Other·April 26, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00888596. Representing the Department, HFEN # 43452. A Class B Citation was written. REGULATORY VIOLATIONS: 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. 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. 22 CR § 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. 22 CCR § 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. On 3/8/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about a resident's death. The facility failed to implement its policy on Unusual Occurrence Reporting by not notifying CDPH local district office of Resident 1's unexpected death that occurred on 2/12/2024 after the resident was found unresponsive. As a result, CDPH was not aware of Resident 1's unexpected death and learned about the resident's death from the resident's family. This also resulted in a delay of an onsite inspection by the Department of Public Health to investigate the circumstances surrounding Resident 1's death. A review of Resident 1's Admission Record, indicated the facility admitted Resident 1, a 70 years-old male on 1/27/2024 with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side, type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and peripheral vascular disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 12/1/2024, indicated Resident 1's cognitive skill for daily decision-making was intact and required supervision for activities of daily livings (ADLs- eating, oral hygiene, toileting hygiene). A review of Resident 1's Advance Healthcare Directive (ACHD - a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitated) Acknowledgment Form dated 1/29/2024, indicated Resident 1 wrote, "DNR", (do-not-resuscitate order, or DNR instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating). A review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST) paradigm form (a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration), dated 1/30/2024, indicated do not attempt resuscitation/DNR, the POLST form did not have a physician's name and no physician's signature. A review of Resident 1's Progress Notes dated 2/12/2024 at 10:51 a.m., indicated during morning medication pass, the charge nurse entered Resident 1's room at 9:50 a.m., to check the resident's blood pressure and resident (1) was found unresponsive. Resident (1) identified as a full code... immediately began CPR... During an interview on 3/8/2024 at 3:17 p.m., Social Services Director/Case Manager (SSD/CM) stated, Resident 1 communicated using a writing board. SSD/CM stated, she provided the ACHD acknowledgement form to Resident 1 on 1/29/2024 where Resident 1 wrote, "DNR" on the form per his request. SSD/CM stated, she did not follow-up with the physician and nursing staffs to initiate a DNR protocol. SSD/CM further stated, she did not document Resident 1's request of DNR which is the resident's right. During an interview on 3/8/2024 at 3:36 p.m., Licensed Vocational Nurse 1 (LVN 1) stated, Resident 1 was found unresponsive on 2/12/2024. LVN 1 stated, the facility's staff provided CPR on Resident 1 upon reviewing his POLST. LVN 1 stated, Resident 1's death was unexpected as he was able to walk to go to the bathroom upon delivering of his breakfast tray at around 8:30 a.m. During an interview on 3/8/2024 at 3:47 p.m., Registered Nurse 1 (RN 1) stated, Resident 1 was found unresponsive, had no pulse and no rise, and fall of the chest. RN 1 stated, they (facility staff) identified Resident 1 was a full code (if a person's heart stopped beating or breathing, the person will allow all medical measures to be taken to maintain and resuscitate life) and provided CPR. RN 1 stated, Resident 1 expired on 2/12/2024. During an interview on 3/8/2024 at 5:33 p.m., Director of Nursing (DON) stated, Resident 1's death was not reported to the State Agency. A review of the facility's policy and procedure (P&P) titled, "Death of a Resident", reviewed date 1/18/2024, the P&P indicated, if a resident dies as a result of unnatural causes or catastrophe, the Facility must report the death within 24 hours by telephone, and confirmed in writing, to the local health officer and the Department of Public Health. A review of the facility's P&P titled, "Unusual Occurrence Reporting", reviewed date 1/18/2024, the P&P indicated, the facility will follow all applicable state and federal laws and regulations regarding the reporting of unusual occurrences... Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing." The facility failed to implement its policy on Unusual Occurrence Reporting by not notifying CDPH local district office of Resident 1's unexpected death that occurred on 2/12/2024 after the resident was found unresponsive. As a result, CDPH was not aware of Resident 1's unexpected death and learned about the resident's death from the resident's family. This also resulted in a delay of an onsite inspection by the Department of Public Health to investigate the circumstances surrounding resident 1's death. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1.