Health inspection·August 15, 2024

42 CFR §483.25 (d)(2) Accidents. The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. 42 CFR §483.21(b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident. 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. (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 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. On 6/20/2024, the California Department of Public Health (CDPH) received a complaint regarding a resident-to-resident altercation. On 7/1/2024, an unannounced visit was conducted at the facility to investigate the allegation. During the investigation, three residents were observed with smoking paraphernalia (lighters and cigarettes) in their possession. The facility failed to ensure: a. Resident 1 did not have a cigarette lighter in her purse on 7/2/2024 at 1:45 p.m. b. Resident 2 did not have a lighter on her wheelchair seat while in the room, on 7/2/2024 at 1:50 p.m. c. Resident 3 was not holding a lighter while coming out of his room on 7/2/2024 at 2 p.m. d. Its Nursing Manual-Resident Rights, titled, "Smoking Residents," which indicated the Interdisciplinary Team ([IDT] group of healthcare professionals working together to provide residents with needed care) will develop an individualized plan of care for safe storage, use of smoking materials, assistance and/or required supervision, for residents who smoke, was implemented. These failures had a potential for Residents 1, 2, and 3 to turn on the lighters, cause a fire which could result in serious injuries, hospitalization, and death for all 56 residents in the facility, staff, and visitors. a). A review of Resident 1's Admission Record indicated Resident 1 was a 60-year-old female, originally admitted to the facility on 11/20/2023 and re-admitted on 6/5/2024. Resident 1's diagnoses included schizoaffective disorder (a mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors), generalized anxiety disorder (persistent worrying), and nicotine dependence (addiction of). A review of Resident 1's care plan titled "Risk for injury related to smoking," dated 6/5/2024, indicated Resident 1 was an assisted smoker and required supervision. The care plan interventions indicated staff will enforce (implement) supervised smoking hours during scheduled times in the designated smoking patio. A review of Resident 1's "IDT Conference Review", dated 6/10/2024, indicated the purpose of the conference was to ensure Resident 1 smoked safely. The IDT goals indicated staff will keep offering Resident 1 an apron (burn protector for smokers) and encourage it's (apron) use. The interventions indicated staff will enforce the facility's smoking hours and supervise residents while smoking. The IDT Conference Review did not indicate a safe storage of Resident 1's cigarettes and lighter. A review of Resident 1's Minimum Data Set ([MDS] an assessment and care planning tool), dated 6/12/2024, indicated Resident 1 had clear speech and had the ability to express ideas and wants, and understood. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, and upper body dressing. During a concurrent observation and interview on 7/2/2024 at 1:45 p.m., Resident 1 was observed sitting on her bed with a cigarette lighter in her purse. Resident 1 stated cigarette breaks were scheduled several times a day and she did not have to ask for a lighter or cigarette from anyone since she already had hers. Resident 1 stated she was unsupervised during some cigarette breaks. Resident 1 stated staff did not check her belongings for the presence of cigarettes or lighters. Resident 1 stated she would feel horrible (fearful) if someone stole her lighter and set a fire, in the facility. During a concurrent interview and record review on 7/3/2024 at 1:40 p.m. with the DON, Resident 1's "Smoking and Safety" form dated 6/5/2024 and Resident 1's care plan titled "Risk for injury related to smoking" dated 6/5/2024 were reviewed. The DON stated Resident 1's "Smoking and Safety" form indicated Resident 1 was able to smoke cigarettes without supervision but did not indicate how the smoking materials will be stored. The DON stated Resident 1's care plan titled "Risk for injury related to smoking," indicated Resident 1 was an assisted smoker and required supervision. The DON stated the care plan interventions did not indicate how Resident 1's cigarettes and lighter will be stored. The DON stated the care plan and smoking, and safety form were misleading, and staff could not implement appropriate interventions to prevent negative outcomes due to the inconsistency of the documents. The DON stated the care plan did not indicate a safe storage of Resident 1's cigarettes and lighter. 2). A review of Resident 2's Admission Record indicated Resident 2 was a 69-year-old-male, admitted to the facility on 1/12/2024, with diagnosis of metabolic encephalopathy (alteration in consciousness due to brain dysfunction), urinary tract infection ([UTI] infection in urinary system, which may include kidneys, ureters, bladder, or urethra), and unsteadiness on feet. A review of Resident 2's "IDT Conference Review," dated 1/16/2024, indicated Resident 2 was safe to smoke independently. The IDT Conference Review indicated staff will explain the facility's smoking policy, store smoking related materials per facility policy and supervise Resident 2, per the smoking assessment. A review of Resident 2's "Smoking and Safety" form dated 4/20/2024, indicated Resident 2 used tobacco and required assistance and supervision when smoking. The "Smoking and Safety" form indicated staff will apply a smoking apron on Resident 2, extinguish (blow out) the resident's cigarette, and refer to the IDT, if Resident 2 was deemed unsafe to smoke. The form did not indicate how Resident 2's cigarettes and lighter were stored. A review of Resident 2's MDS, dated 4/20/2024, indicated Resident 2 had a clear speech and had the ability to express ideas and wants, and understood. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, and personal hygiene. A review of Resident 2's care plan titled, "Risk for injury related to smoking, an assisted smoker requiring supervision, and refusing to wear an apron," dated 7/1/2024, indicated staff will keep offering and encouraging Resident 2, to use an apron, to protect the resident. The care plan interventions indicated staff will enforce supervised smoking hours at scheduled times in the designated smoking patio. The care plan interventions indicated staff will light Resident 2's cigarette and bring the cigarette to his mouth for assistance. The care plan did not indicate how Resident 2's cigarettes and lighter were stored. During an observation and interview on 7/2/2024 at 1:50 p.m., Resident 2 was observed lying in bed and a wheelchair next to his bed. An orange cigarette lighter was observed on the seat of the wheelchair. Resident 2 stated he kept his cigarettes and lighter and smoked as needed without staff's supervision. Resident 2 stated he would feel horrible if someone stole his cigarette lighter and use the lighter to start a fire in the facility. During a concurrent interview and record review on 7/3/2024 at 1:45 p.m. with the DON, Resident 2's "IDT Conference Review", dated 1/16/24 was reviewed. The DON stated the IDT conference review goals and outcomes indicated staff will give Resident 2 smoking related material per facility's protocol and supervise the resident per his smoking assessment. The DON stated smoking materials were supposed to be stored by the activities department. The DON stated all residents were supposed to be supervised during smoking to prevent burn related injuries. The DON stated the safe storage of Resident 2's cigarettes and lighter was not indicated in the plan of care. 3). A review of Resident 3's Admission Record indicated Resident 3 was a 54-year-old male, originally admitted to the facility on 4/11/2024 and re-admitted on 6/11/2024. Resident 3's admitting diagnoses included schizoaffective disorder, suicidal ideations (act of thinking about or a state of preoccupation with taking one's own life) and homicidal ideations (a thought pattern characterized by the desire to kill another person or persons, along with a mental plan for a method of doing it). A review of Resident 3's "Smoking Safety" form, dated 6/6/2024, indicated Resident 3 utilized (used) cigarettes and supervision was required during designated smoking times. A review of Resident 3's MDS, dated 6/10/2024 indicated Resident 3 had severe cognitive impairment (ability to think and reason). The MDS indicated Resident 3 was independent with eating, toileting, and personal hygiene. A review of Resident 3's "IDT Conference Review", dated 6/14/2024, indicated Resident 3 was safe to smoke independently. The IDT Conference Review indicated staff interventions included to store smoking materials per facility protocols, explain facility smoking policy to Resident 3, and assist Resident 3 to and from the designated smoking area. A review of Resident 3's care plan titled "At risk for injury related to smoking, an assisted smoker requiring supervision and refusing to wear apron," dated 6/14/2024, indicated staff will enforce supervised smoking hours in the designated smoking patio. The care plan did not indicate if Resident 3 required his cigarettes and lighter stored. During an observation and interview on 7/2/2024 at 2 p.m., Resident 3 was observed coming out of his room, holding a lighter. Resident 3 refused to answer what could happen if he lost his cigarette lighter and/or someone stole his cigarette lighter. During an observation on 7/2/2024 at 3:45 p.m., in the smoking patio, Resident 3 was observed smoking a cigarette by himself, and unsupervised. During a concurrent interview and record review on 7/3/2024 at 1:55 p.m. with the DON, Resident 3's "Smoking Safety Evaluation", dated 6/6/2024 was reviewed. The DON stated, the Smoking Safety Evaluation indicated Resident 3 smoked cigarettes and required supervision during designated smoking times. The DON stated the Activity's Department kept the lighters and cigarettes in an unlocked, unsecured tacklebox (utility box). The DON stated she was unaware if residents were stealing cigarettes and lighters from the tacklebox. The DON stated unsecured cigarettes and lighters were a safety concern in case residents light cigarettes and smoked in a room where other residents might be using oxygen. A review of the facility's Nursing Manual-Resident Rights, titled, "Smoking Residents," dated 8/18/2023, indicated the licensed nurse will assess residents who express a desire to smoke upon admission, quarterly, annually and upon significant change of condition, and present to the interdisciplinary team (IDT) for review. The manual indicated, the IDT will develop an individualized plan of care for safe storage, use of smoking materials, assistance and/or required supervision, for residents who smoked. The facility failed to ensure: 1. A comprehensive person-centered care plan was developed and implemented for the safe storage of smoking paraphernalia. 2. Resident 1 did not have a cigarette lighter in her purse on 7/2/2024 at 1:45 p.m. 3. Resident 2 did not have a lighter on her wheelchair seat while in the room, on 7/2/2024 at 1:50 p.m. 4. Resident 3 was not holding a lighter while coming out of his room on 7/2/2024 at 2 p.m. 5. Its Nursing Manual-Resident Rights, titled, "Smoking Residents," which indicated the IDT will develop an individualized plan of care for safe storage, use of smoking materials, assistance and/or required supervision, for residents who smoke, was implemented. These failures had a potential for Residents 1, 2, and 3 to turn on the lighters, cause a fire which could result in serious injuries, hospitalization, and death for all 56 residents in the facility, staff, and visitors. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.