Other·December 11, 2023

Facility: Las Colinas Post Acute HFEN: 3165 Date of Exit: November 2, 2023 Intake: CA00867749 Event ID:II4611 State Citation A REGULATORY VIOLATIONS: Title 22 California Code of Regulations 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The facility failed to reassess and monitor one patient (Patient 1) for signs and symptoms of depression with mood changes after Patient 1's family member expressed her father's feelings of wanting to die. This failure led to the decline of Patient 1's mental health and psychosocial (emotional) well-being, beginning September 18, 2023, which resulted in Patient 1's death by suicide on October 27, 2023. A review of Patient 1's clinical record, the "Face Sheet " (contains demographic and medical information) indicated that Patient 1 was admitted on September 15, 2023, with diagnoses which included: Parkinson's disease (brain disorder that causes unintended or uncontrollable movement) and encephalopathy (disturbance in the way the brain functions). A review of Patient 1's clinical record, the "Licensed Nurses Progress Note,” dated September 18, 2023, indicated, “Late entry: Today Care conference was conducted ...family member stated her dad was feeling sad and wanted to go home with her. Family member explained that she was unable to provide care for him at home. Order for psychiatric (mental illness) consult was input and sent to [Psychiatrist (specializing in the diagnosis and treatment of mental illness) name]. The Charge nurse (caring for Patient 1) was informed to follow up and to continue to monitor patient.” No documentation could be found to show Patient 1 was monitored daily for sadness or mood changes after September 18, 2023. A review of Patient 1's clinical record, the "Physicians Order,” dated September 18, 2023, indicated, "May have consult with psychiatrist due to verbalization of feeling sad." A review of Patient 1's, "Minimum Data Set (MDS- set of assessments)”, Section D for Mood, dated September 18, 2023, indicated, over the last two weeks Patient 1 had the presence of these symptoms: little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, poor appetite, or overeating. The frequency of these symptoms averaged between 7 to 14 days. Section D indicated the symptoms happened half or more of these days. Patient 1's Total Severity Score (an indicator of depression) was 11. A score of 11 indicated Patient 1 had signs and symptoms of moderate depression. No documentation could be provided of Patient 1's medical records that indicated Patient 1 was monitored or assessed daily for sadness, mood changes or signs and symptoms of depression after this assessment. A review of Patient 1's care plan (outline of what needs to be done to manage the care, needs of a patient) titled, "Mood," dated September 18, 2023, indicated, “Patient 1 was at risk for decreased psychosocial well-being and adjustments issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social or spiritual well-being related to: a. feeling down, depressed, or hopeless, b. Feeling tired or having little energy, little interest, or pleasure in doing things, c. poor appetite or overeating, d. trouble falling, staying asleep or sleeping too much. The interventions listed included: Assess for clinical issues that may be causing or contributing to the mood pattern.” No documentation could be found to indicate Patient 1 was monitored or assessed daily for sadness, mood changes or signs and symptoms of depression after this care plan was initiated. A review of Patient 1's clinical record titled, "Interdisciplinary Team Conference Summary Note (IDT- team members from different disciplines working together to make decisions),” effective date September 18, 2023, at 9:37 AM, and signed by a Licensed Vocational Nurse on October 27, 2023, indicated, "New orders for patient [Patient 1] to be seen by psychiatrist regarding the patient stating that he is feeling sad. Sent over face sheets and order to (Psychiatrist) for patient to be seen from verbalization from the family member that her father stated he was sad and wanted to go home. Informed [Psychiatrist name] about order so patient can be seen, continuing to monitor." No documentation could be found that indicated Patient 1 was monitored or assessed daily for sadness, mood changes or signs and symptoms of depression after this note. A review of Patient 1's, "Physicians Order,” dated September 27, 2023, indicated that Patient 1’s last cover date (end of insurance coverage) was September 29, 2023. Patient 1 became a custodial care patient (receives non-medical care that can be safely given by non-licensed caregivers at home or in a nursing home) of the facility on September 30, 2023. A review of Patient 1's, "Physician's Progress Note,” dated September 25, 2023, indicated the Psychiatrist was unable to see Patient 1 because Patient 1 had (name of insurance carrier) and there was no prior authorization to see the Psychiatrist. A further review of the document indicated to refer Patient 1 to a neurologist (specialist in the diagnosis and treatment of disorders of the nervous system). A review of Patient 1's, "Neuropsychological (the study of behavior, the mind, and their relationship with the central nervous system) Consultation Summary,” from [Name of Neurologist] dated October 16, 2023, indicated, "Parkinson's ..., agitated before his evening medications. Patient had an altercation where he was physical with his family member (while in the facility) ..." No documentation could be found that indicated the facility documented the report of an altercation between Patient 1 and the family member before the neurological consult or after the consultation was completed. A review of Patient 1's clinical record, the "Licensed Nurses Progress Note" dated October 13, 2023, at 1:16 PM, indicated, "(Patient 1) left out on pass with family member in a wheelchair." The subsequent nurses note was dated October 15, 2023. No documentation could be found that indicated Patient 1's mood or behavior after his return to the facility on October 13, 2023. A review of Patient 1's "Licensed Nurses' Progress Notes” dated October 16, 2023, indicated the nurses note was a late entry which was documented on October 27, 2023, at 5:58 PM, which indicated, "Received an order for Seroquel (antipsychotic medication used to treat agitation or depression), for agitation from [Neurologist name] during telehealth appointment. Family member was present during telehealth appointment. Consent obtained from family member. Order carried out." No documentation could be provided of incidents or behaviors that indicated Patient 1 was agitated. No documentation could be found in Patient 1's medical records, the nurses' notes, assessments, and the weekly summaries from September 18, 2023, to October 27, 2023, that demonstrated incidents of agitated behaviors that warranted the use of Seroquel. A review of Patient 1's "Licensed Nurses' Progress Note," dated October 30, 2023, at 11:25 PM, indicated upon cleaning the Patient 1's room, around 11:15 PM, a handwritten note was found on the side table by a Registered Nurse and Unit manager. The Family member was called and made aware of the note. The nurse read the note to the family member, which indicated, “I [used his name] am offering my pain to God to help those with Parkinson’s but that was all I could take. My God, I love you and ask you to forgive me.” A review of Patient 1's clinical records, the nurses' notes, nurses' assessment notes, and the weekly summaries dated September 18, 2023, to October 27, 2023, indicated Patient 1 was not monitored or assessed daily or weekly for signs and symptoms of depression, sadness, or mood changes. A review of Patient 1's "History and Physical" (H&P) dated September 19, 2023, the H&P indicated Patient 1 had the capacity to understand and make decisions. During an interview with Licensed Vocational Nurse (LVN 1) on October 30, 2023, at 3:11 PM, LVN 1 stated, "On October 27, 2023, I walked into the room to give medication. I called out his name. Patient 1 did not respond. Patient 1 had the blanket over his head. He was on his back looking up at the ceiling. No response. I looked to see if he was breathing. I pulled the blanket back. The patient belongings bag was tied around his neck. The black charger cord was wrapped around his neck three or four times." LVN 1 stated further, "Seroquel? We received an order for 25 mg (milligram, unit of measurement) of Seroquel for agitation. Patient 1 was not agitated for me. I got the order for Seroquel from [Neurologist's name]. The family member set the appointment to see the Neurologist." No documentation could be provided that indicated Patient 1 had episodes of agitation or changes in mood. During a phone interview with Patient 1's family member on October 30, 2023, at 3:26 PM, the family member stated, "(Patient 1) was not happy and wanted to go home. The last week that he was in the facility he was making the adjustment. Doing the activities and making friends. (Patient 1) was saying that he wanted to die at home. (Patient 1) did say it again, that he wanted to die, when he was in the facility, the first week he was there. I asked them for a psychiatric evaluation. That request for a psychiatric evaluation was a month ago. I told the nurse one time. She was in the room with me when (Patient 1) said that he wanted to die and that's when I asked for a psychiatrist to see him. One of them I told was (Registered Nurse 1, RN 1). (RN 1) said, they would put it in the notes that they would have someone go talk to him.” A continuation of the phone interview with Patient 1's family member on October 30, 2023, at 3:26 PM, family member stated further, “I had gone to see him after my daughter's wedding. He was upset because he did not go to the wedding. On October 13, 2023, I took him out on pass, and he had no intentions of going back there. He wanted to go home. He was trying to walk away, and I grabbed his shirt, and he started punching at me. It was not like him at all. I said you're hurting me. I yelled for help. (Staff members) eventually came out and helped me." "(Staff members) told me to drive away because he was trying to resist going inside. He said he wanted to die the next day." Patient 1's family member then stated, on (October 16, 2023), "the neurologist wanted to make sure his medications were right with LVN 1, who was there at the time " of this visit. I told the Neurologist about the incident on Friday and the neurologist was concerned that it was the first sign of dementia. That's why the Neurologist ordered the Seroquel. During a phone Interview with LVN 2 on October 30, 2023, at 4:35 PM, LVN 2 stated, the day, October 13, 2023, Patient 1 “went out on pass with his family member,” Patient 1 took a shower early and was excited. LVN 2 further stated, when Patient 1 came back from pass, he did not want to go back to the facility. Patient 1's family member asked if we could “redirect him." LVN 2 stated "they redirected him with pizza, but he [Patient 1] did say he wanted to go home with the family member." No documentation could be found that indicated Patient 1 was assessed or monitored for behavior or mood after he returned from his out on pass visit with his family member. During a phone interview with LVN 3 on October 30, 2023, at 4:53 PM, LVN 3 stated on October 13, 2023, LVN 3 stated, "I noticed he was with his family member. I noticed that he was mad at the family member. He was hitting the family member when he came back from out on pass." When LVN 3 was asked further about Patient 1 hitting the family member, LVN 3 stated, "I don't remember who told me about (Patient 1) hitting the family member. I didn't pay much attention." No documentation could be found that indicated Patient 1 was assessed and or monitored for changes in mood, signs and symptoms of depression or sadness when he returned from out on pass on October 13, 2023. During an interview with the Director of Nursing (DON) on October 30, 2023, at 6:01 PM, the DON stated Registered Nurse (RN 1) reported, "Patient 1 was mad at the family member, because the family member can't take him home." (RN 1) said, " I can't, I don't want to be caught in the middle. (RN 1) said the family member looked like help me that day" (October 13, 2023.) "(Staff members) lured him back inside with pizza and that was it. I didn't know or they did not mention anything about Patient 1 hitting the family member. There was no documentation about that. (RN 1) should have documented that." When asked about the psychiatrist consultation for Patient 1, The DON stated further and confirmed the facility has two psychiatrists [NAMES] and they did not see Patient 1 due to insurance. The DON further stated if Patient 1's psychiatrist consultation was not covered by his insurance. Case management was to follow up. During a concurrent interview and record review of Patient 1's medical record with the DON on October 30, 2023, at 6:01 PM, DON reviewed Patient 1's "Care Plan (outline of what needs to be done to manage the care needs of a patient) for Mood,” dated September 18, 2023. The DON stated, "We don't monitor at risk care plans for mood." After speaking with the social services director (SSD) and reviewing the clinical records for Patient 1, the DON stated, "They should have documented about his mood." The DON could not provide documentation that indicated Patient 1 was monitored daily or weekly for sadness, signs and symptoms of depression or mood changes. The DON confirmed there was no documentation to show Patient 1 was monitored and assessed for changes to mood, signs and symptoms of depression or sadness daily or weekly. During an interview and record review on October 31, 2023, at 2:20 PM with the Assistant Director of Nursing (ADON), ADON stated, "The first assessment on Minimum Data Set (MDS) dated September 18, 2023, Section D (Mood), based on the PHQ9 (patient health questionnaire, is an instrument used for screening, diagnosing, monitoring, and measuring the severity of depression), the total severity score was 11. All this was based on Patient 1's interview.” The ADON stated, “The MDS was done for every admission, or significant change in condition. I don't think a new Preadmission Screening and Patient Review (PASRR) was done, because we would only have to do it again if the patient had a Change of condition. The one we have is from [outside hospital]. There was no suicide assessment done because he was negative on his PASRR from the [outside hospital].” The ADON stated that there was no care plan developed for Seroquel. The ADON further stated, for Seroquel medication, monitoring was not documented on Patient 1's Medication Administration Record (MAR). It's not on the MAR. The ADON verified and confirmed that Patient 1's feeling of sadness and monitoring was not documented in the clinical records and the facility was unable to provide any documented evidence. During a review of the facility's policy and procedure (P&P) titled, "Change in a Patient's Condition or Status" dated February 2021, the P&P indicated, "Our facility promptly notifies the patient, his or her attending physician, and the patient representative of changes in the patient’s medical/mental condition and/or status. 1. The nurse will notify the patient's attending physician when there has been a: accident or incident involving the patient ...d. signific