Health inspection·October 22, 2024

§ 72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. The facility failed to notify the California Department of Public Health (CDPH) when the air conditioning unit (AC) was not working and did not address and provide temporary cooling measures/interventions while waiting for the AC to be repaired. This failure resulted in the CDPH being unaware and unable to investigate the equipment failure or what facility's interventions were implemented to ensure the health, safety, comfort, and welfare of the patients (also referred to as residents). On 8/21/24, an unannounced visit was made to the facility in response to a complaint of the facility not allowing a patient to open a room window, after complaints of being hot, during the summer month. On 8/21/24 at 10:35 A.M., an observation was conducted of the west/south hallway. The wall thermostat indicated a temperature of 79 degrees Fahrenheit (F). The Director of Maintenance (DM) was not available for interview. A concurrent observation of the west/south hallway thermostat and interview with the maintenance aide (MA) was conducted on 8/21/24 at 10:39 A.M. The MA stated the AC on the (west/south) unit stopped working two days prior. The MA stated that an AC company came out yesterday (8/20/24) and again that morning (8/21/24) and determined that parts were needed. Invoices were provided as proof. The MA did not know how long it would take for the repair, because he first needed permission from the Administrator (ADM), who was currently on vacation. The MA was asked about using the large portable AC unit that was observed at the end of the hallway. The MA stated he did not have the required hoses for the AC unit, and he would need to order them, after obtaining permission from the ADM. The MA stated that 12 stand-up fans were ordered last week, but the fans had not yet arrived. Interviews were conducted randomly, with patients in the west/south hallway. A review of Patient 3's Admission Record was conducted. Patient 3 was admitted to the facility on 1/4/24, with diagnoses which included fracture of left side ribs. Patient 3's Minimum Data Set, (MDS-a clinical assessment tool), dated 8/8/24, listed a cognitive (the mental process of thinking, remembering, the ability to comprehend, and make decisions), score of 14, indicating cognition was intact. An observation and interview were conducted with Patient 3 on 8/21/24 at 11:21 A.M., as he sat on his bed. A small fan was clipped to the left upper bed rail. Patient 3 stated he was warm and uncomfortable. Patient 3 stated his family brought him the small fan, since he was complaining about the temperature in his room. Patient 3 stated the facility never asked him if he wanted a fan, even though he complained to the staff about the heat. A review of Patient 7's Admission Record was conducted. Patient 7 was admitted to the facility on 7/4/24, with diagnoses which included cerebral infarction (stroke). Patient 7's MDS, dated 8/2/24, listed a cognitive score of 11, indicating that Patient 7's cognition was intact. An interview was conducted with Patient 7 on 8/21/24 at 11:26 A.M., in his room. Patient 7 stated he felt hot and uncomfortable and would like a fan. Patient 7 stated no one at the facility had asked him if he felt hot or would like a fan. On 8/21/24 at 1:45 A.M., the MA conducted room temperature checks in the west hallway. The MA retrieved an infrared thermometer (a non-contact thermometer that measured temperature of an object by detecting thermal radiation it emits). Random rooms were selected, and the infrared thermometer was pointed on the wall farthest from the room entrance. Patient 7's room temperature was 82.5 F. Patient 3's room temperature was 82 F. Additional rooms were checked on the west and east unit. Three rooms had temperatures recorded at 81.5 F. A follow-up interview was conducted with the MA on 8/21/24 at 2 P.M. The MA stated the maintenance department did not routinely check patient room temperatures and they had no documentation or temperature log to prove that temperatures were being checked and monitored. The MA stated no, they had not been checking room temperatures since the AC went out, and maybe they should have been. The MA stated he had never been instructed to proactively check or document patient room temperatures. An observation of staff working areas was conducted on 8/21/24 at 2:15 P.M. Fans and portable air conditioning units were located and in use, in the admission office, the west nursing station, the Director of Staff Services office and training room, the Director of Nursing (DON) office, and the social service office. The DON was not available for interview. An interview was conducted with the Assistant Director of Nursing (ADON) on 8/21/24 at 2:22 P.M. The ADON stated she and the DON were notified earlier by the MA about the temperature concerns. The ADON stated they had not ordered more fans or portable AC units at that time. The ADON stated they were waiting for the AC company to make repairs but did not know when that would occur. The ADON stated she was unaware residents were complaining about the warm temperature and confirmed no staff had been asked to go "room to room" to inquire. The ADON stated she was unaware the maintenance department was not conducting routine temperature checks. The ADON was surprised to learn that staffing departments had fans and AC units, but none had been offered to the patients. The ADON stated she expected the residents to be comfortable. The ADON was unaware the California Department of Public Health (CDPH) had not been notified of the "AC problem", stating "yes, it was an unusual occurrence and CDPH should have been notified by the Administrator, before leaving on vacation..." The temperature log for 8/21/24 from 4:15 P.M. through 4:23 P.M., was reviewed: Of the 35 rooms located on the west unit, nine room temperatures were above the 81 F. limit. One room was 90 F. One room was 84 F. One room was 83.5 F. Two rooms were 83 F. Two rooms were 82.5 F. One room was 82 F. One room was 81.5 F. An interview was conducted with the DM on 8/28/24 at 12:13 P.M. The DM stated he performed rounds (routine checks throughout the facility) when the AC company came to inspect the facility on 8/20/24. The DM stated that per the AC company, the AC units had not been serviced for a long time, the filters were dirty, and the AC blower fans needed to be replaced. The DM informed the ADM, and he was instructed to order three AC units. The DM stated that he routinely checked patient room temperatures but did not document the temperatures or maintain a temperature log because he was never told that he had to. The DM stated the patient room temperatures should be maintained between 72 F. and 80 F. The ADM was not available for interview. A joint interview was conducted with the ADON and DON on 9/4/24 at 4:53 P.M. The DON stated that concerns of the AC not working was an unusual occurrence and acknowledged that the issue should had been reported to the CDPH. A review of the facility policies was conducted. The facility's policy, titled Room Temperature, revised January 2012, "...1. Resident care areas/resident rooms will be maintained at a minimum temperature of 71 degrees Fahrenheit to 81 degrees Fahrenheit per state regulation. 2. The Maintenance department is responsible for checking room temperatures and record in the maintenance logbook...4. All resident rooms will be checked monthly and logged in the maintenance temperature logbook." The facility's policy, titled Resident rooms and Environment, revised January 2012, "The facility provides residents with a safe, clean, comfortable, and homelike environment...I. Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following: ... F. Comfortable temperatures..." The facility's policy, titled Unusual Occurrences Reporting, dated August 2012, indicated, "...The facility will follow all applicable state and federal laws and regulations regarding the reporting of unusual occurrences... I. The facility reports the following events...: A. Safety-Related Events: i. Interruption of essential services (...Air conditioning...) provided by the Facility...III. Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing..." The facility failed to notify the California Department of Public Health (CDPH) when the air conditioning unit (AC) was not working and did not address and provide temporary cooling measures/interventions while waiting for the AC to be repaired. In addition, the facility had no system in place for routinely checking and documenting room and other environmental temperatures. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.