Health inspection·June 19, 2024

Granite Hills 892481 Citation A 22 CCR § 72311 (a)(1)(A)(B)(C)(2) (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 72311 (a)(2) (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 42 CFR §483.25(d)(2) (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. Failings On 4/3/2024 at 1 P.M., an unannounced onsite visit at the facility was conducted for an abbreviated survey related to a facility-reported incident. It was determined that the facility failed to provide a safe environment for one of the three residents (Resident 1) reviewed for accidents. Resident 1, who was known to have a history of suicidal attempts (the act of intentionally causing one's death), was left unattended during mealtime and swallowed part of a metal fork. Specifically, the facility failed to: 1. Implement patient care plan per close monitoring during patient mealtime. 2. Ensure an environment free of accident hazards and provide adequate supervision during patient mealtime per patient's documented history of suicidal attempts by swallowing foreign objects. As a result, Resident 1 was transferred to the hospital to remove the metal fork non-surgically from her body. Findings: A review of Resident 1's Admission Record was conducted. Resident 1 was admitted to the facility's secured unit (a specially designed space for residents to have the resources they require to live safely) on 2/12/24 and had a diagnosis which included personal history of suicidal behavior. A review of Resident 1's hospital clinical record prior to being admitted to the facility was conducted. According to Resident 1's ED (Emergency Department) Note, dated 10/27/23, Resident 1 swallowed the temple (the arms on each side of the frame, extending from the front of the frame to behind the ears) part of a pair of reading glasses. The note indicated that Resident 1 had a history of suicidal ideation and had multiple visits to the hospital due to swallowing foreign objects. According to Resident 1's Hospital Discharge Summary, dated 2/12/24, Resident 1's primary diagnosis was a history of attempted suicide. A review of Resident 1's facility's plan of care, initiated on 2/17/24, was conducted. The care plan indicated that Resident 1 had a behavior problem of harming self. According to Resident 1's care plan, one of the interventions initiated on 3/6/24 was to provide close monitoring of Resident 1 during mealtime. On 3/26/24, per the IDT (Interdisciplinary Team) meeting notes, the Director of Nursing (DON) documented Resident 1 would be closely monitored during mealtime. A record review of Resident 1's progress notes, dated 3/26/24 at 5:07 P.M., written by licensed nurse (LN) 3, was conducted. LN 3 documented that Resident 1 had shown breaking the plastic and metal forks in half during mealtime. LN 3 further documented that Resident 1 would be closely monitored and one-to-one assistance would be provided to Resident 1 during meals. On 3/28/24 at 4:38 P.M., under System Note, LN 2 documented that Resident 1 continued to be supervised when eating. A record review of Resident 1's progress notes, dated 3/29/24 at 9:29 A.M., written by the Assistant Director of Nursing (ADON) was conducted. The ADON documented that [on 3/29/24] Resident 1 verbalized ending her life and swallowed a fork. The progress note indicated that the staff (CNA 1) found a broken fork with a missing handle. Resident 1 was transported to the hospital via 911 (emergency responders). A record review of Resident 1's hospital x-ray (a photographic or digital image of the internal composition of something, especially a part of the body, produced by X-rays being passed through it and being absorbed to different degrees by different materials) report dated 3/29/24, indicated an elongated metallic density (the degree of film darkening) measuring 13.5 centimeters (cm) by 1.5 cm projecting over the left upper abdomen. A record review of Resident 1's GI (Gastro-Intestinal-) Procedure Report, dated 3/29/24, indicated Resident 1 had an EGD procedure (Esophagogastroduodenoscopy - a procedure that involves removing foreign objects from the esophagus, stomach or intestine using flexible tube-like instrument into the body to look inside. The report indicated the physician removed the utensil handle from Resident 1's stomach. On 4/3/24 at 1:15 P.M., an interview was conducted with the DON. The DON stated on 3/29/24 Resident 1 swallowed a metal fork and went to the hospital. Resident 1 was currently in the hospital for the removal of the object. On 4/3/24 at 4:20 P.M., Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 stated that the LNs told her to stay in Resident 1's room the entire time during meals. On 4/3/24 at 4:30 P.M., an interview was conducted with LN 1. LN 1 stated she was the assigned LN for Resident 1 on the day of the incident (on 3/29/24, when Resident 1 swallowed the fork). LN 1 stated she told CNA 1 in the morning to provide one-to-one supervision and monitor Resident 1 closely, and to not leave Resident 1 with utensils. On 4/4/24 at 4 P.M., an interview was conducted with CNA 3. CNA 3 stated that the LN instructed her to always sit with Resident 1 while eating for safety. On 4/4/24 at 4:14 P.M., an interview was conducted with LN 2. LN 2 stated she documented on 3/28/24 that Resident 1 was supervised when eating and Resident 1 remained safe when supervised. On 5/7/24 at 1:45 P.M., an interview was conducted with LN 3. LN 3 stated on 3/26/24, he observed Resident 1 bending the plastic and the metal utensils. LN 3 stated, for Resident 1's safety nursing and medical staff accelerated the plan of care, and the intervention was to provide Resident 1 with one-to-one feeding assistance, not to feed Resident 1, but to ensure Resident 1 did not swallow anything that was not meant to be eaten. On 5/7/24 at 3:55 P.M., an interview was conducted with CNA 1. CNA 1 stated she was the assigned CNA to Resident 1 on 3/29/24, and LN 1 told her not to leave Resident 1 alone during mealtime. CNA 1 stated Resident 1 was having breakfast in her bed and asked for a blanket. CNA 1 further stated she knew not to leave Resident 1, but she was "naive" and believed Resident 1 would be okay alone, so she left to get a blanket. CNA 1 stated she left Resident 1's room for a minute and heard Resident 1 cough when she (CNA 1) was outside of Resident 1's room. When CNA 1 returned to Resident 1's room with a blanket, CNA 1 noticed Resident 1's fork was missing. CNA 1 stated, Resident 1 said she swallowed the fork, and she (CNA 1) called LN 1, the ADON and DON came in the room, and Resident 1 was transferred to the hospital via 911. The facility could not provide a policy about a safe environment or supervision during mealtime. Conclusion In violation of the above cited standards, the facility failed to provide a safe environment for Resident 1. Resident 1, who was known to have a history of suicidal attempts (the act of intentionally causing one's death), was left unattended during mealtime and swallowed part of a metal fork. 1. Implement patient care plan per close monitoring during patient mealtime. 2. Ensure an environment free of accident hazards and provide adequate supervision during patient mealtime per patient's documented history of suicidal attempts by swallowing foreign objects. As a result, Resident 1 was transferred to the hospital to remove the metal fork non-surgically from her body. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, a result in a Class A Citation.