Other·October 9, 2023

The following reflects the findings of the California Department of Public Health during the investigation of Complaint # CA00856314. Survey Event ID: CWPK11. Representing the Department, HFEN # 46658. State Citation B was written. CLASS B CITATION - PHYSICAL ENVIRONMENT F 584 CFR 483.10(i)(6) Safe Environment The resident [Patient, the terms 'patient' and 'resident' can be used interchangeably] has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide - (6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81ºF. On 8/17/23 at 2:14 pm, an unannounced visit was conducted at the facility to investigate a complaint regarding the facility's physical environment. The facility failed to maintain the facility cooling system to provide eight of 12 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8) an environment with a safe and comfortable temperature. The failure to prevent excessive heat (temperatures in excess of 81ºF, degrees Fahrenheit) in the facility resulted in: 1. physical discomfort for Patients 3, 4, 6, 7, 8; 2. Patient 5 was nauseous for three days; 3. Patient 2 had difficulty sleeping; and 4. Patient 1 was unable to receive restorative nursing care for two days. During a review of Patient 1's Admission Record (AR), dated 8/21/23, the AR indicated Patient 1 was a 72-year-old male admitted to the facility on 4/30/17. The AR indicated Patient 1 had diagnoses that included quadriplegia (paralysis of the torso and all four limbs), neuropathy (damage to the nerves outside the brain and spinal cord), and contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of both ankles. Review of Patient 1's Minimum Data Set (MDS, a patient assessment tool used to direct patient care), dated 6/8/23, indicated Patient 1 had a Brief Interview for Mental Status (BIMS, an assessment tool used to screen and identify the cognitive condition of patients) of nine (an indication of moderate cognitive impairment). During a concurrent interview and record review, on 8/21/23, at 12:40 p.m., with the DON, Patient 1's care plan titled, "Restorative Nursing Program: Splint/Brace Assistance," dated 3/2/23, and Record dated 8/12/23 to 8/20/23, was reviewed. The DON stated Patient 1's care plan indicated for two hours per day, five days per week, Patient 1 should have splints applied to both ankles/feet and both hands/fingers. The DON stated the Treatment Record indicated Patient 1 had refused the ankle/foot and hand/finger splints on 8/16/23 and 8/17/23; the Treatment Record did not indicate the reason for the splint refusal. During a concurrent observation and interview on 8/17/23, at 3:20 p.m., with the Ombudsman (OMB) and Maintenance Supervisor (MS), in Patient 1's room, Patient 1 sat in a wheelchair next to his bed under the air conditioning (A/C) vent. MS stated Patient 1's room had functional air conditioning, and no portable A/C unit was necessary to maintain adequate cooling. MS stated the air vent directly above Patient 1 was for cool air entry from the A/C unit in the attic and used an infrared surface thermometer (device that uses infrared light to measure surface temperature) to obtain a temperature of 69ºF at the surface of the vent outlet. During a concurrent observation and interview, on 8/17/23, at 3:25 p.m., in Patient 1's room, with Patient 1, and OBM and MS, Patient 1 was in a wheelchair in his room next to his bed with a bedside table in front of him. Patient 1's forehead and neck were glistening with sweat. Patient 1 stated he was a quadriplegic and was unable to reposition himself for comfort or for cooling. Patient 1 stated he was uncomfortable because there was no cool air in the room and the room was getting hot. Patient 1 stated he had contractures of his limbs and needed to wear splints on his hands and feet, but the past few days were so hot, and the portable A/C had been taken out of his room a few days ago, so he could not tolerate wearing the splints. A clinical digital thermometer (CDT) was placed on Patient 1's bedside table with the probe tip left in free air and allowed to equilibrate for six minutes: the CDT indicated the air temperature was 84.9ºF. During a review of Patient 2's Admission Record, dated 8/21/23, the AR indicated Patient 2 was a 72-year-old male admitted to the facility on 7/22/23. The AR indicated Patient 2 had diagnoses that included aftercare following knee replacement surgery. During a review of Patient 2's MDS, dated 7/28/23, the MDS indicated Patient 2 had a BIMS of 14 (an indication of intact cognitive status). The MDS indicated Patient 2 required a wheelchair and extensive assistance from one person for locomotion between rooms. The MDS indicated Patient 2 had received physical therapy five days out of the seven day look back period. During a concurrent observation and interview, on 8/17/23, at 4:12 p.m., with Patient 2, Patient 2 sat in a wheelchair in the rehabilitation therapy room. The wall thermostat (device which measures room temperature and adjusts the function of the A/C based on the temperature) indicated the rehabilitation therapy room temperature was 86ºF. A second temperature reading taken with a CDT with the probe tip left in free air and allowed to equilibrate for 5 minutes indicated an air temperature of 86ºF. The rehabilitation therapy room had two portable A/C units operating in the room. Patient 2 stated the temperature and comfort of the facility was "a joke." Patient 2 stated he had been here a month and his room was always hot and uncomfortable. Patient 2 stated his room got so hot this week he had difficulty sleeping at night. Patient 2 stated when he complained to staff about the heat, he had received one [expletive] popsicle and a warm drink to help him cool down. Patient 2 became visibly upset and started pointing and shaking his finger. Patient 2 stated he was here for rehabilitation after knee surgery, but the rehabilitation therapy room was too hot for therapy. Patient 2 stated he had complained about the rehabilitation room temperature, but nothing was done to correct it. Patient 2 stated he did his physical therapy in the front hallway with other patients because the therapy room was so hot. Patient 2 stated the facility knew they needed to fix the A/C, but they refused and allowed patients to suffer. During an interview, on 8/17/23, at 4:05 p.m., with rehabilitation staff (RS), RS indicated the rehabilitation therapy room was too hot for patients to safely complete rehabilitation despite the portable A/C units and fans in the room. RS stated the rehabilitation equipment had been moved into the hallway for patients to complete their therapy. RS stated the rehabilitation room A/C was not functional. During a review of Patient 3's Admission Record, dated 8/21/23, the AR indicated Patient 3 was a 73-year-old female admitted to the facility on 12/22/22 with a diagnosis of chronic (long-term) difficulty in breathing. During a review of Patient 3's MDS, dated 5/24/23, the MDS indicated Patient 3 required extensive assistance from one person to reposition herself in bed. The MDS indicated Patient 3 required a wheelchair and was totally dependent on one person for locomotion. The MDS indicated Patient 3 had a BIMS score of 13 (an indication of intact cognitive status). During a concurrent interview and observation, on 8/17/23, at 3:53 p.m., with Patient 3, in her room, Patient 3 lay in bed with no covers on. Patient 3's bed was next to an open window; outside air was blowing through the window into the room. There was no portable A/C unit in the room. Patient 3 stated the room was hot right now but had been hotter the past few days. Patient 3 stated for the past few days she was "melting "from the heat because her room did not have A/C. Patient 3 stated staff gave her popsicles, but the relief was temporary and not enough to keep her comfortable and cool. The CDT was placed at the foot of Patient 3's bed in free air and allowed to equilibrate for 3 minutes and indicated a temperature of 88.2ºF. A second temperature was taken with the CDT placed near the room entrance and indicated a temperature of 88ºF. Review of Patient 4's Admission Record, dated 8/21/23, the AR indicated Patient 4 was a 78-year-old female admitted to the facility on 8/15/23 with diagnoses that included depression, high blood pressure, and difficulty breathing. The AR also indicated that Patient 4 was her own responsible party. During a concurrent observation and interview, on 8/17/23, at 3:03 p.m., with MS, in Patient 4's room, Patient 4 lay in bed with no covers on. MS stated Patient 4's room was not supplied with cool air from the working A/C units but would be supplied with a portable A/C unit if the room temperature was over 79ºF. During a concurrent interview and observation, on 8/17/23, at 3:46 p.m., with Patient 4, in Patient 4's room, Patient 4 wore a hospital gown and lay in bed on top of the bed covers. Patient 4 stated it was uncomfortably hot in the room, and she was waiting for staff to bring her a popsicle. Patient 4 stated her room has been unbearably hot for the past few days. Patient 4 stated she would never keep her own home at this temperature. The CDT was placed on Patient 4's bedside table exposed to free air and allowed to equilibrate for 3 minutes. The CDT indicated the room was 86.2ºF. The room did not have a portable A/C unit. During a review of Patient 5's Admission Record, dated 8/21/23, the AR indicated Patient 5 was a 62-year-old female originally admitted in 2015 with diagnoses that included quadriplegia, hypothyroidism (a malfunctioning thyroid gland which can cause disruptions of heart rate, and body temperature) and familial dysautonomia (a genetic disease which can cause disruptions in the nervous system and affect body temperature control, blood pressure, and digestion). The admission record further indicated she was her own responsible party. During a concurrent interview and observation, on 8/18/23, at 12:20 p.m., with Patient 5, Patient 5 sat in a wheelchair in her room next to a window with an air conditioning unit and fan pointed directly toward her. Patient 5 stated she had been in the facility for years and there had never been a summer when the temperatures were comfortable. Patient 5 stated the past week the hallway became so hot and uncomfortable she got nauseous when she went out to the hallway and had to take additional medication to keep from vomiting. Patient 5 stated she took [brand name ondansetron] (a medication for nausea) and [brand name dimenhydrinate] (a medication for nausea). Patient 5 stated she normally doesn't take [brand name dimenhydrinate] but she had to take it a few times this week because the heat was making her nauseous. Patient 5 stated she had brought up the temperature issues during Resident Council numerous times, but the facility response was a "band-aid " fix for the air conditioning units that broke again within a month. During an observation on 8/17/23, at 5:15 p.m., a wall thermometer in Patient 5's room indicated a room temperature of 84ºF. During a review of Patient 5's August Medication Administration Record (MAR), the MAR indicated Patient 5 received dimenhydrinate for nausea on 8/17/23 at 10:37 a.m., 8/16/23 at 12:51 p.m., and on 8/13/23 at 10:12 a.m., and ondansetron for nausea twice a day on 8/12/23, 8/13/23, 8/14/23, 8/15/23 and on 8/17/23. The MAR indicated Patient 5 received ondansetron once on 8/16/23. During a record review of "Resident Council Minutes," dated 5/5/23, the Minutes indicated "resident's rooms need to be checked for temperature regulation and rooms need fans as it gets hotter. " During a record review of "Resident Council Minutes," dated 6/2/23, the Minutes indicated a current discussion about temperature control in resident rooms and maintenance issues for resident room thermostats and in the Franchesca Room. The Minutes indicated the resident rooms' temperature control and thermostat maintenance issues were also entered under Old Business. During a review of Patient 6's Admission Record, dated 8/21/23, the AR indicated Patient 6 was an 84-year-old female originally admitted to the facility in 2015 with diagnoses that included heart failure (a chronic condition in which the heart does not pump blood as well as it should), chronic obstructive pulmonary disease (a long-term condition of breathing difficulty), and diabetes (uncontrolled blood sugar). The record further indicated Patient 6 was self-responsible and able to make health care decisions. During a review of Patient 6's MDS, dated 6/30/23, the MDS indicated Patient 6 had a BIMS score of 15 (an indication of intact cognitive status). During a concurrent interview and observation, on 8/18/23, at 1:00 p.m., with Patient 6, Patient 6 sat in a wheelchair in her room. Patient 6 stated she had lived here for five years, and her room A/C and heat have never worked right so every summer residents had to suffer through the heat. Patients 6 stated she had breathing problems and diabetes and being hot made those conditions worse. Patient 6 stated on 8/17/23 in the afternoon, she was in the activities room listening to music and felt so hot she thought she was having a heart attack and had to return to her room to recover. During an observation, on 8/17/23, at 4:50 p.m., a wall thermometer in the activities room indicated a temperature of 85ºF. During a review of Patient 7's Admission Record, dated 8/21/23, the AR indicated Patient 7 was an a 70-year-old female admitted to the facility on 5/10/19 with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), and hypothyroidism. The admission record indicated Patient 7 was responsible for herself and had capacity to make health care decisions. A review of Patient 7's MDS, dated 3/17/23, indicated she required assistance from two people for bed mobility and one person's assistance for transfer to a wheelchair. The MDS indicated Patient 7 had a BIMS score of 12 (moderate cognitive impairment). The MDS indicated Patient 7's choice of clothing was "very important. " A record review of Patient 7's annual physical exam, dated 8/19/22, indicated Patient 7 had capacity to make health care decisions. During a concurrent interview and observation on 8/17/23, at 2:36 p.m., with Patient 7, Patient 7 lay in bed in her room, on top of the bed covers, next to the window. Patient 7 wore a hospital gown. There was a fan in the room circulating room air toward Patient 7. Patient 7 stated her room was always hot, so she was limited to wearing a hospital gown. Patient 7 stated she had complained to staff about the heat in her room, so a portable A/C unit had been brought to her room but had then been removed. Patient 7 stated her room felt like it was 80ºF, and she was only comfortable at 70ºF due to her difficulty in repositioning herself. During an observation on 8/17/23, at 3:33 p.m., the CDT was placed on Patient 7's bedside table and allowed to equilibrate for 5 minutes. The CDT indicated a temperature of 82.2ºF. During a review of Patient 8's Admission Record, dated 8/21/23, the AR indicated Patient 8 was a 75-year-old female admitted to the facility in 2022 with diagnoses that included difficulty breathing, diabetes, and generalized muscle weakness. The AR further indicated Patient 8 was responsible for herself and had capacity to make health care decisions. During a review of Patient 8's MDS, dated 6/6/23, the MDS indicated a BIMS score of 15. During a concurrent observation and interview on 8/18/23, at 12:35 p.m., with Patient 8, Patient 8 sat in a wheelchair in the hallway. Patient 8 stated the A/C in her room was working today but had not worked yesterday or in the past week. Patient 8 stated for the past week, her room got so hot she could not stay in her own room but went to her friend's room to stay cool. D