Other·April 12, 2024

42 CFR §483.90(g) Resident Call System The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from- §483.90(g)(1) Each resident's bedside; and §483.90(g)(2) Toilet and bathing facilities. 22 CCR § 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 22 CCR § 72631. Signal Systems. (a) A nurses' signal system shall be maintained in operating order as required by Section E702-30 of Title 24. On 3/12/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the annual recertification survey. The facility failed to provide alternate call system for Residents 26, 49, 51, 58, 64, 119, 120, and 219 while the call light system (lights and sound alarm system at residents' bedside to summon nursing staff for assistance) was nonfunctional from 3/9/2024 to 3/12/2024. As a result, multiple residents banged on the tables, yelled, shout, or screamed from their rooms for nursing staff assistance and: a. On 3/11/2024, Resident 218 fell on the floor. b. Resident 120 waited 30 minutes to one hour to get help from staff and becoming distressed and uncomfortable. c. Residents 119 and 51 waited long time to be assisted to the bathroom. d. Resident 64 had to use her personal phone to call the staff for assistance. e. Resident 49 became anxious from having to yell out to get assistance. f. Resident 58 had difficulty getting pain medication timely and waiting for two hours for assistance. g. Resident 26 said she was uncomfortable and would be petrified in an emergency without working late. On 3/12/2024 at 7:20 a.m., the survey team entered the facility and heard several residents, yelling, screaming, shouting, and banging asking for help. a. A review of Resident 218's Admission Record indicated the facility admitted Resident 218, a 91-year-old female, on 3/10/2024 with diagnoses including memory loss. A review of Resident 218's History and Physical (H&P) examination, dated 3/11/2024, indicated Resident 218 underwent a left total hip arthroplasty (a surgical removal of the diseased parts of the hip joint and replaced them with new, artificial parts) on 3/06/2024. A review of Resident 218's Situation-Background-Assessment-Recommendation/ (SBAR - a technique that provides a framework for communication between members of the health care team ) / Change of Condition (COC), dated 3/11/2024 timed at 8:02 p.m., indicated, Resident 218 had an unwitnessed fall. On 3/12/2024 at 2:09 p.m., during an interview, Resident 219 (Resident 218's roommate) stated that Resident 218 would get out of bed, "when she wants to." Resident 219 stated that on 3/11/2024, she (Resident 219) ran out of the room to shout /yell to the staff that Resident 218 had fallen. on the floor. Resident 219 stated staff did not provide other means of calling the staff. b. A review of Resident 120's Admission Record, indicated the resident was a 92-year-old male, admitted on 3/1/2024, with diagnoses including unspecified intracapsular fracture (a break along the length of the bone) of left femur (thigh bone), history of falling, atherosclerotic heart disease (damage or disease in the heart's major blood vessels), muscle weakness, dysphagia (inability to swallow), and low back pain. A review of Resident 120's Minimum Data Set (MDS, standardized assessment and care-screening tool), dated 3/4/2024, indicated Resident 120 was able to understand, communicate, make needs known, and required moderate staff assistance with upper body dressing and personal hygiene. On 3/12/2024 at 10:07 a.m., during an observation of Resident 120 in bed, yelling for help and concurrent interview, Resident 120 stated he needed to be repositioned and that the call light was not working. Resident 120 stated he had to wait for 30 minutes to one hour to get help from staff. Resident 120 was observed to be visibly distressed and uncomfortable. c. A review of Resident 119's Admission Record, indicated the resident was an 84-year-old male, admitted on 3/8/2024, with diagnoses including pancreatic and liver cancer. A review of Resident 119's MDS dated 3/15/2024, indicated Resident 119's cognition was moderately impaired. A review of Resident 51's Admission Record, (Resident 119's roommate), indicated Resident 51 was an 84-year-old male admitted on 3/6/2024 with diagnoses including history of falling, chronic respiratory failure, and bladder. A review of Resident 51's MDS dated 1/17/2024, indicated Resident 51's cognition was moderately impaired. Resident 51 required moderate to extensive staff assistance with oral hygiene, eating, and upper body dressing. On 3/12/2024 at 10:32 a.m., Residents 119 and 51 were observed in their room. Residents 119 the call light was not working and had not been able to get any help from staff. Resident 119 stated he had to wait a long time to be assisted to the bathroom. On 3/12/2024 at 11:12 a.m., during interview, Resident 51 stated his call light was not working and both Resident 119 and him had to bang their tables to get help. Resident 51 stated the facility had not provided him with an alternative to call for help and was feeling distressed. d. A review of Resident 64's Admission Record, indicated the resident was an 85-year-old female admitted on 2/18/2024 with diagnoses including muscle weakness. A review of Resident 64's MDS dated 1/17/2024, indicated Resident 64 was able to understand, communicate and make decisions. Resident 64 required moderate to extensive staff assistance with oral hygiene, eating, and upper body dressing. On 3/12/2024 at 10:58 a.m., Resident 64 was observed in bed and upon interview stated the resident stated she had not had a functioning call light for three days and used her cell phone to call the staff whenever she needed help. Resident 64 stated, she would be in trouble if she did not have her cell phone because there was no other way to get help from a nurse. e. A review of Resident 49's Admission Record, indicated the resident was an 80-year-old female admitted on 5/23/2023 with diagnoses including type 2 diabetes (elevated blood sugar), lack of coordination, and transient ischemic attack (TIA - a short period of symptoms like a stroke). A review of Resident 49's MDS dated 2/15/2024, indicated Resident 49 was able to communicate, understand and make decision. Resident 64 required moderate staff assistance with oral hygiene, eating, and personal hygiene. On 3/12/2024 at 11:40 a.m., Resident 49, was observed in bed. Upon interview, Resident 49 stated she did not have a working call light since the weekend. Resident 49 stated she had to yell out for help which made her anxious. Resident 49 stated she was not provided with any other options to call for help. f. A review of Resident 58' s Admission Record dated 3/13/2024, indicated the resident, a 67-year-old male, was admitted on 10/18/2022 with diagnoses including muscle weakness and hemiplegia (weakness on one side of the body). A review of Resident 58's MDS dated 1/17/2024, indicated Resident 58 was able to understand and make decisions. The MDS indicated Resident 58 was dependent on staff for care. On 3/12/2024 at 9:40 a.m., during an interview, Resident 58 stated the call lights needed to be fixed because they had not been working for about three days. Resident 58 stated he was having difficulty getting pain medication on time because his call light was not working. Resident 58 stated he needed the call light because his left leg pain would start at any time of the day or night. Resident 58 stated he had to yell for help and for pain and waited for about two hours for someone to respond. Resident 58 stated he was very upset not getting the needed help. g. A review of Resident 26's Admission Record indicated the resident was a 79-year-old female admitted on 2/24/2024 with diagnoses including congestive heart failure (a long-term condition in which a person's heart cannot pump blood well enough to meet a person's body's needs), abnormalities of gait and mobility. A review of Resident 26's H&P exam, dated 2/26/2024, indicated Resident 26 had the capacity to understand and make decisions. On 3/12/2024 at 10:46 a.m., during an interview, Resident 26 stated Resident 26 uncomfortable and would be petrified if in case of an emergency, she would not be able to get help because the call light was not working. During an interview on 3/12/24 at 12:02 p.m., the Maintenance Supervisor (MS) stated that on 3/9/2024 (Saturday) at 3:15 a.m., he notified the DON that the call light system was not working. The MS stated that the next day, on 3/10/2024, the MS contacted the company that performs maintenance and repairs on the facility call lights system and the company informed the MS that a maintenance person could not be sent out until Tuesday, 3/12/2024, after 5 p.m. to repair the call light system. The MS stated he called another company, but they could not get to the facility sooner. The MS stated MS tried several times to fix the call light system but there was a need of a part that the MS was unable to purchase. The facility had to wait until 3/12/2024 for the contacted company to repair the call light system. During an interview on 3/12/2024 at 3:13 p.m., the Director of Staff Development (DSD) stated that the facility had designated a staff for each shift to check on all residents every 15 minutes until the call light system was repaired. During an interview on 3/12/2024 at 3:32 p.m., Licensed Vocational Nurse 1 (LVN 1) stated verified the DSD statement of having assigned a staff to make round every 15 minutes. On 3/12/2024, at 3:43 p.m. during an interview, Restorative Nursing Assistant 1 (RNA 1) stated that from 3/9/2024 through 3/11/2024 he was asked to work 16 hours to make rounds due to the nonfunctional call lights. RNA 1 stated that from Saturday (3/9/2024), he started coming at noon. RNA 1 stated he was also assigned to assist Certified Nursing Assistants (CNAs) place their assigned residents back in bed, provide personal hygiene to residents, and perform his regular RNAs' duties. A review of the facility's policy and procedures (P&P) titled, "Call Light Answering" revised 8/12/2021, indicated, "It is the policy of this facility to provide the resident a means of communication with nursing staff as indicated based on resident assessment ... In the event that the resident is not able to use the call light, the resident will be checked by the nursing staff during care and more frequently as indicated." A review of the facility's P&P titled "Call System, Resident" dated 9/2022, indicated, "Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor ... The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional. If resident call light system is down, an alternative means of communication will be used such as call bells and frequent room rounds. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan. The resident call system is routinely maintained and tested by the maintenance department. Calls for assistance are answered as soon as possible. Urgent requests for assistance are addressed immediately." On 3/12/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the annual recertification survey. The facility failed to provide alternate call system for Residents 26, 49, 51, 58, 64, 119, 120, and 219 while the call light system was nonfunctional from 3/9/2024 to 3/12/2024. As a result, multiple residents banged on the tables, yelled, shout, or screamed from their rooms for nursing staff assistance and: a. On 3/11/2024, Resident 218 fell on the floor. b. Resident 120 waited 30 minutes to one hour to get help from staff and becoming distressed and uncomfortable. c. Residents 119 and 51 waited long time to be assisted to the bathroom. d. Resident 64 had to use her personal phone to call the staff for assistance. e. Resident 49 became anxious from having to yell out to get assistance. f. Resident 58 had difficulty getting pain medication timely and waiting for two hours for assistance. g. Resident 26 said she was uncomfortable and would be petrified in an emergency without working late. The above violations had a direct relationship to the health, safety, and security of Residents 26, 49, 51, 58, 64, 119, 120, and 219.