Other·April 11, 2024

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident CA00886995. Representing the Department, Health Facility Evaluator Nurse # 43452. A Class B State citation was written. Regulatory Violations: Cal. Code Regs. Tit. 22, § 72541-Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or 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 local health officer and the Department. An incident report shall be 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 Marshal. Cal. Code Regs. Tit. 22, § 72549. Patient Death Reports. (a) All patients' deaths shall be reported by the licensee when requested by the Department or its designee. The report shall be made accurately at a time and in such a manner as may be requested by the Department or its designee. On 2/27/2024, the Department of Public Health (State Survey Agency [SSA]) made an unannounced visit to the facility to investigate a complaint regarding resident's death. The facility failed to implement its policy and procedures (P&P) of incident reporting for unusual occurrence for Resident 1 by failing to report an unusual occurrence to the State Survey Agency and send a written report within 24 hours of Resident 1's death. As a result, there was a delay of an onsite investigation by the SSA to the specific circumstances behind Resident 1's death. A review of Resident 1's Admission Record indicated Resident 1, a 77 years-old female was originally admitted to the facility on 1/29/2024 and readmitted on 2/8/2024 with diagnosis including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), malignant neoplasm of unspecified part of bronchus [a large airway that leads from the trachea (windpipe) to a lung] or lung (a disease in which malignant (cancer) cells form in the tissues of the lungs). A review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST) dated 2/2/2024, indicated to attempt cardiopulmonary resuscitation (CPR, it can help save a life during cardiac arrest, when the heart stops beating or beats too ineffectively to circulate blood to the brain and other vital organs) if the resident have no pulse and is not breathing. A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 2/12/2024, indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired for daily decision-making and required maximal assistance to dependent from staff for activities of daily living (ADL- shower/bathe self, upper and lower body dressing, and putting on/taking off footwear). A review of Resident 1's Progress Notes dated 2/20/2024 at 6:43 a.m., entered by Licensed Vocational Nurse 3 (LVN 3) indicated, Paramedics (a healthcare professional trained in the medical model, whose main role has historically been to respond to emergency calls for medical help outside of a hospital) arrived at approximately 6:43 a.m., and determined patient (Resident 1) has expired. During an interview Licensed Vocational Nurse 1 (LVN 1) on 2/28/2024 at 11:12 a.m., LVN 1 stated, it was unexpected when Resident 1 passed away as Resident 1 was alert and oriented. LVN 1 stated, Resident 1 was compliant with her medications and her vital signs were stable. During an interview with Licensed Vocational Nurse 3 (LVN 3) on 2/28/2024 at 12:59 p.m., LVN 3 stated, she did not see Resident 1 on the time of her expiration and the last time she checked on Resident 1 was around 12:06 a.m. when she administered her medication dexamethasone (works on the immune system to help relieve swelling, redness, itching and allergic reactions). LVN 3 further stated, the last time she saw Resident 1 was stable. During an interview with Director of Nursing (DON) on 2/28/2024 at 5:04 p.m., DON stated, Resident 1's death was not reported to the State Department as she was informed that it doesn't need to be reported. DON further stated, Resident 1's death was unexpected. A review of the facility's policy and procedures (P&P) titled, "Unusual Occurrence Reporting", reviewed on 1/2024 indicated, "As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees, or visitors... Our facility will report the following events to appropriate agencies: death of a resident, employee, or visitor because of unnatural causes." The facility failed to implement its P&P of incident reporting for unusual occurrence for Resident 1 by failing to report an unusual occurrence to the SSA and send a written report within 24 hours of Resident 1's death. As a result, there was a delay of an onsite investigation by the SSA to the specific circumstances behind Resident 1's death. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1.