Health inspection·August 14, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00901349. Class A Citation was written. 42 CFR §483.25(d) Free of Accident Hazards/Supervision/Devices §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR §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. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CR §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 § 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. On 6/25/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct an annual recertification survey. The facility failed to provide an environment that is safe and free of hazards for one of 13 residents (Resident 108) by failing to: 1. Ensure the staff did not leave a hot cup of coffee at Resident 108's bedside table. 2. Ensure Certified Nursing Assistant 7 (CNA7) did not prepare hot liquid in an electric water kettle on the resident's bedside table, served, and left the cup of hot coffee unattended, within the resident's reach. 3. Ensure a licensed nurse assessed and measured Resident 108's skin immediately after the resident was burnt with the hot coffee. As a result, on 4/2/2024, Resident 108 reached, grabbed, and spilled the hot cup of coffee onto the resident's right upper lateral (side) hip resulting in a 2nd degree burn (involving the two layers of the skin) injury and pain, and treatment with Lidocaine (medication for pain) and Silvadene 1% (medication used to treat and prevent wound infections in people with severe burns) on the resident's right upper lateral hip. A review of Resident 108's admission record indicated Resident 108 was originally admitted to the facility on 12/24/2021 and readmitted on 1/13/2024 with diagnoses that included diabetes mellitus type II (DM- high blood sugar), chronic (on-going) obstructive pulmonary disease (COPD- a lung disease causing restricted airflow and breathing problems), congestive heart failure (CHF- a weak heart), peripheral vascular disease (the narrowing of blood vessels) cervical spinal stenosis (narrowing of the spinal canal), abnormalities of the gait and mobility and generalized muscle weakness. A review of Resident 108's medical record titled, "Change in Condition" (CIC- a deterioration in health, mental, or psychosocial status in either life-threatening circumstances or clinical complication), dated 4/2/2024, indicated, "Resident's care provider (Medical Doctor -MD) was notified of coffee burn on 4/2/2024 at 7:30am. The MD ordered to apply Lidocaine (dose not indicated) for pain not on the blister and Silvadene 1% to Resident 108's right hip 2nd degree burn. A review of Resident 108's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 5/29/2024, indicated Resident 108's cognition (the mental ability to understand and make decisions of daily living) was intact, required partial/moderate assistance with eating and upper body dressing. The MDS indicated Resident 108 was dependent on staff for dressing. The MDS indicated Resident 108 was non-ambulatory. A review of Resident 108's medical record on 6/27/2024 with MDS coordinator, the medical record titled, "Progress Note dated 4/27/2024-6/27/2024" were reviewed. The progress notes indicated the facility did not take the initial and rogress pictures of the burn injury, did not conduct/complete burn injury evaluation assessment, did not perform/complete burn injury measurement and/or did not document the degree level of the burn injury. During initial tour observation and concurrent interview with Resident 108 on 6/25/24 at 9:50 AM, Resident 108 was observed in bed with both hands covered with a towel. Resident 108 did not move either hands. Resident 108 stated that on 4/2/2024 during early hours of the morning on the 11PM-7 AM shift, Resident 108 requested CNA7 to heat up some hot water using Resident 108's electric hot water kettle on the resident's bedside table and make a cup of coffee for the resident. Resident 108 stated CNA7 heated water in an electric hot water kettle owned by the resident and made a cup of coffee for the resident. Resident 108 stated CNA7 placed the cup with hot coffee on the resident's bedside table and told Resident 108 to wait a few minutes because the coffee was still hot. Resident 108 stated Resident 108 waited for few minutes (unable to recall the wait time) then grabbed the coffee cup from the bedside table, tried to bring the cup of hot coffee close to the her mouth, and the resident spilled the coffee on herself. The resident states she has hand tremors (shaking or trembling movements). Resident 108 stated she sustained burns to the right hip as a result. During an interview on 6/25/2024 at 3:19 PM, the Director of nursing (DON) stated the DON could not recall the exact date Resident 108 sustained the 2nd degree burn. The DON stated the DON did not investigate how Resident 108 sustained the 2nd degree burn to the right upper lateral hip. The DON stated DON did not report the incident to the appropriate agencies as required by law because there was no suspicion of abuse. A review of Resident 108's "Summary Report" with active orders from 6/27/2024, indicated the change the treatment orders for Resident 108 as follows: 1. Right Hip fragile (delicate) scar: Cleanse (wash) with Normal Saline (NS- Solution for wound care), pat dry, apply triple antibiotic (medication to prevent/treat infection) and cover with dry dressing (DD) daily (QD) and as necessary (PRN) x 14 days ... 2. Right hip reddened area/peeled area: Cleanse with NS, pat dry, apply xeroform (non-stick wound care material) and cover with foam dressing (a bandage that cushions a wound) QD and PRN x 14 days ... During an observation of treatment and measurement of Resident 108's right hip burn injury by Treatment Nurse 1 (TX1) on 6/27/2024 from 11:13 AM, Resident 108's right hip burn injury was measured by the TX1. The burn injury measured 13 centimeters (cm- unit of measurement) x 12cm, pink in color with some bleeding observed. TX1 cleansed the burn injury with NS, patted the wound dry, applied triple antibiotic then applied xeroform dressing and covered the wound with foam dressing. During a concurrent interview and record review, TX1 stated that on 4/2/2024 at 7 AM, a change of condition evaluation regarding Resident 108's burn was documented, Resident 108's care provider (MD) was notified at 7:30AM. A treatment order for Lidocaine for pain, not on the blisters and Silvadene 1 % was given and carried out. Resident TX1 stated she did not assess, measure and document Resident 108's 2nd degree burn injury because the burn injury was red and blistered (a fluid filled sac). TX1 stated Resident 108 sustained the burn injury from hot coffee prepared and provided by CNA7. TX1 stated CNA7 boiled water and made the coffee for Resident 108 using Resident 108's personal hot water kettle. During an interview on 6/27/2024 at 4:11 PM, CNA7 stated that on 4/2/2024 at about 7 AM, CNA7 used Resident 108's personal electric hot water kettle to boil water and made coffee for the resident. CNA7 stated the electric hot water kettle was on top of Resident 108's bedside table. CNA7 stated CNA7 left the cup of hot coffee at Resident 108's bedside and instructed the resident not to touch the coffee, and to let the coffee cool down because the coffee was hot. CNA7 stated that on 4/2/2024 during 11 PM - 7 AM shift, CNA7 found out that Resident 108 had accidentally spilled the very hot coffee on herself [Resident 108], sustained a burn on the right hip, and a bandage/dressing was applied. A review of the facility's policy and procedures (P&P) titled "Safety and Supervision of Resident," revised 1/2024 indicated, "Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The risk factors and environmental hazards include Electrical safety and water temperatures." A review of facility's P&P titled, "Assistance with Meals," dated 1/2024, indicated, "Residents shall receive assistance with meals in a manner that meets the individual needs of each Resident. Facility will serve...and will help residents who require assistance with eating." The facility failed to provide an environment that is safe and free of hazards for Resident 108 by failing to: 1. Ensure the staff did not leave a hot cup of coffee at Resident 108's bedside table. 2. Ensure CNA7 did not prepare hot liquid in an electric water kettle on the resident's bedside table, served, and left the cup of hot coffee unattended within the resident's reach. 3. Ensure a licensed nurse assessed and measured Resident 108's skin immediately after the resident was burnt with the hot coffee. As a result, on 4/2/2024, Resident 108 reached, grabbed, and spilled the hot cup of coffee onto the resident's right upper lateral hip resulting in a 2nd degree burn injury and pain, and treatment with Lidocaine and Silvadene 1% on the resident's right upper lateral hip. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result for Resident 108.