Health inspection·August 15, 2023

REGULATION VIOLATION: 483.25(d) Accidents. The facility must ensure that - 483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. Title 22 section 72311 Nursing Service - General. (a) Nursing service shall include, but not limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. Title 22 section 72311 Nursing Service - General. (a) Nursing service shall include, but not limited to, the following: C) An unusual occurrence, as provided in Section 72541, involving a patient. Title 22 section 72541 Unusual Occurrence. Occurrence such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety of health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the retained-on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshall. On July 13, 2023, at 12:20 PM, an unannounced visit was conducted at the facility to investigate a complaint regarding the death of a patient (Patient 1). Patient 1, who was wheelchair bound, had diagnoses that included Alzheimer's disease (memory loss) and a care plan for monitoring for physical/non-verbal indicators of discomfort or distress because of his communication problems related to his cognitive impairment. The facility failed to ensure one of three sampled patients (Patient 1) was being properly monitored and supervised. The facility failed to: 1) Monitor and supervise Patient 1 on July 11, 2023, when he was left unattended and found outside on the patio on a hot day, one and half hours after he was last seen. 2) Implement Patient 1's care plan requiring monitoring for physical/non-verbal indicators of discomfort or distress because of his communication problems related to his cognitive impairment. 3) Implement its policies and procedures to target interventions to reduce individual risks related to hazards in the environment, including adequate supervision. As a result of these failures, Patient 1 was found unresponsive and pronounced dead on July 11, 2023. Findings: A review of Patient 1's "Admission Record" (contains demographic data) indicated Patient 1 was admitted to the facility on December 18, 2021, with the diagnoses of Alzheimer's disease (memory loss), heart failure (a heart does not pump enough blood), and hemiplegia (caused by a brain injury resulting in varying degree of weakness on one side of the body). A review of Patient 1's "Care Plan,", dated on September 20, 2022 , indicated:, "Patient 1 had a communication problem related to poor condition...Patient 1 is dependent on staff for activities, cognitive [(relating to the mental process involved in knowing, learning, and understanding things)] stimulation, social interactions related to cognitive deficient...The patient is high risk for unavoidable falls with injury...Provide patient a safe environment...The patient has a communication problem r/t [(related to)] poor cognition...Monitor/document for physical/non-verbal indicators of discomfort or distress, and follow-up as needed...Monitor/document patient ability to express and comprehend language, memory, reasoning ability, problem solving ability and ability to attend...Use effective strategies...short direct phrases, speak slowly, speak in a calm, distinct manner, interpreter, time to communicate, 1:1 [(one to one)], quiet setting for communicating with patient..." A review of Patient 1's "MDS [(Minimum Data Set, a standardized assessment tool that measures health status in nursing home residents)] 3.0 Section C-Cognitive Patterns," dated June 22, 2023 indicated, "[Patient 1] has BIMS [(Brief Interview for Mental Status, an initial tool to identify a patient's cognitive function changes)] score of 4 as severely impaired [(significantly limits the patient's physical or mental abilities to do basic work activities)]." During an interview on July 17, 2023, at 2:15 PM with the Minimum Data Set Coordinator, he stated Patient 1 was confused, wanders, was wheelchair bound but able to scoot himself with his wheelchair around the facility and needed to be re-directed. He further stated Patient 1 needed minimal assist in transfers from wheelchair to bed, bed to wheelchair. A review of Patient 1's "Progress Notes,", documented by Licensed Vocational Nurse (LVN), on July 11, 2023, at 5:15 PM, indicated: "...at 4:15 PM during rounds, patient was not seen in his room or dining room. Upon checking patio, where patient goes at times, patient was seen sitting in patio. Upon approaching, patient was unresponsive and had no pulse. A code blue was called and simultaneously checked POLST [(Physician Orders for Life-Sustaining Treatment)], patient is a DNR [(Do Not Resuscitate, a medical order written by a doctor to instruct health care providers not to do (Cardio- Pulmonary Resuscitation, an emergency life-saving procedure that is done when someone's breathing, or heartbeat stops)] with comfort measures, CPR was not initiated. Patient 1 was found on patio and hydroplaned [(sliding over)] using sheets back to bed. Time of death called at 5:10 PM by the DON." During the tour and observation of the facility's Memory Care Unit patio with the Director of Nursing (DON) on July 13, 2023, at 1:50 PM, the DON stated there was no door alarm to alert the staff that someone was going out to the patio. She stated the facility recently installed a door alarm on the Memory Care Unit double exit doors on July 12, 2023. The DON stated Patient 1 was found unresponsive, not breathing, with skin pale, and warm to touch by Certified Nursing Assistant (CNA 2) in the Memory Care Unit patio on July 11, 2023, at 4:30 PM. During the interview, the DON checked and read the weather in Redlands (city where the facility was located) using a mobile phone. The DON stated the weather on July 11, 2023, was at 94 to 97 degrees Fahrenheit from 3:00 PM to 6:00 PM. During an interview, on July 13, 2023, at 1:20 PM, with (CNA 1), CNA 1 stated she was assigned to Patient 1 on July 11, 2023, during the morning shift from 7:00 AM to 3:00 PM. CNA 1 stated she last saw Patient 1 in the hallway scooting in his wheelchair, around 3:00 PM, as she was clocking out to leave the unit. CNA 1 stated Patient 1 was able to wheel himself alone, however she did not see Patient 1 going to the patio. She stated, she did not let Patient 1 out in patio because he was confused, and it was hot on July 11, 2023. During a telephone interview, on July 13, 2023, at 2:45 PM with (CNA 2), she stated she was assigned to Patient 1 during the afternoon shift, from 3:00 PM to 11:00 PM. CNA 2 stated it was a change of shift, and she did not do her afternoon check and round with CNA 1 (outgoing staff) for she was starting to work with other residents. CNA 2 stated she was looking for Patient 1 around 4:15 PM to prepare him for dinner but was unable to find him. At 4:30 PM, she found Patient 1 sitting on patio bench on the Memory Care Unit patio. She stated he was unresponsive, had vomited (matter from the stomach that has come up into and may be ejected beyond the mouth, due to the act of vomiting) seen on his shirt and she immediately notified the Charge Nurse. She further stated she had not seen Patient 1 since the start of her shift until she found him on the patio. During a follow up interview with the DON on July 18, 2023, at 9:10 AM, the DON stated she did not call 911 for Patient 1 because the POLST was "Do Not Resuscitate." She stated although they did not call the police, they did promptly notify Patient 1's physician and family member. She further stated she could not remember if she saw Patient 1 on the patio. During an interview with Activity Director Assistant, on July 18, 2023, at 9:50 AM, she stated, she had seen Patient 1 trying to open the patio door in previous instances but had not seen Patient 1 able to make it outside. She stated Patient 1 should not be left alone, unassisted, and unsupervised. She further stated Patient 1 had memory problems and needed to have constant re-direction. She stated patient's' safety was the facility's concern, and the facility cannot leave confused patients by themselves. She further stated facility should have checked him more often and kept their eyes on him. She stated Patient 1's passing could have been avoided if there was adequate supervision. A review of the facility's policy and procedure (P&P) titled, "Safety and Supervision of Patients,", dated July 2017, indicated: "2. Safety risks and environmental hazards are identified on an ongoing through a combination of employees training, employee monitoring, and reporting process...4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents...2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual patients...3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices...2. Patient supervision is a core component of the systems approach to safety. The type and frequency of patient supervision is determined by the individual patients assessed needs and identified hazards in the environment..." During an interview, on July 19, 2023, at 10:30 AM, (DON), the DON further stated all patients in the Memory Care Unit were vulnerable for accident or harm and it was possible the death of Patient 1 might have been prevented or avoided if Patient 1 was seen earlier and further stated this was unusual occurrence and should have been reported. Conclusion: The facility failed to: 1) Monitor and supervise Patient 1 on July 11, 2023, when he was left unattended and found outside on the patio on a hot day, one and half hours after he was last seen. 2) Implement Patient 1's care plan requiring monitoring for physical/non-verbal indicators of discomfort or distress because of his communication problems related to his cognitive impairment. 3) Implement its policies and procedures to target interventions to reduce individual risks related to hazards in the environment, including adequate supervision. The violations, jointly, separately, or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and were a substantial factor in the death of Patient 1.