Health inspection·March 18, 2022

Facility ID: 056294 District Office: Bakersfield HFES: 2224 The following reflects the findings of the California Department of Health during the investigation of Entity Reported Incident #750496. Event ID: Y6EC11 Representing the Department: 40081, HFEN State "A" citation was written. Regulation: §483.35 Nursing Services The facility must have sufficient nursing staff 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 the facility assessment required at §483.70(e). §483.35(a) Sufficient Staff. §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. On 9/13/21, at 10:30 AM, California Department of Public Health conducted an unannounced visit at the facility to investigate a facility reported incident regarding a nurse "abandonment of post." The facility failed to ensure four residents (Resident 1, Resident 2, Resident 3, and Resident 4) were provided any nursing services when the nursing care unit they were in (a single, 4-bed isolation room known as "the red zone," where COVID-19 positive residents were housed) went completely unstaffed and unmonitored for a period of at least sixty (60) minutes. As a result, Resident 1 fell to the floor, and no staff responded to Resident 1 as she lay on the floor unassisted, until her roommate, Resident 2, finally called "911" and activated Emergency Medical Services (EMS). Upon their arrival, EMS documented that Resident 1 was found "cold" and "lying on floor in water." The facility's failure to have any staff in the "red zone" for a period of approximately 60 minutes put Resident 1 in imminent danger of death or serious harm, or had the substantial probability of death or serious physical harm would occur from Resident 1 laying on the floor, cold and in water, without any staff awareness or intervention. Resident 1 was a 75-year-old female admitted to the facility on 8/23/21 with diagnoses that included muscle weakness, difficulty in walking, history of stroke, history of respiratory failure, nerve damage, heart disease, depression, adjustment disorder with anxiety, and hallucinations. Her cognition was severely impaired. Resident 1 required the extensive physical assistance of one staff person to complete activities of daily living such as bed mobility, toilet use, and personal hygiene. Resident 2 was a 65-year-old female admitted to the facility on 8/1/21 with diagnoses that included spinal disorder, difficulty in walking, respiratory disease, anxiety, heart disease, and joint pain. Her cognition was intact. During a review of a facility document, dated 8/29/21, titled "Investigation Alleged Abandonment of Post [IAAP]," the IAAP indicated, that "The administrator. . . was made aware that a [Licensed Vocational Nurse (LVN) 1] in the red zone had left her post sometime after 7am on [8/29/21]. Her replacement took over around 8am." The document was written by the facility Administrator. A follow-up facility document, dated 9/2/21, titled "Investigation Alleged Abandonment of Post [IAAP]," the IAAP indicated, LVN 1 ". . . had left her post shortly after 7am on 8/29 [8/29/21]." The document was written by the facility Administrator. During a review of Resident 1's clinical record, the document Minimum Data Set (MDS, a standardized assessment and screening tool), dated 8/24/21, indicated Resident 1's cognitive skills (cognition refers to conscious mental activities and includes thinking, reasoning, understanding, learning, and remembering) for daily decision making was severely impaired. The MDS indicated Resident 1 required "extensive assistance" for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed) and for toileting (how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination), and required the physical assistance of one person to complete these activities. During a review of the facility document titled, "Detail Time Report," dated 8/28-29/21, for LVN 1, it indicated LVN 1's "In Time" was at 6 PM on 6/28/21, and "Out Time" was at 7:30 AM on 8/29/21. During a phone interview, on 9/17/21, at 4:20 PM, with LVN 1, LVN 1 hung up the phone when asked to give her account of the events of 8/29/21. During an interview, on 9/23/21, at 12:40 PM, with Resident 2, Resident 2 stated that on 8/29/21, she heard Resident 1 fall, and saw that the bed across from her, belonging to Resident 1, was empty. Resident 2 stated that she tried to ring her call bell and call for the nurse but nobody came. Resident 2 stated that after fifteen (15) minutes of continuously calling the nurse, she decided to call "911" herself. This activated EMS, which dispatched an ambulance to the facility. During a review of Resident 2's clinical record, the MDS, dated 8/7/21, indicated Resident 2's Brief Interview for Mental Status (BIMS) score was "13," which indicated her cognitive skills for daily decision making were intact. During an interview, on 9/23/21, at 12:47 PM, with Resident 4, Resident 4 stated that she saw Resident 1 walk towards the window and fall to the floor with a bedside table on top of her. Resident 4 stated that she called the nurses for help but nobody came. During a review of Resident 4's clinical record, the MDS, dated 8/2/21, indicated Resident 4's BIMS score was "13," which indicated her cognitive skills for daily decision making were intact. During an interview, on 9/23/21, at 1:12 PM, with the Administrator, the Administrator stated that there was no Certified Nursing Assistant (CNA) assigned in the "red zone" nursing unit with LVN 1 to assist her with the four residents (Resident 1, Resident 2, Resident 3, and Resident 4). The Administrator stated that after LVN 1 had left the "red zone", there was no staff left in there to care for the four residents. The Administrator stated the outcome of this was that Resident 1 fell. The Administrator stated that he did not care that LVN 1 had another job to go to, and that LVN 1 was not supposed to leave, that's not how we run things here. The Administrator stated when Resident 1 fell, it was a negative outcome. During an interview, on 9/23/21, at 3:22 PM, with LVN 2, LVN 2 stated that on 8/29/21 she started her shift at 7 AM. LVN 2 stated she was instructed to take over the care of the four residents in the "red zone" on 8/29/21, at 8:30 AM. LVN 2 stated that when she arrived in the "red zone," she witnessed ambulance personnel with Resident 1 on the gurney (a wheeled stretcher used for transporting hospital patients). LVN 2 stated, Resident 1 would not have fallen if she and CNA 1 were there. During an interview with CNA 1, on 9/23/21, at 3:29 PM, CNA 1 stated that on the morning of 8/29/21, the charge nurse told her to go to the "red zone" at 8:30 AM. CNA 1 stated when she got in the room, Resident 1 was in a gurney, and the paramedics were there already. During a review of the Ambulance Service Record (ASR), from EMS, dated 8/29/21, the ASR indicated, "Per roommates on scene, pt [patient, Resident 1] had a fall approx 30 mins ago, roommates state no staff has been in to check on her or help." The ASR indicated, "pt found lying on the floor in water in room, there is electrical around pt with water covering the floor. pt is cold to touch and seeming lethargic [slow to respond]. pts vitals taken and bp [blood pressure] noted to be low. all others wnl [within normal limits]. pt transported to the hospital..." The ASR indicated that "call received" at "8:04 AM," and was "Requested by [a] bystander." The ASR indicated EMS was "at patient [at] 8:08 AM," and "Depart[ed] Scene [at] 8:29 AM." During a review of Resident 1's clinical record, the "Progress Notes," dated 8/29/21, at 9:15 AM, indicated, ". . . received call to report to red zone, upon arrival to red zone CNA [Certified Nursing Assistant] and ems were present resident was strapped to gurney. . . ems stated they were called because a patient had fallen and needed assistance. . ." The Progress Note was written by LVN 2. During a review of facility's policy and procedure (P&P) titled, "Staffing," dated 10/1/17, the P&P indicated, "The facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with the resident care plans and facility assessment. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services." In violation of the above cited standards, the facility failed to ensure nursing staff were available to provide care to the four residents in the "red zone" for a period of approximately 60 minutes. As a result, no staff responded when Resident 1 fell to the floor, where she lay unassisted until finally attended to by paramedics, who were summoned by Resident 2 due to no facility staff answering calls for help. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.