Other·November 1, 2022

The following reflects the findings of the California Department of Public Health during the investigation of two complaints. Complaint numbers: 799338 and 800177 Representing the Department: 40484, Health Facilities Evaluator Nurse. The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. State Citation A 230018079 was written for complaint numbers 799338 and 800177 at 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 8/22/2022 at 2:00 pm, an unannounced visit was conducted at the facility to investigate a complaint of a heat-related resident death. Based on observation, interview, and record review, the facility failed to ensure that residents were safe from heat-related accidents when: 1) The facility did not have policies regarding resident care during hot weather, or resident patio use, and 2) One of six sampled residents (Resident 2) was allowed outside, during the time of day in which outdoor temperatures are the highest, and left unattended on an outdoor patio for an unknown length of time in hot weather. This resulted in Resident 2 being found unresponsive on the patio, and his subsequent death. These failures presented a substantial probability to cause significant health issues such as heat stroke and dehydration contributing to the death of Resident 2 and presented an imminent danger of death or serious harm to all residents by providing access during high temperatures with no care plan in place to ensure safe use. A review of the clinical record indicated that Resident 2 was a 79 year-old male, admitted on 10/9/18, with diagnoses that included lung disease, heart disease requiring a pacemaker (a medical device that generates electrical impulses to the chambers of the heart), and kidney failure. Resident 2 was unable to make his own healthcare decisions and was conserved by the Public Guardian (a court appointed decision maker). The Physician Orders for Life-sustaining Treatment, signed 5/20/22, indicated not to attempt cardiopulmonary resuscitation (a medical procedure involving repeated compression of a resident's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest). A review of the Minimum Data Set (MDS, a resident assessment tool) dated 8/21/22 indicated that Resident 2 required extensive assistance (staff provide weight-bearing support) from one person for dressing and personal hygiene, limited assistance (staff provide guided maneuvering of limbs or other non-weight-bearing assistance) from one person for moving about in his wheelchair, and supervision by one person for eating. The MDS indicated that walking with or without assistance did not occur during that reporting period. A review of the National Oceanic and Atmospheric Administration (NOAA) temperature readings for the facility location on 8/21/22 at 4:29 pm indicated that the temperature was 102øF (degrees Fahrenheit). During an observation and interview on 8/30/22 at 2:12 pm on the small patio, the Maintenance Director (Maint) confirmed that there was no thermometer in the small patio. The temperature was observed to be uncomfortably hot, and there was no fan or other cooling device present. A review of a nursing progress note dated 8/21/22 at 6:39 pm, indicated that nursing staff [Staff F] had observed Resident 2 on 8/21/22 at 4:50 pm on the small patio unresponsive in his wheelchair. Nursing staff assisted him to bed for assessment. RN [Staff H] assessed Resident 2 and it was determined the Resident 2 had no pulse or respirations (breathing). During an interview on 8/22/22 at 4:10 pm, Staff A stated that Resident 2 was last seen between 3 pm and 4 pm on 8/21/22 sitting in the hallway in front of Nursing Station 1 near the small patio. During an interview on 8/24/22 at 11:10 am, Staff C stated that the last time Resident 2 was seen was between 3 pm and 4 pm on 8/21/22 sitting in the hallway in front of Nursing Station 1 near the small patio. During an interview on 8/24/22 at 11:25 am, Staff E stated that Resident 2 was found unresponsive on the small patio at about 4:50 pm on 8/21/22. During an interview on 8/24/22 at 1:50 pm, the Medical Director (MD) stated that Resident 2 had been declining over the last six months and he was considering hospice services for him. MD stated he did not think Resident 2 could open a door while manipulating his wheelchair, and that someone opened the patio door for him on 8/21/22. A review of an IDT (Interdisciplinary Team, a group of facility staff with different clinical expertise working toward a common goal) note dated 8/25/22 at 10:35 am indicated that on 8/21/22 between 4:50 pm and 5 pm, Resident 2 had been assessed to have a temperature of 101.6øF, but that temperature had not been documented at the time. During an interview on 8/25/22 at 11:47 am, Staff F stated that she found Resident 2 on 8/21/22 on the small patio slumped over, unresponsive, and pulseless. Staff F took Resident 2 to his room to better assess him and was unable to obtain any life signs. Staff F stated residents who are not independent are not allowed outside alone. Staff F stated that usually staff turn Resident 2 around when they find him trying to get outside. During an interview on 8/29/22 at 1:25 pm, Staff F confirmed that she took Resident 2's temperature when he was found on 8/21/22 but did not record it. She stated his temperature was 101.6øF. During an interview on 8/25/22 at 2:51 pm, Assistant Director of Nursing (ADON) stated that there were no facility policies regarding resident care during hot weather or resident patio use. During an interview on 8/29/22 at 2:20 pm, Staff G stated that the last time Resident 2 was seen on 8/21/22 was between 3 pm and 4 pm, sitting in the hallway across from nursing station 1 near the small patio. During an interview on 8/29/22 at 2:25 pm, Staff H stated that on 8/21/22 a nurse [Staff E] came to nursing station 2, where he was assigned, and asked for help with Resident 2. They went to nursing station 1 where Resident 2 was. Staff H stated Resident 2 was cyanotic (a bluish discoloration due to lack of oxygen) and slumped in a wheelchair. Four staff [Staff A, E, F and H] put Resident 2 in bed. Staff H stated that Resident 2 had no heart rate or respirations, and the oximeter (an instrument used to measure oxygen in the blood) did not register any reading. During an interview on 8/30/22 at 11:30 am, the Conservator for Resident 2 (Cons) stated that Resident 2 had been slowly declining over the last year, since having COVID-19 in November 2020. Cons stated Resident 2 had experienced difficulty swallowing and weight loss, with decreased food intake starting in August 2020. Cons stated Resident 2 had also lost mobility and needed more assistance from facility staff. Cons stated that she was aware of his decline. A review of the Recreation Quarterly Progress Note dated 7/7/22 at 4:13 pm indicated that Resident 2 regularly enjoyed sitting out on the outdoor patio. During an interview on 8/30/22 at 2:50 pm, the Activities Director (AD) stated that Resident 2 liked the small patio by nursing station 1 and would try to exit to it, but staff would redirect him. AD stated Resident 2 would use the patio independently and with groups. AD confirmed Resident 2 had no care plan addressing his use of the patio with supervision. AD stated Resident 2 used to use the patio daily, but lately had used it less and less. During an interview on 8/30/22 at 3:45 pm, Staff F stated that Resident 2 would not go outside alone. The last time she saw him he was sitting across from nursing station 1 near the small patio between 3 pm and 3:30 pm. During an interview on 9/7/22 at 10:40 am, Staff L stated that Resident 2 had required increased assistance the last four months and was unable to coordinate opening a door while propelling his wheelchair independently. A review of the NOAA temperature readings for the facility location on 9/7/22 at 1:29 pm indicated that the temperature was 105øF, and at 2:29 pm the temperature was 108øF. During an observation and interview on 9/7/22 at 2 pm on the small patio, Maint measured the temperature on the patio and confirmed that the reading was 158øF. Maint stated that the fan running in the corner had been installed on 9/2/22. During an interview on 9/7/22 at 2:15 pm, the Social Services Director (SS) stated that Resident 2 could no longer walk independently, but he could get out a door in his wheelchair. During an interview on 9/12/22 at 3:23 pm, the Administrator (Admin) confirmed that the facility did not have policies for resident care during hot weather, or for resident use of the patios. Admin stated they followed the current All Facilities Letter (AFL) regarding hot weather from the California Department of Public Health. A review of AFL 21-16 dated 5/28/21 indicated that facilities must have plans in place to ensure residents are free of adverse conditions that may cause heat-related health complications. The AFL recommends facilities implement measures to keep residents indoors and out of the sun during the hottest parts of the day. A review of the Centers for Disease Control and Prevention (CDC) website on 9/28/22 indicated that people aged 65 or older are more prone to heat-related health concerns. During the warmer months, the CDC warns that people with Alzheimer's or related dementias may not always be aware of their surroundings and may be at risk of wandering. Older adults may have difficulty adjusting to sudden changes in temperature, and chronic medical conditions or prescription medicines may affect the body's natural responses to heat and hinder its ability to control temperature or sweat. The CDC recommends a care plan to ensure elderly people have ways to stay cool during extreme heat conditions. (https://www.cdc.gov/aging/emergencypreparedness/older-adults-extreme-heat/index.html.) A review of a physician order dated 7/30/22 at 1:51 pm, indicated that Resident 2 was to receive Lasix (a medication used to reduce extra fluid in the body caused by conditions such as heart failure, liver disease, and kidney disease) 20 milligrams (mg, a unit of measure) daily unless his systolic (a part of the cardiac cycle during which the heart contracts) blood pressure was less than 110 millimeters of mercury (mm Hg, a unit of measure). A review of the manufacturer's package insert for Lasix, dated 8/2011, "excessive diuresis (increased production of urine) may cause dehydration and blood volume reduction with circulatory collapse (severe low blood pressure) and possibly vascular thrombosis (occurs when blood clots block your blood vessels) and embolism (obstruction of an artery, typically by a clot of blood), particularly in elderly residents." In violation of the above cited standards, the facility failed to ensure that residents were safe from heat-related accidents when the facility did not have policies regarding resident care during hot weather, or resident patio use during hot weather, and Resident 2 was allowed outside, during the time of day in which outdoor temperatures are the highest, and left unattended on an outdoor patio for an unknown length of time in hot weather. This resulted in Patient 2 being found unresponsive on the patio, and his subsequent death. These violations, jointly, separately, or in any combination presented a substantial probability that death or serious physical harm would result.