record indicated the resident was admitted on 8/2/23 with diagnoses to include bipolar disorder (mental disorder with extreme changes in mood, thought, energy, and behavior and characterized by periods of mania and depression) and depression (a mood disorder that caused persistent feelings of sadness, hopelessness, and loss of interest). A review of Resident 1's MDS assessment dated 8/8/23, indicated the resident scored 15 on the brief interview of mental status (a score of 15 meant the resident was cognitively intact). A review of Resident 1's facility History and Physical exam, signed by the physician on 8/16/23, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 1's admitting paperwork from the general acute care hospital (GACH) 2 dated 8/2/23, indicated the resident had a history of SI. A review of Resident 1's facility clinical record indicated the resident's suicide risk had not been assessed upon admission and there was no written plan of care developed with person-centered interventions to address the resident's bipolar disorder, depression, and SI until 8/25/23 (the day after Resident 1 left the facility). A review of Resident 1's facility nursing progress notes indicated, on: 8/7/23, The resident became "very upset" during the medication administration and was yelling at the licensed nurse (LN). 8/9/23, "Pt [patient] presented with behavioral problems today demanding to be discharged, aggressive, calling nurses out their name or title with bad language and profanity, slammed telephone and slammed door. She demanded to speak to social services to be discharged." 8/10/23, "Resident...started yelling and demanded me to go out from her room. She wants to go home. No one paying attention to her. Resident left alone." 8/20/23, "...Pt stated she was very upset with her care here and feels like she is in prison. Pt is very upset with [family members] for putting her here and they don't come and visit her. Pt refusing medications at this time and believes that if she stops taking her medications she will die faster...asked pt if she has thoughts of hurting herself and pt denies...will follow up with doctor...." 8/20/23, "Late entry for 8/20/23: ...Pt was sitting in room with [family member, FM 1] laughing and eating chips...." 8/24/23, "At 12:05 AM Resident came out from the room and stating she swallowed a glass. We would like to come to the room she wont [sic] let us in and she pushed the bed at the door...physician notified... Resident hold the phone and saying you are not my [expletive] doctor...911 called and with difficulty evaluating her and took her at 110 AM. Room has been assessed broken glass found at the window." A review of Resident 1's GACH 1 physician documentation dated 8/24/23, indicated, "...Patient was seen and evaluated by writer and the SW [social worker] at the ED [emergency department]. Pt appears to be restless, maintained no eye contact, report feeling depressed, overwhelmed