Health inspection·August 9, 2024

California Code of Regulations, Title 22, section 72507 (b), Smoking. (b) The facility shall provide designated areas for smoking. Patients shall be permitted to smoke only in designated areas. The designated areas shall be under the periodic observation of facility personnel or responsible adults. This does not preclude the designation of the patient’s rooms as smoking areas. California Code of Regulations, Title 22, section 72523 (a), Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure patient related goals and facility objectives are achieved. Code of Federal Regulations, Title 42, 483.25 (d) (1) (2)-Accidents. The facility must ensure that- (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On June 20, 2024, at 8:35 a.m., an unannounced visit to the facility was conducted to investigate a safety concern. As a result of the investigation, California Department of Public Health (CDPH) determined that the facility failed to: a. Ensure patient was smoking in a designated area at the facility in accordance with the policy and procedure, dated October 2023. b. Provide adequate supervision during smoking while at the facility; and c. Ensure the smoking paraphernalia was not kept in possession of the patient in accordance with the facility policy and procedure, dated October 2023. These failures resulted in Patient C being able to smoke unsupervised by staff at the smoking patio and burn Patient A’s arm with a lit cigarette on June 9, 2024. Patient A sustained a cigarette burn on the right arm. On June 20, 2024, at 10:50 a.m., during an interview, Patient A stated he was outside on June 9, 2024, and one of the patients burned him with a cigarette on his right arm. Patient A held out his right forearm (section of the arm from the elbow to the wrist), and a circle (approximate circumference of a cigarette) was noted to his skin, whitish in color with pink edges surrounding the area consistent with the size of a cigarette burn. Patient A stated that on the day of June 9, 2024 (the day of the incident), while he was at the vending machine, located at the smoking patio, Patient C came over to him and touched a lit cigarette to his right forearm. On June 20, 2024, during an interview from 11:15 a.m. to 11:22 a.m. with Patient F (Patient A’s roommate), Patient F stated he was at the smoking patio when Patient C attacked Patient A, on June 9, 2024. He stated Patient A showed him the burn mark on his right arm caused by Patient C’s lit cigarette. He stated there was no staff outside the smoking patio when the incident occurred, involving Patient A and Patient C. In addition, Patient F stated the patients were allowed to keep their cigarettes and lighter within their possession. On June 20, 2024, at 11:30 a.m., an interview was conducted with Patient B, at the smoking patio. Patient B stated no one consistently supervises the patients while smoking, and he stated staff only came out to the patio if they are looking for a patient. On June 20, 2024, at 3:50 p.m. a review of Patient C’s medical record titled, “ Admission Record,” indicated the patient was admitted to the facility initially on December 8, 2023, and readmitted on June 3, 2024, with diagnoses which included COPD (chronic obstructive pulmonary disease-a group of lung diseases that block airflow and make it difficult to breathe) and bipolar disorder (associated with mood swings ranging from depressive lows to manic highs). A review of Patient C’s smoking observation assessment, dated June 3, 2024, indicated the patient may smoke with supervision and that the patient will have supervision during smoke break for safety. A review of Patient C’s care plan, dated June 4, 2024, indicated Patient C has potential for injury related to smoking with episodes of non-compliance to smoking rules, smoking schedule, smoking supervision, smoking materials to be given and retained by staff. Further review of the care plan indicated interventions included cigarette and lighter will be stored in the nurse’s station. A review of Patient C’s record titled,” SBAR (type of communication stands for Situation, Background, Assessment, and Recommendation) Summary for Providers,” dated June 9, 2024, at 3:52 p.m. indicated, “…fellow resident c/o (complain of) that [Patient C] slapped him 2 X in the face and another c/o being burnt with cigarette on his hand in the arm she was hallucinating (a false sense something is real), threatening student nurse…Physical aggression…verbal aggression…other behavioral symptoms, worse delusions (a false belief of reality, occurs in mental conditions), hallucinations noted…” On June 21, 2024, at 11:15 a.m., during an interview with the Director of Staff Development (DSD), the DSD stated they all keep an eye on patients who are smokers. The DSD stated if there is a smoker who is not independent, the smoker will be supervised by a staff member to ensure safety. On June 21, 2024, at 12:20 p.m., during an interview with the Activities Director (AD). The (AD) stated the DSD and the activities department, work together to ensure patients on the smoking patio, have supervision. The AD stated, on Sunday, June 9, 2024, the activity assistant was at the facility from 8:00 a.m. to 4:30 p.m.; however, the activity assistant was not outside the smoking patio when the incident occurred and did not witness the incident involving Patient C and Patient A. The AD stated there is no formal schedule regarding who would monitor the patients on the patio while smoking, but most staff know to watch. On June 21, 2024, at 1:25 p.m., a telephone interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated, she was the charge nurse for Patient C on June 9, 2024, the day the incident occurred. LVN 1 stated it was reported to her that Patient C flicked a lit cigarette at a student in the front of the facility. LVN 1 stated patients were not allowed to smoke at the front patio. A review of Patient A’s medical record titled, Admission Record,” indicated Patient A was admitted to the facility on December 7, 2017, with diagnoses which included paraplegia (Paralysis that affects the lower portion of the body) and cerebral palsy (an abnormal development in parts of the brain that control movement). Patient A’s SBAR, dated June 9, 2024, at 4:00 p.m., indicated, “…change in condition…Resident reported to charge nurse getting a cigarette burn to R (right) arm by another resident when getting a soda from vending machine…monitor site…” Patient A’s Interdisciplinary team (IDT) note, at 3:00 p.m., indicated, “…Resident reported an allegation that another resident burned his right forearm with cigarette on 06/09/2024 (June 9, 2024) while outside by the smoking area using the vendo [sic] machine…said he is fine and it’s not a big thing…” A review of the facility’s Smoking Policy/Procedure, dated June 8, 2018, that is read and signed by all residents identified as smokers indicated, “…A designated smoking area outside the building is available…No lighting materials (e.g. matches, lighters), tobacco products, or smoking devices will be allowed to be kept in the possession of the residents…residents who desire to smoke will be assessed for their ability to do so safely. The Interdisciplinary Team will assess residents by using the Smoking Assessment form and a review of the resident’s clinical record…the resident will be offered to smoke…under staff supervision…no lighting materials…tobacco products, or smoking devices will be allowed to be kept in the possession of the resident either on their person or in their room…The frequency of smoking for residents under staff supervision will be: 8:00 am, 11:00 am, 1:30 pm, 4:00 pm, 7:00 pm these times will be no more than twenty (20) minute increments…all smoking materials will be retained by staff…” A review of the facility’s policy titled “Smoking Policy-Residents”, dated October 2023, indicated, “…This facility has established and maintains safe resident smoking practices…smoking is only permitted in designated resident smoking areas…resident smoking status is elevated upon admission…ability to smoke safely with or without supervision…A resident’s ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive)…any smoking related privileges, restrictions, and concerns…need for close monitoring…are noted in the care plan…any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member…or volunteer worker at all times while smoking…Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision…” As a result of the investigation, CDPH determined that the facility failed to: a. Ensure patient was smoking in a designated area at the facility in accordance with the policy and procedure, dated October 2023. b. Provide adequate supervision during smoking while at the facility.; and c. Ensure the smoking paraphernalia was not kept in possession of the patient in accordance with the facility policy and procedure, dated October 2023. These failures resulted in Patient C to be able to smoke unsupervised by staff at the smoking patio and burn Patient A’s arm with a lit cigarette on June 9, 2024. Patient A sustained a cigarette burn on the right arm. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient A.