Health inspection·May 10, 2023

42 CFR § 483.40 Behavioral health services Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident’s whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. 42 CFR § 483.21(b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following — (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. 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. 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. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. On 3/20/2023, the California Department of Public Health (CDPH) received a facility reported incident (FRI) regarding a resident (Resident 1) who was found hanging in the closet with a shoelace-like rope or string wrapped around his neck and expired. On 3/21/2023, CDPH conducted an unannounced visit at the facility. The facility failed to provide Resident 1 necessary behavioral health care and services for treatment of the resident’s emotional and mental condition by failing to: 1. Ensure Resident 1, who verbalized feelings of being depressed (serious mood disorder) for approximately five (5) months was assessed, monitored, and provided intervention to address Resident 1’s symptoms of depression. 2. Notify the physician, psychiatrist (a physician who specializes in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders), psychiatrist nurse practitioner, and interdisciplinary team ([IDT] group comprised of professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological [mental and emotional) needs) when Resident 1 verbalized feeling depressed. 3. Ensure Resident 1’s emotional and mental status were being monitored, supervised and a care plan was developed to addressed residents increasing depression. These deficient practices resulted in a lack of care plan interventions to address Resident 1’s increasing symptoms of depression and Resident 1 did not receive the necessary care, services, and interventions to address Resident 1’s emotional, behavioral, and psychosocial (the psychological dimension [internal, emotional, and thought processes, feelings, and reactions] and the social dimension [ includes relationships, family and community network, social values and cultural practices] of a person) needs. Resident 1 died by suicide by hanging himself in the resident’s closet. Paramedics pronounced Resident 1 dead on 3/19/2023 at 1:57 a.m.  A review of Resident 1’s Admission Record (face sheet), dated 3/21/2023, indicated Resident 1 was an 86 year-old male, admitted to the facility on 1/11/2020, and readmitted on 6/15/2020 with diagnoses including delusional disorder (characterized by one or more firmly held false beliefs that persist for at least one month), cardiac arrhythmia (irregular heartbeat), presence of cardiac pacemaker (a small device that was placed in the chest to help control the heartbeat to prevent the heart from beating slowly), and hypertension (high blood pressure). A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 2/20/2023, the MDS indicated the resident’s cognitive (the ability to think and process information) skills for daily decisions making were mildly impaired, and the resident required supervision for activities of daily living. The MDS indicated Resident 1 had no active diagnosis of depression. During a concurrent interview and record review of MDS section D (Mood) on 3/26/2023 at 10:00 a.m., Social Service Assistant (SSA1) stated that she conducted a Resident Mood Interview using PHQ9 (nine [9] item Patient Health Questionnaire- a validated interview that screens for symptoms of depression) questionnaires with Resident 1 on 10/25/2022, 1/23/2023 and 2/20/2023. SSA 1 stated she asked Resident 1 if over the last two weeks, was he bothered by any of the following problems listed on the PHQ 9 questionnaire: a. Little interest or pleasure in doing things. b. Feeling down, depressed, or hopeless. c. Trouble falling or staying asleep or sleeping too much. d. Feeling tired or having little energy. e. Poor appetite or overeating. f. Feeling bad about your self- or that you are a failure or have let yourself or your family down. g. Trouble concentrating on things, such as reading the newspaper or watching television, h. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual. i. Thoughts that you would be better off dead or hurting yourself in some way. The MDS PHQ-9 from 10/2022 to 2/20/2023 indicated the following: On 10/25/2022, the MDS indicated a decline in mood. Resident 1 was feeling down, depressed, or hopeless nearly half or more of the days for 7-11 days. The MDS indicated Resident 1 was feeling bad about self or that he was a failure or had let himself or his family down nearly every day for 12-14 days. On 1/23/2023 and 2/20/2023 the MDS indicated a further decline in the resident’s mood. Resident 1 was feeling down, depressed, or hopeless nearly every day for 12-14 days. The MDS also indicated Resident 1 was feeling bad about self or that he was a failure or have let himself or family down nearly every day for 12-14 days. A review of Resident Assessment Instrument (RAI) Manual for Long Term Care Facility 3.0 User’s Manual Version 1.17 dated October 2019 indicated Responses to PHQ-9 can indicate possible depression. Responses can be interpreted as follows: Minor Depressive Syndrome is suggested if, of the 9 items, (1) feeling down, depressed or hopeless, (2) trouble falling or staying asleep, or sleeping too much, or (3) feeling tired or having little energy are identified at a frequency of half or more of the days (7-11 days) during the look-back period and at least one of these, (1) little interest or pleasure in doing things, or (2) feeling down, depressed, or hopeless is identified at a frequency of half or more of the days (7-11 days). A record review of Resident 1’s Social Service (SS) Assessment -Type Quarterly, dated 10/31/2022 and 1/23/2023, indicated Resident 1 spent most of his time alone or watching television, and the resident napped regularly throughout the day. The SS Assessment indicated over the last two weeks, Resident 1 had been bothered by feeling or appearing down, depressed, or hopeless, feeling bad about himself, feelings of failure, or letting self or family down, expressed adjustment issues, expressed difficulty coping with current health status and rejection of care occurred daily. The Social Service Plan indicated the following: a. Establish/continue a positive, trusting relationship with resident and family. b. Communicate with resident, family, interdisciplinary team to assess for home care needs upon discharge and coordinate appropriate referrals c. Participate in ongoing communication with the interdisciplinary team to identify and accommodate resident specific needs. d. Address psychosocial needs (mood, behavior, communication, and mental status), invite to resident-to-resident council meetings e. Invite resident to care plan meetings. f. Covert/open conflict with or repeated criticism of staff. During an interview on 3/26/203 at 10:15 a.m., SSA 1 stated she was not sure if she mentioned Resident 1’s increasing symptoms of depression to the nurses and said she might have mentioned the result of the Social Service Assessment to Social Service Director (SSD) 1 but SSD 1 no longer works at the facility. SSA 1 stated she did not document she notified SSD 1 or any nurses and did not recall notifying SSD 2, the physician, or the psychiatrist regarding Resident 1’s symptoms of depression. SSA1 stated SSD 3 had not started working at the facility at that time. SSA 1 was unable to say or provide documentation of how Resident 1’s symptoms of depression were addressed including a social service plan. During an interview on 3/26/2023 at 10:45 a.m., the Director of Nursing (DON) stated SSD 1 last physically worked at the facility on 12/15/2022. The next SSD was SSD 2, who was hired on 1/19/2023 and last worked at the facility on 2/24/2023. The next SSD was SSD 3, who just started working on 3/20/2023. During a review of the Care Area Assessment ([CAA] provide guidance to focus on key issues identified in comprehensive MDS; direct staff to evaluate triggered areas) worksheet dated 11/8/2022, indicated Resident 1’s “mood interview total severity score, and frequency was greater than the prior assessment and triggered mood state as potential problem.” The CAA indicated to assess and refer accordingly, psychiatry (the medical specialty devoted to the diagnosis, prevention, and treatment of mental conditions) consults as needed and proceed to care planning to focus on safety, nutritional status, health activity pattern, and ensuring the resident was not a danger to self or others. A review of the CAA worksheet dated 11/8/2022, indicated behavioral symptoms were triggered as a potential problem due to Resident 1 rejecting evaluation of care daily, changes in behavior, and care rejection or wandering has gotten worse since the prior assessment. Resident 1 rejected care that was necessary to achieve his goals for health and well-being. Resident 1 had episodes of refusing nursing care including medications. The CAA indicated to proceed to care planning to focus on the resident’s safety, nutritional status, behavior approach, health activity pattern, and ensuring the resident was not a danger to self and others. During a concurrent interview and record review on 3/26/2023 at 11:00 a.m., with SSA 1, MDS Coordinator (MDSC 1), and the DON, Resident 1’s clinical record from January 1, 2022, to March 26, 2023, were reviewed including the care plan, IDT notes, physician notes, nurses progress notes, Change of Condition ([COC] a clinical deviation from a resident's baseline), psychiatrist, and psychosocial notes. SSA 1, MDSC 1, and the DON all verified and stated there was no documentation in Resident 1’s electronic or paper clinical record that indicated Resident 1’s depression was communicated to or addressed by the physician, psychiatrist, or psychologist. SSA 1, MDSC 1 and the DON verified that the referral for the psychiatrist and psychologist were for refusing medications and was not a referral to address Resident 1’s symptoms of depression. During an interview with MDSC1 on 3/26/23 at 10:30 a.m., and concurrent review of Resident 1’s IDT meeting notes from January 1, 2022, to 3/26/2023, MDSC 1 stated the IDT notes did not indicate the IDT addressed a plan of care how to address Resident 1’s verbalization of feeling depressed and hopeless. A review of Resident 1’s care plan titled “Non-Compliance Behavior”, date initiated 12/1/2021 and revised 3/20/2023, indicated Resident 1 manifested refusing medications, sudden outbursts of anger, aggressive behavior, and Resident 1 expressed feeling down, hopeless, and bad about self. The care plan did not indicate an individualized plan of care to address Resident 1’s continued verbalization of feeling depressed on 10/25/2022, 1/23/2023 and 2/20/2023. The care plan goal was to minimize adverse effects of non-compliant behavior of refusing medications and did not indicate a goal to ensure Resident 1’s depression will be resolved or improved. The care plan did not address how Resident 1 will be monitored and ensure Resident 1 will not harm himself or others as indicated on the CAA. A review of Resident 1’s Psychiatrist Note, dated 11/22/2022, indicated Resident 1 continued to refuse to be seen by psychiatry, per nursing there was no acute problematic or concerning behaviors and Resident 1 was not on a psychotropic (drugs that affect a person's mental state) regimen. Resident 1 was receiving Depakote (used to prevent migraine headaches, seizures [sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness], or to treat manic [period of abnormally elevated, extreme changes in mood or emotions, energy level or activity level] episodes related to bipolar disorder [condition that causes extreme mood swings]) for seizures. A review of Resident 1’s Psychiatrist Note, dated 1/11/2023, indicated Resident 1 was refusing assessment and there were no behavioral concerns per nursing. A review of Resident 1’s Psychiatrist Note, dated 2/8/2023, indicated Resident 1 did not wish to be seen by psychiatry and per nursing there were no acute problematic behaviors or concerns. The psychiatrist would remain available if Resident 1 was willing to be interviewed. The Psychiatric Note indicated staff were aware of the emergent option to call for Psychiatric Emergency Teams ([PET] mobile teams operated by psychiatric hospital to perform evaluations for involuntary detention of individuals determined to be at risk of harming themselves or others or who are unable to provide food, clothing, or shelter because of a mental disorder) if needed. A review of Resident 1’s Psychiatrist Note, dated 3/8/2023, indicated staff requested evaluation to see Resident 1 but Resident 1 refused a psychiatric evaluation and Resident 1 had no acute problematic behaviors present. The Psychiatric Note indicated per staff Resident 1 had been over all stable despite refusing care from psychiatry and advised staff that psychiatry would remain available for changes in behavior or to