Health inspection·December 17, 2024

The following reflects the findings of the California Department of Public Health during the investigation of the Facility Reported Incident Number CA00926214. A WMF Citation (WMF) was written for the Facility Reported Incident Number CA00926214. 1424 (f) (1) Any willful material falsification or willful material omission in the health record of a patient of a long-term health care facility is a violation. (2) "Willful material falsification," as used in this section, means any entry in the patient health care record pertaining to the administration of medication, or treatments ordered for the patient, or pertaining to services for the prevention or treatment of decubitus ulcers or contractures, or pertaining to tests and measurements of vital signs, or notations of input and output of fluids, that was made with the knowledge that the records falsely reflect the condition of the resident or the care or services provided. On 11/04/2024, an unannounced visit was conducted at the facility to investigate an abbreviated survey regarding falsification of resident records. The facility failed to ensure that staff did not falsify Resident 2's medical records when the Director of Nursing (DON) documented that the DON received an order for "no new orders, 72 hours monitoring per COC protocol" from Medical Doctor 1 (MD 1) when Resident 2 was displaying inappropriate sexual behavior (blowing kisses in the air to LVN [Licensed Vocational Nurse] 3). As a result, the facility inaccurately documented the physician's order in Resident 1's chart. review of Resident 2's face sheet (Admission Record- a document containing demographic and diagnostic information), indicated, Resident 2 was admitted to the facility on 6/16/2024 with diagnoses including: epilepsy (a long-lasting brain disorder that causes seizures causing abnormal electrical activity in the brain), metabolic encephalopathy (brain dysfunction caused by an underlying condition), and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2's history and physical (H&P - a physician's complete patient examination) dated 7/06/2024, the H&P indicated, Resident 2 had intermittent (not happening regularly or continuously) capacity to make decisions. During a review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/12/2024, the MDS indicated, Resident 2 was cognitively intact (mental ability to make decisions on activities of daily living), used a wheelchair to assist with ambulation, and required staff assistance with dressing and personal hygiene care. During a review of Resident 2's Physician Progress Notes dated 11/01/2024, indicated, the physician progress notes indicated Resident 2 had intermittent capacity to make decisions. Review of Resident 2's Short Term Problem notes dated 11/04/2024, indicated, Resident 2 had a problem of inappropriate behavior (Resident 2 telling LVN 3 "I love you" and blew kisses in the air to LVN 3) towards staff. The goal was for Resident 2 not to have inappropriate behavior towards staff. The plan for Resident 2 was to encourage proper verbalization of needs towards the staff, monitor vital signs, provide activity as desired and follow up with a psychiatrist. During a review of Resident 2's care plan (a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient), dated 11/04/2024, under problem, indicated Resident 2 was displaying inappropriate sexual behavior as evidenced by making comments to male staff. During an interview on 11/04/2024 at 1:21 PM with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated Resident 2 said something inappropriate to LVN 3. LVN 3 stated on 11/03/2024 "around 8 AM-8:30 AM, [Resident 2] was eating breakfast...while checking the resident's blood pressure, Resident 2, said to me I love you [LVN 3] then made kisses in the air. I was very uncomfortable. I told him to stop it" and then Resident 2 became quiet when asked if LVN 3 reported the incident, LVN 3 stated "no...my thinking is, if it happens again then that's a pattern then I will report it. I know what [Resident 2] did to me was inappropriate." When asked if Resident 2 had been similarly inappropriate with other residents in the facility, LVN 3 stated "no." During a telephone interview on 11/05/2024 at 4:21 PM with MD 1, MD 1 was asked if any of the facility's licensed nurses contacted MD 1 regarding Resident 2's inappropriate behavior where Resident 2 said "I love you" and blew kisses to a staff, MD 1 stated, "no one called me." MD 1 stated MD 1 checked all emails and text messages, but no messages were found. MD 1 stated, "I would have remembered that incident." MD 1 stated the facility staff should have called MD 1 about the incident on the same day of the incident. MD 1 stated "the staff will feel uncomfortable, will not feel safe at work. The patients (residents) will not feel safe; it is an inappropriate behavior." During a concurrent interview and record review of Resident 2's Situation, Background, Assessment, Recommendation (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) dated 11/04/2024 at 5 PM, the SBAR indicated the DON documented that the DON took a telephone order from MD 1 on 11/04/2024 at 5 PM for "no new orders, 72 hours monitoring per Change of Condition (COC - a significant change in a resident's health or functional status protocol). The SBAR also indicated under the nursing notes: "MD notified with no new orders noted. Resident [2] was inappropriate towards male charge nurse as evidenced by blowing kisses." DON confirmed and stated that she documented/completed the SBAR. During an interview and concurrent record review on 11/05/2024 at 5:11 PM with the DON, Resident 2's SBAR dated 11/04/2024 at 5 PM, was reviewed. The DON stated LVN 3 notified the DON that Resident 2 exhibited inappropriate behavior by blowing kisses to LVN 3 while LVN 3 was taking Resident 2's blood pressure. The DON stated that on 11/04/2024 at 5 PM, DON contacted MD 1 twice through MD 1 answering service operator. DON stated, "Whoever answered the phone (MD 1's answering service) told me, "No new orders, 72 hours monitoring." When asked if DON talked/spoke to MD 1 on the phone, DON stated, "No, not directly (to MD 1), no." When asked about the facility's protocol regarding follow up with a physician, DON stated, "I don't know." The DON confirmed and stated that she (DON) documented that on 11/04/2024 she spoke with MD 1 and received "No new orders, 72 hours monitoring" on Resident 2's SBAR about the resident's inappropriate behavior. During a concurrent interview and record review on 11/05/2024 at 5:51 PM with the Administrator (Adm), Resident 2's SBAR written by the DON dated 11/04/2024 at 5 PM was reviewed with Adm. The SBAR indicated Resident 2 had an inappropriate behavior towards a staff. When asked what the facility's protocol is when a doctor does not return a nurse's call about a resident, Adm stated "you call again maybe 1 or 2 more times, if no answer, call the Medical Director." Adm stated "a doctor must be notified about a resident's COC, to give orders, treatments, and treatment plans." Adm stated because of Resident 2 having inappropriate behavior, the staff will have negative emotions, ignore, and may resent Resident 2. The surveyor informed Adm that MD 1 informed the surveyor that MD 1 did not receive any telephone calls from any licensed nurses about Resident 2's inappropriate behavior. The surveyor informed Adm that the DON took the order "no new orders, 72 hours monitoring per COC protocol" directly from the answering service operator/staff and that DON did not take/speak with MD 1. When Adm was asked what Adm would call DON's documentation on a medical record, Adm stated, "well...she did not reflect the truth." During a review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled "Telephone Orders" reviewed on 7/12/2024, indicated, "Entry must contain the instructions from the physician... The nurse transcribing the order must read the order back to the physician to ensure that the information is clearly understood and correctly transcribed." During a review of the facility's P&P titled "Change of Condition" reviewed on 7/12/2024, indicated, "any sudden or serious change in a resident's condition...will be communicated to the physician..." and "if unable to contact attending physician or alternate physician timely, the facility's medical director will be notified. Recommendations by the physician will be documented on the Advanced SBAR Change of Condition Documentation/COC form." During a review of the facility's P&P titled "Physician Services" reviewed on 7/12/2024, indicated, "a physician provides... treatment when contacted by the facility." The facility failed to ensure that staff did not falsify Resident 2's medical records when the DON documented that the DON received an order from MD 1 when Resident 2 was displaying inappropriate sexual behavior and got into a fight with Resident 1. As a result, the DON documented that on 11/04/2024, the DON received a "No new orders. 72 hours Monitoring" order from MD 1 inaccurately. The DON spoke with the answering service for MD 1 and did not speak with MD 1. The above facts indicate that there was a willful material falsification in the medical records for Resident 2.