Health inspection·July 30, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow the most recent care plan for one of two residents (Resident 1) to provide one on one checks per physician orders for safety after a recent suicide attempt. This failure had the potential to cause Resident 1 physical and psychosocial harm. Findings: A review of the facility's policy titled Depression-Clinical Protocol revised 11/2018, indicated number 2, The nurse shall assess and document/report the following: Vital signs, description of affect, level of activity and responsiveness, whether mood decline is associated with anorexia, (not eating), crying and sleeplessness; pain assessment, suicidal ideation, (If present, follow facility policy/protocol for suicide threats). A review of the facility's policy titled Suicide Threats dated 12/2007, indicated resident suicide threats shall be taken seriously and addressed appropriately. Number seven stated, If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised 3/2022, indicated Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation including the right to receive the services and/or items included in the care plan. During a record review of a document titled, Care Plan revised [DATE], indicated new interventions for new problem, Resident 1 had mood problem and verbalized want to self-harm, as well as engaged in actual self-harm, cutting behavior. One on one supervision to be provided for increased visual accountability of safety and wellness of patient. Every fifteen-minute checks for safety, daily visits daily with DSS for 72 hours, and longer if indicated. A review of a document titled Individual Progress Note dated [DATE] from a local hospital for Crisis evaluation indicated Resident 1 was being evaluated for danger to self, following [Resident 1] engaging in cutting behavior, he has a superficial cut to the left wrist. Resident 1 was admitted to the facility on [DATE] for diagnoses that included repeated falls, injury of the head, and major depressive disorder (a persistently low or depressed mood that causes a Page 1 of 3 555356 555356 07/30/2023 Quartz Hill Post Acute 2120 Benton Drive Redding, CA 96003

F 0656 sense of loss and sadness, and anxiety (feeling of uneasiness, worry and fear of everyday life). Level of Harm - Minimal harm or potential for actual harm During a record review for Resident 1, a document titled Minimum Data Set (MDS, a resident assessment), dated [DATE] indicated Resident 1 had a slight cognitive impairment, (ability to think, reason, and recall) with a Brief Interview Mental Status score of 10. Residents Affected - Few During a record review for Resident 1, a document titled Social Service Note dated [DATE], indicated Follow up to recent event: Resident 1 self-harming by cutting wrist causing a superficial laceration. During an interview on [DATE] at 7:30 am, Licensed Nurse (LN) A stated, Yes, Resident 1 is still on every fifteen-minute checks related to a suicide attempt. During an observation on [DATE] at 7:45 am through 8:45 am, no fifteen minutes were completed for Resident 1 from any staff members, which was in the updated care plan for safety. During an observation on [DATE] at 7:35 am, Resident 1 was eating breakfast while sitting on the side of the bed. Left wrist had a Band-Aid with dried, dark red colored substance. During an interview on [DATE] at 7:50 am, Resident 1 (tearful) stated, Yes, I am sad. My wife died a couple of months ago; she was my wife for over 60 years. I feel so lost without her, just lost. I miss her, I met my wife in grade school. I was supposed to go home after rehab. I tried to cut my wrist, but all I had was a butter knife. Resident 1 confirmed left wrist Band-Aid had dried blood from cutting his wrist. During an interview with the physician on [DATE] at 8:20 am, the physician confirmed every fifteen-minute checks should be completed on Resident 1 for safety related to recent self-harm attempt on [DATE], and recent hospitalization for suicide attempt. During a follow up interview on [DATE] at 8:30 am, Resident 1 stated, I am so sad, I miss my wife, tearful at intervals. No one understands, my wife was my best friend, I was supposed to go home and not live here. I don't want to hurt my son, but I am just lost. I can't stop feeling this way. A document titled Safety Check log for Resident 1, undated indicated no fifteen-minute checks were completed for 8:00 am, 8:15 am, 8:30 am and 8:45 am on [DATE]. These time periods were blank and no initials. During an interview on [DATE] at 9:10 am, Director of Nursing (DON) stated, Yes, I was called about Resident 1 and came in on a Holiday and updated the care plan to complete every fifteen-minute checks. The staff should be doing every fifteen-minute checks, the Certified Nursing Assistants, (CNA) should be getting verbal reports from the nurses. During a record review of Resident 1's medical record a document titled Physician Verbal Order , dated [DATE] at 9:21 am, indicated One on one for resident, 24 hours a day, every shift, for observation for three days, 24 hours a day for 72 hours. During an interview on [DATE] at 9:56 am, the Director of Social Services stated, I knew Resident 1 had not been paid by the Veteran's Administration (VA) for 90 days and he was upset his money was late. I did not know his wife had passed. I will call the VA back to find out if they are working on 555356 Page 2 of 3 555356 07/30/2023 Quartz Hill Post Acute 2120 Benton Drive Redding, CA 96003

F 0656 it. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 10:35 am, CNA B stated, From my understanding, I thought it was me and the nurse doing the checks on Resident 1, not just me. I did not get report from the nurse this morning, I was running late. Residents Affected - Few During an interview on [DATE] at 11:30 am, the Administrator confirmed Resident 1 had 24-hour supervision effective 10:00 am [DATE] for three days per physician order and a new appointment was made for the VA to evaluate depression. During an interview on [DATE] at 11:35 am, the Director of Nursing (DON) confirmed Resident 1's care plan was revised, but not followed by staff. DON also confirmed the fifteen-minute checks were not completed on [DATE] from 8:00 am to 8:45 am, and the recording log was blank for those time frames. DON confirmed the nurse did not give report or communicate to the CNAs on [DATE] on the hall for safety, supervision of Resident 1. 555356 Page 3 of 3