Health inspection·September 10, 2021

The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for one facility reported incident. Facility reported incident: 726950 Representing the Department: 32643, Health Facilities Evaluator Supervisor, (HFES) 32797, HFES 41715, Health Facilities Evaluator Nurse CLASS AA CITATION was written HSC 1424(c) – Class “AA” violations are violations that meet the criteria for a class “A” violation and that the state department determines to have been a direct proximate cause of death of a patient or resident of a long-term health care facility. Except as provided in Section 1424.5, a class “AA” citation is subject to a civil penalty in the amount of not less than five thousand dollars ($5,000) and not exceeding twenty-five thousand dollars ($25,000) for each citation. In any action to enforce a citation issued under this subdivision, the state department shall prove all of the following: (1) The violation was a direct proximate cause of death of a patient or resident. (2) The death resulted from an occurrence of a nature that the regulation was designed to prevent. (3) The patient or resident suffering the death was among the class of persons for whose protection the regulation was adopted. If the state department meets this burden of proof, the licensee shall have the burden of proving that the licensee did what might reasonably be expected of a long-term health care facility licensee, acting under similar circumstances, to comply with the regulation. If the licensee sustains this burden, then the citation shall be dismissed. 42 CFR § 482.25(d)(1) & (2) – Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: F689 483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 2/26/2021, at 9:15 am, an unannounced visit was conducted at the facility to investigate a complaint of a resident injury. The facility failed to provide safe smoking practices and supervision as required per facility policy and federal regulations, and failed to identify an accident hazard. The facility further failed to properly assess the resident (Resident 1) to determine if Resident 1 could safely smoke unsupervised. This resulted in Resident 1 smoking without supervision or adequate monitoring, dropping smoking materials on his clothing and setting fire to himself. Resident 1 required an emergency transfer to a general acute care hospital (GACH). Resident 1 sustained a major burn with wounds over 50 to 60% of his body area and died the following day. On 2/25/2021 at 3:38 pm, California Department of Public Health received a facility reported incident. On 2/25/2021 at 8:00 am, Resident 1 went out to smoke unsupervised, dropped a pipe into his lap and caught on fire. Resident 1 was transferred to a GACH for evaluation. Resident 1's record indicated he was admitted to the facility on 5/30/2020 with diagnoses that included dementia, generalized muscle weakness, restless leg syndrome, unspecified osteoarthritis, nicotine dependence, and long term and current use of opiate analgesic (strong pain medication). Resident 1 previously worked as a horseshoer for many years. Resident 1 was not capable of making his own healthcare decisions and had a RR (Resident Representative - healthcare decision maker). A review of Resident 1's most recent quarterly MDS (Minimum Data Set-a resident assessment) dated 2/10/2021 indicated Resident 1 was alert with intermittent confusion, was hard of hearing, had poor safety awareness and had a BIMS (Brief Interview of Mental Status) score of 3 (severe cognitive impairment). His admitting MDS score was11 (moderately impaired) on 6/2/2020. Resident 1 needed extensive assistance with dressing and toilet use, as well as limited assistance with transfer and personal hygiene. A review of the physician's order dated 5/30/2020 indicated Resident 1 was taking Namenda daily to treat dementia. During an interview on 3/2/2021 at 10:35 am, SSA confirmed Resident 1 was confused at times because of dementia. A review of Resident 1's "Safe Smoking Risk Assessment," completed on 1/18/2021 at 3:28 pm by Assistant Director of Nursing (ADON), indicated that Resident 1 had a memory problem and his BIMS score indicated "severe impairment." The assessment indicated Resident 1 declined to agree to use safety equipment provided by staff, including a smoking vest and declined supervision or that his equipment be secured by staff. A review of a facility document titled, "[Facility Report]", dated 2/25/21, indicated, "On 5/30/2020, Resident's [Resident 1] primary care physician [MD], assessed Resident [Resident 1] as incapable of understanding or making decisions." During an interview on 4/1/2021 at 2:40 pm, Occupational Therapist (OT) stated that Resident 1's past occupation was labor intensive as he was a horseshoer. Resident 1 was not meeting his therapy goals and thereby stayed long term. OT stated that Resident 1 could not live alone and needed assistance. OT confirmed that Resident 1 had poor safety awareness due to severe cognitive impairment. A review of the nursing progress notes dated 2/25/2021 at 8:43 am, indicated that at approximately 8:10 am a Certified Nursing Assistant (CNA) alerted nursing staff that Resident 1 was on fire in the smoking area. The staff ran to the smoking area where Resident 1 was sitting in his wheelchair covered in flames yelling. Staff grabbed the fire extinguisher and extinguished Resident 1. Resident 1 complained of groin area still feeling on fire. Resident 1’s breathing was labored and there was black ash around Resident 1's mouth, singed hair on his head, and burns to his chest and legs. A review of Nursing Progress notes, dated 2/25/2021 at 8:43 am, indicated Resident 1 was transported via emergency services to the hospital. A review of Resident 1's hospital records on 2/25/2021 at 9:15 am indicated Resident 1 had major burns or partial full thickness burns over 50-60% of his body, including the face, neck, chest wall, and all four extremities. Resident 1 was given comfort care, which included medications for anxiety, fentanyl, dilaudid and morphine (strong narcotic pain medications) for pain. On 2/26/2021 at 4 am, Resident 1 expired (a day later). During an interview on 3/30/2021 at 3:25 pm, the Medical Director (MD) stated Resident 1 had multi-joint arthritis in his hands and legs. During an interview on 3/2/2021 at 10:55 am, Physical Therapy Assistant (PTA) stated, "two handled cups are normally used because of shakiness or unsteadiness of hands." A review of Resident 1's progress notes indicated that on 2/10/2021, the facility's dietary manager indicated that Resident 1 received a "two handled sippy cup" with meals. During an interview on 3/2/2021 at 11:05 am, Occupational Therapist (OT) stated Resident 1 had coordination issues. He had shoed horses his whole life so his hands were stiff. OT stated Resident 1 couldn't manipulate things and that would definitely have been a factor in his accident. A pipe was small. "I don't know how they deemed him OK to smoke. Someone probably noticed that he was having trouble managing his hands. They were big and they were stiff." During an interview on 4/2/2021 at 12:15 pm, CNA 2 stated Resident 1 had stiffness and soreness at his hands and knees. CNA 2 further explained Resident 1 moved very slowly. CNA 2 stated Resident 1 was able to transfer himself from chair to bed with standby assistance, and did not wait for staff for assistance at times due to poor safety awareness. CNA 2 explained Resident 1 had to use a lighter for his pipe when matches were not available and required assistance. CNA 2 stated he would assist Resident 1 when he had time, and they used to supervise all smoking Residents when there were more smokers in the facility and had more staff. CNA 2 explained there were video monitors at each of the nursing stations. Station 2, which had a charge nurse, monitored smokers more often than Station 1, even though Station 1 was closest to the smoking area. CNA 2 stated staff were not always aware of when residents went to go smoke because of the lack of adequate monitoring. A review of a facility document titled, "Smoking Acknowledgement and Agreement (Un-Supervised)," dated 1/14/2021, which was verbally consented by RR over the phone, was intended to ensure residents who smoke while at the facility will 1) have a smoking assessment using methods including evaluating cognitive abilities, judgement, manual dexterity and mobility, 2) use a smoking apron while they smoke in designated areas, understand they have the right to refuse use of smoking apron but release the facility of any liability associated with injury that may result from their choice, and 3) will not provide material or lighter/matches to any other resident for any reason at any time. A review of the Interdisciplinary Team (IDT-group of healthcare disciplines that discuss residents’ care needs) notes dated 1/14/2021 indicated that Resident 1 agreed to abide by smoking policies, declined to wear a smoking apron and the RR gave verbal consent for Resident 1 to waive the smoking apron. Resident 1 preferred to keep his smoking pipe on him with his belongings. On 2/10/2021 at 2:11 pm, Social Services Assistant (SSA) indicated Resident 1 was able to make their needs known to staff but with intermittent confusion. On 2/18/2021 at 7:27 am, Resident 1 was alert with confusion and able to tell staff about his discomfort. On 2/19/2021 at 11:35 pm, Resident 1 was alert with confusion. Monitoring was in place due to his poor safety awareness and he was required to use a double handled cup with a lid. During an interview on 2/26/2021 at 9:15 am, ADON stated, "If someone has dementia, it doesn't mean they are not capable of safely smoking. After they sign the waiver, of course we try to ensure their safety by watching monitors at the nursing station... When unsupervised, they can go out and smoke whenever they want. This is their home." ADON further confirmed that both of the two other residents who smoked also had waivers in place. "[Resident 1] did have dementia, but a lot of dementia Residents smoke." We have a fire blanket, fire extinguisher, alarm cord, and everything is on camera. Nursing staff watches it from the nursing station." During an interview on 2/26/2021 at 10:10 am, CNA 1 confirmed that no one was directly supervising Resident 1 when he lit his clothing on fire. "I was sitting at the nursing station 2 waiting for the breakfast cart to come. I saw on the monitor that Resident 1 had a bright orange flare up his chest area." During an interview on 2/26/2021 at 9:15 am, ADM provided Resident 1’s waiver to smoke unsupervised without a flame-retardant vest. ADM stated that two other Residents who were smokers had also been assessed and waived the need for supervision and protective vests. During an interview on 2/26/2021 at 11:50 am, CNA 2 stated, "He was evaluated by our Director of Nursing (DON) to be safe to smoke unsupervised. He couldn't perform the function with his lighter, so we provided him with matches." During an interview on 3/2/2021 at 12:30 pm, DON stated, "We're looking at the policy now to see if it needs to be changed and they need to be supervised, but we can't have ongoing supervision of them. It restricts their ability to smoke at will and infringes on their Resident rights. We are honoring peoples' right to smoke. Resident 1 had a BIMS of 3, but I don't feel he was severely impaired. I don't feel it was a reflection of his cognitive ability. He didn't like to be asked questions." During an interview on 3/4/2021 at 10:25 am, Resident 1's RR stated that there had been no interruption in Resident 1's smoking when he came to the facility, contrary to the January assessment. "He had been smoking the whole time he was at the facility. He had never not smoked. He was asking another Resident who smoked for tobacco in the beginning." "He was progressively getting worse in his hand dexterity," RR continued. "He had arthritis from running horses all his life. He had used a lighter to smoke in the past but because his dexterity was so bad he couldn't turn the wheel on the lighter anymore," and, "I realize that I consented to him smoking, but I don't remember them ever saying it was unsupervised. During an interview on 3/4/2021 at 10:58 am, ADM stated, "Resident 1 may have been thought not to smoke because he came from the rehabilitation side of the facility to Station 1. Under COVID isolation, we weren't allowing any residents to smoke, so it may not have been visible that he was an active smoker...In hindsight, what would I do differently now? Now that we know we can take away Residents' rights, we would require supervision of smoking." During an interview on 3/26/2021 at 11:15 am, ADM stated that changes were made to the smoking policy. The waiver was removed and residents who smoke were required to be directly supervised. ADM confirmed that residents' safety should always be considered along with Resident rights. During a concurrent interview and record review on 3/26/2021 at 11:45 am, both ADM and DON explained they did not consider the safety of the entire facility and other residents. ADM and DON were unaware that the other Resident who smoked was sharing smoking supplies with other Residents. They both stated Residents have the right to refuse supervision and wear safety equipment. Residents signed a waiver releasing liability outlining the risks of smoking unsupervised and without safety equipment. DON stated that looking back the smoking apron would have helped. ADM was asked if the facility had general rules to follow while at the facility. Both ADM and DON confirmed that residents have to follow rules living at the facility such as smoking. They also confirmed that smoking was a fire hazard. Both confirmed that they didn't consider transfer or discharge when smoking rules were not followed. A review of a facility policy titled, "Smoking Policy -- Residents," revised April 2012, indicated the facility shall establish and maintain safe resident smoking practices. Staff "shall consult with the Attending Physician and the Director of Nursing Services to determine any restrictions on a resident's smoking privileges, either supervised or unsupervised smoking. Smoking articles for residents with independent smoking privileges must keep cigarettes, pipes, tobacco or other articles at the nurse's station unless otherwise determined by the Interdisciplinary Team. Residents with independent smoking privileges may not give smoking articles to other residents with restricted smoking privileges. Resident will be educated and encouraged to use smoking apron. If resident declines use, a risk versus benefits form must be signed acknowledging the risks up to and including major injury or death.” The facility failed to provide safe smoking practices and supervision as required per facility policy and Resident assessments when Resident 1’s smoking assessment did not reflect his abilities to safely smoke unsupervised. The above violation either jointly, separately, or in combination had presented imminent danger that death or serious harm would result or substantial probability that death or serious harm w