Health inspection·June 21, 2023

California Code of Regulations, Title 22 § 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. Federal Code of Regulations §483.25(m) Trauma-informed care The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. On 4/6/23, an announced visit was conducted at the facility to conduct a recertification survey. Resident 22 was a 74-year-old male who was admitted to the facility on 10/21/19. Resident 22 was a United States veteran. Resident 22's diagnoses included chronic pain syndrome, sleep disorder, dementia, aftercare following joint replacement surgery, deep vein thrombosis (blood clot), post-traumatic stress disorder (PTSD- mental disorder that may occur in people who have experienced or witnessed a traumatic event), chronic obstructive pulmonary disease (COPD, constriction of the airways and difficulty breathing), anxiety (mental health disorder) disorder, recurrent depressive disorder (mental health disorder). Resident 417 was a 51-year-old male who was admitted to the facility on 4/4/23. Resident 417's diagnoses included abscess (tender mass usually caused by bacterial infection) of the buttock, human immunodeficiency virus (damages the immune system and interferes with the body's ability to fight infection), diabetes (condition that causes blood sugar to be too high), unspecified psychosis (mental condition that affects a person's thoughts and emotions) , peripheral vascular disease (narrowed blood vessels causing reduced blood flow to the limbs), acute myocardial infarction (blockage of blood flow to the heart muscle or heart attack), seizures (sudden uncontrollable burst of electrical activity in the brain causing changes in behavior and movements), schizoaffective disorder, bipolar type (mental condition that affects a person's thoughts and emotions), major depressive disorder (mental condition that affects a person's thoughts and emotions), suicidal ideations (thoughts of killing one's self) and amputation (surgical removal) of the left leg above the knee. Resident 115 was a 68-year-old male who was admitted to the facility on 3/13/23. Resident 115 was a United States veteran. Resident 115's medical diagnoses included syncope (fainting) and collapse (falling), urinary tract infection, cellulitis (skin infection) of right and left lower legs, Type 2 diabetes mellitus (body does not produce enough insulin or the insulin is ineffective in controlling the amount of sugar in the blood), sepsis (body's life-threatening response to infection), congestive heart failure (heart pumps blood ineffectively), atrial fibrillation (rapid, irregular heart beat which can cause blood clots), acute respiratory failure with hypoxia (lungs work ineffectively leading to low oxygen levels), major depressive disorder, polyneuropathy (malfunctioning of the nerves outside of the brain and spinal cord), acute kidney failure, difficulty in walking, pain, and history of falling. Resident 10 was a 60-year-old female who was admitted to the facility on 2/28/23. Resident 10's diagnoses included pulmonary embolism (blood clot in the lung's blood vessels), dependence on renal dialysis (artificial cleansing of the blood), end stage renal disease (condition when kidneys stop functioning requiring dialysis or a kidney transplant to sustain life), Type 2 diabetes mellitus, legal blindness, morbid obesity (excessively overweight), chronic pain syndrome, anemia (low number of red blood cells), polyneuropathy, chronic gout (crystals accumulate in the joints causing pain), and generalized muscle weakness. Resident 38 was a 66-year-old female who was re-admitted to the facility on 3/27/23. Resident 38 diagnoses included acute kidney failure, tubulo-interstitial nephritis (kidney infection), asthma, lupus erythematosus (an autoimmune disease) , low potassium (a necessary mineral), anemia, heart failure, high blood pressure, major depressive disorder, recurrent, cutaneous (skin) abscess, pressure induced deep tissue damage (area of discolored skin or blood-filled blister due to damage of underlying tissues), history of falling, history of right leg fracture, hyperlipidemia (high amount of fat/cholesterol in the blood), abnormal posture, muscle weakness, abnormalities of gait (walking) and motion, chronic pain syndrome, hydrocephalus (abnormal build-up of cerebrospinal fluid in the brain), rhabdomyolysis (breakdown of muscle tissues), Resident 39 was a 74-year-old male who was re-admitted to the facility on 3/7/23. Resident 39 was a United States veteran. Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P), titled "Trauma [event that causes long-lasting mental or emotional damage] Informed Care: Screening [assess for risk factors], Training, and Care Integration Program," when: 1. Medical Records (MR) staff and Dietary Aide (DA) 3 did not respond to one of one resident's (Resident 22) request to identify themselves. This failure resulted in Resident 22 weeping and expressing fear when staff triggered his trauma response. 2. Social services did not screen newly admitted residents for a history of trauma for five of six sampled residents (Resident 417, Resident 115, Resident 10, Resident 38, and Resident 39). This failure resulted in the facility not being aware of Resident 417's, Resident 115's, Resident 10's, Resident 38's, and Resident 39's history of trauma, residents' trauma triggers and resident specific trauma informed care. 1. During a concurrent observation and interview on 4/3/23, at 6:46 AM, with Resident 22, in Resident 22's room, Medical Records Staff (MR) and Dietary Aide (DA) 3 were cleaning out the refrigerator behind a privacy curtain. Resident 22 was heard calling out, "Stop it, who's there, what's happening." MR and DA 3 left the room without responding to Resident 22. Resident 22 stated, "I think I'm having a bad dream, I have PTSD [Post Traumatic Stress Disorder-] sorry I shouted." Resident 22 was crying. Resident 22 wiped his eyes with a napkin. Resident 22 stated, he thought he was "hearing the radio." Resident 22 stated, when he hears "the radio" he hears the voices of killed soldiers calling out for their mothers in the form of radio transmissions. During an observation on 4/3/23, at 8:44 AM, in Resident 22's room, Resident 22's privacy curtain was pulled around his bed. Maintenance Supervisor (MS) checked the temperature of Resident 22's room. Resident 22 stated, "hello?" when he heard the footsteps of MS. MS did not respond to Resident 22. During an interview on 4/6/23, at 8:46 AM, with the Director of Nursing (DON), DON stated, staff should knock and introduce themselves before entering; staff should try to approach residents in a calm way and honor resident preferences. During an interview on 4/6/23, at 11:54 AM, with MR, MR stated, Resident 22 was part of her assigned room rounds. MR stated, she was cleaning out the refrigerator in the room when she heard Resident 22 say "get out, stop it." MR stated, "I don't know why we didn't respond to him, I thought he was maybe talking in his sleep. I should have done better; I know he has a history of trauma." During a review of Resident 22's "Order Summary Report," dated 4/4/23, the Order Summary Report indicated, Resident 22 had a diagnosis of "Post-Traumatic Stress Disorder, Chronic [long term]." During a review of Resident 22's Care Plan (undated), Care Plan indicated, staff will "Approach resident in a calm unhurried manner and provide 1:1 interaction. . . while providing care." 2a. During an interview on 4/5/23, at 4:11 PM, with the Social Services Assistant (SSA), SSA stated, "We do not complete any trauma screening tool on admission, I have never even seen that assessment." SSA was unable to find a facility trauma screening tool. During an interview on 4/6/23, at 8:46 AM, with DON, DON stated, the trauma screening tool should be done, but it was not. During an interview on 4/6/23, 3:40 PM, with Resident 417, Resident 417 stated, facility did not screen him for PTSD or trauma upon admission. Resident 417 stated, he does experience PTSD related to living on the street and being homeless. Resident 417 stated, he had witnessed suicides and his trauma was triggered by loud noise, a lot of traffic, and too many people in his personal area. During a review of Resident 417's Care Plans, (undated) no trauma or PTSD care plans were developed or implemented for Resident 417. 2b. During an interview on 4/3/23, at 11:29 AM, Resident 115 stated, he was a Vietnam veteran and was diagnosed with "delayed PTSD" and sometimes hearing the nurses speaking in another language triggers feelings of anxiousness. Resident 115 stated, he was not asked if he had PTSD or any trauma in his history when he was admitted to the facility on 3/13/23. During an interview on 4/6/23, at 8:52 AM, with Registered Nurse (RN) 1, RN 1 stated, there were no questions about PTSD or history of trauma on the resident initial assessment form. During an interview on 4/6/23, at 9:49 AM, with DON, DON stated, the facility currently had no method to assess for PTSD or trauma. During a concurrent interview and record review on 4/6/23, at 10:01 AM, with MR, Resident 115's medical record was reviewed. MR stated, she was unable to find a trauma assessment for Resident 115. 2c. During an interview on 4/6/23, at 3:41 PM, with Resident 10, Resident 10 stated, she was not asked at the time of her admission if she had a diagnosis of PTSD or any life trauma. Resident 10 stated, she suffered trauma as a child from her parents constantly yelling at each other. Resident 10 stated, the yelling forced her into a "shell." Resident 10 stated, she lost her vision about six years ago and now her hearing was heightened. Resident 10 stated, when residents yell in the hallway, she feels the same frightened feelings she did as a child. 2d. During an interview on 4/6/23, at 3:34 PM, with Resident 38, Resident 38 stated, she did not remember if the facility provided a form or questions about any post-traumatic stress disorder. Resident 38 stated, in her past she was abused. 2e. During an interview on 4/6/23, at 3:46 PM, with Resident 39, Resident 39 stated, he had traumatic events in his past. Resident 39 stated, he was active duty in a war and his jeep exploded. Resident 39 stated, he did not recall facility staff asking him about traumatic events on admission. During a review of the facility's P&P, titled "Trauma Informed Care: Screening, Training, and Care Integration Program," dated 6/28/19, the P&P indicated, "The facility will ensure residents who are trauma survivors receive culturally competent, trauma informed care; account for resident experience and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. . . A Trauma Screen Tool (SS-03 Form B) will be completed by Social Services upon admission." This violation(s) caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient and constitutes a class "B" citation. 12-40516-18811 Page 2