Other·March 30, 2023

F742 §483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that- §483.40(b)(1) A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being 72523 (a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 73311(a) Nursing Service - General Nursing service shall include, but not be limited to, the following: (a)Identification of problems and development of an individual plan of care for each patient based upon initial and continuing assessment of the patient's needs by eh nursing staff and other health care professionals. The plan shall be reviewed and revised as needed but not less often than quarterly. 73313(a) -Nursing Service - Drug Administration Nursing service e shall include but not be limited to the following, with respect to the administration of drugs: (a) Medications and treatments shall be administered as prescribed and shall be recorded in patient's health records. On 1/20/2023 the California Department of Public Health (CDPH) received an anonymous complaint indicating "one resident stabbed two residents. One resident expired. One resident went to the hospital." On 1/20/2023 at 7:15 p.m., an unannounced visit was conducted at the facility to investigate the reported allegations. During the course of the investigation it was determined that Resident A was admitted to the facility on 11/14/2022, with diagnoses including schizophrenia (a mental disorder often characterized by abnormal social behavior and failure to recognize what is real), a psychotic disorder (a mental disorder characterized by a disconnection from reality), suicidal ideations (preoccupation with thoughts of suicide) with a plan in place for self-harm, and an order for the administration of Zyprexa (a medication used to treat schizophrenia). However, the diagnoses and medication were not transcribed to Resident A's current and active care regimen at the facility. On 1/20/2023 Resident A obtained a 7.5-inch knife, which he used to stab two residents (Residents B and C), who resided at the facility. Resident B was stabbed multiple times by Resident A in his neck and chest and expired from his wounds at the facility. Resident C was stabbed by Resident A in his abdomen and was transferred to a General Acute Care Hospital (GACH) where he underwent two surgical procedures and a blood transfusion because of his wounds. The facility failed to: 1. Develop a care plan (CP) with goals and interventions related to Resident A's diagnoses of schizophrenia, a psychotic disorder, suicidal ideations with a plan in place for self-harm, and a prescription for Zyprexa. 2. Conduct a comprehensive assessment and identify Resident A's diagnoses of schizophrenia, psychotic disorder, and suicidal ideations with a plan in place for self-harm. 3. Verify orders from the transferring physician, document/transcribe the orders to Resident A's current and active care regimen and administer a medication, Zyprexa, prescribed to Resident A from the transferring GACH. 4. Ensure Resident A did not leave the facility without an out on pass (OOP) order from the physician, per the facility's policy and procedure titled "Out on pass." 5. Ensure the facility's Marketer provided continued supervision to Resident A while out on pass with the resident at a local general store, to prevent Resident A from stealing a knife and using it later to stab and kill Resident B and stab and injure Resident C. As a result of these deficient practices Resident A's care needs based on his diagnosis of schizophrenia, psychotic disorder, and suicidal ideations with a prescription for Zyprexa were not identified nor met. Resident A was left alone and unsupervised at a local area general store on 1/20/2023, which subsequently led to Resident A stealing a 7.5-inch kitchen knife from that store, while unsupervised by facility staff, and later the same day (1/20/2023) use that knife to stab Resident B in his neck and chest and Resident C in his abdomen, leading to the death of Resident B and a major injury to Resident C. Findings: A review of Resident A's GACH records including the Face Sheet, History of Present Illness (HPI), Past Psychiatric History (PPH), Past Medical History (PMH), Mental Status Examination (MSE), Medical Impression and Plan (MIP), Discharge Instructions (DI), and Clinical Summary Report (CSR) was conducted. The reviewed records indicated the following: 1. According to the GACH's Face Sheet, Resident A was admitted to the GACH on 11/8/2022. 2. According to the HPI, Resident A, a 55-year-old male with a history of depression, psychotic disorder, and substance abuse, was admitted to the GACH for suicidal ideation with intention to cut himself. Resident A presented with target symptoms of depressed mood, anhedonia (inability to feel pleasure), anxiety (extreme worry), hopelessness, helplessness, insomnia (inability to sleep and/or remain sleep), and mood lability (rapid, often exaggerated changes in mood, where strong emotions or feeling [uncontrollable laughing or crying, or heightened irritability or temper] occur with suicidal thoughts. 3. According to the PPH, Resident A had a long history of chronic depression, psychosis as well as suicidal thoughts and has not been consistently taking his medications. 4. According to the MSE, Resident A was awake, oriented to self, place, and situation. His mood was depressed and anxious, his affect was blunted (a prominent symptom of schizophrenia in which the patient has difficulty expressing their emotions, characterized by diminished facial expression, expressive gestures, and vocal expressions in reaction to emotion provoking stimuli), and his thought process was linear (following one path a process in which answers are "yes" or "no"). Resident A's thought content was positive for suicidal ideation, his cognition was intact and his insight and judgment (awareness of themselves and their condition) was limited. 5. According to the PMH, Resident A was diagnosed with schizophrenia and psychotic disorder. 6. According to the MIP, Resident A needed psychiatric care and to continue medications. 7. According to the DI, dated 11/14/2022, under section titled, Problem List, Resident A had schizophrenia and suicidal ideations. 8. According to the CSR, Resident A was receiving Zyprexa 10 mg at bedtime, as an active medication ordered/recommended on discharge from the GACH. During a review of Resident A's skilled nursing facility (SNF) Admission Records (Face Sheet), the Face Sheet indicated Resident A was admitted to the facility on 11/14/2022 with diagnoses including pneumonia (lung infection), extrapyramidal ([EPS] involuntary movement disorders induced usually by antipsychotic medications and other mental and emotional conditions) and movement disorder (a group of nervous system (neurological) conditions that cause either increased movements or reduced/slow movements), recurrent major depressive disorder (MDD), hypertension ([HTN] a condition where the pressure of the blood in the blood vessels was higher than it should be), lack of coordination, and generalized muscle weakness. During a review of Resident A's SNF clinical records, the clinical records indicated, there was no written documentation of Resident A's diagnoses of schizophrenia, psychotic disorder, and/or suicidal ideations with intentions for self-harm including Zyprexa, which was not administered. During a review of Resident A's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/21/2022, the MDS indicated Resident A had no difficulty seeing, hearing, expressing his ideas and wants, understanding others or making himself understood. The MDS indicated Resident A was able to make independent decisions that were consistent and reasonable. During a review of Resident A's History and Physical (H&P), dated 11/15/2022, the H&P indicated Resident A had diagnosis of pneumonia, EPS disorder, MDD, HTN, lack of coordination, muscle weakness and a history of substance abuse. During a review of Resident A's care plans from 11/2022 through 1/2023, the review indicated there was no written documentation to indicate a care plan (CP) for the resident's diagnoses of schizophrenia, suicidal ideations, and/or the need for the administration of Zyprexa medication was developed to identify Resident A's care goal and staff's interventions related to Resident A's psychiatric diagnoses or the need for administration of Zyprexa medication. During a review of Resident A's Physician's Orders (PO) from 11/14/2022 through 1/20/2023, the PO indicated there was no written documentation indicating Resident A's diagnoses of schizophrenia, psychotic disorder, suicidal ideations, or an active order to administer Zyprexa or any antipsychotic medications to Resident A. During an interview on 1/23/2023 at 2:45 p.m., and subsequent interviews on 1/24/2023 at 1:10 p.m., and 2/1/2023 at 1:45 p.m., with the ADON, the ADON stated Resident A's H&P, from the transferring GACH, should have been reviewed by the admitting nurse and a care plan developed based on Resident A's care needs identified during admission to the facility and ongoing as the resident's care needs changed. The ADON stated Resident A's clinical records were currently being reviewed by management and they were aware of Resident A's transferring diagnoses of schizophrenia, psychotic disorder, and suicidal ideations, as well as the medication, Zyprexa, that was not transcribed to Resident A's orders upon admission (11/14/2023) to the SNF. The ADON stated they were looking into why the resident's medication was not transcribed as recommended by the GACH. The ADON stated during the residents' admission process the admitting orders and H&P from the transferring GACH should be reviewed by the admitting nurse and verified with the resident's attending physician and documented that this was done. On 1/21/2023 through 1/30/2023 (nine days), multiple attempts to interview the admitting nurse, LVN 2, were made by telephone and texts to no avail. During a review of Resident A's Change of Condition (COC) documentation, dated 1/20/2023 and timed at 3:45 p.m., the COC indicated "the staff" reported Resident A had an altercation with another resident. The residents were separated and 911 (emergency service) was called. The police arrived and Resident A was handcuffed and escorted out of the building by the police. During a review of Resident A's Nurses Progress Note (NPN) dated 1/21/2023 and timed at 2:32 a.m., the NPN indicated staff reported Resident A had an altercation with another resident. The residents were separated and 911 was called. During an observation on 1/20/2023 at 7:25 p.m., from approximately 15-20 feet, Resident B was observed lying on the floor in the hallway of the "Annex" Station, after being pronounced deceased (time unknown) by the local coroner (an official who investigates violent, sudden, or suspicious deaths). At approximately 8:15 p.m., on 1/20/2023, Resident C was observed being transported by the coroner out of the facility. During a review of the facility's video surveillance (close observation through a camera) the following was seen: On 1/20/2023, at approximately 3 p.m., Resident A was seen sitting on a cement wall adjacent to the facility's outside patio and across from the entrance to the "House" side of the facility. At approximately 3:10-3:15 p.m., Resident A was seen leaving the facility with a staff person, identified as the facility's Marketer. Approximately, 10-15 minutes later Resident A and the Marketer were seen on the video returning to the facility. Resident A was then seen going into the building's entrance leading to the "House" (name of area in the facility) side of the facility. Later in the video Resident A was seen coming from the "House" side of the facility, initially going toward the outside walkway (he is out of video view), then appearing again in the video, sitting on a chair just outside the door leading to the "Annex" (name of area in the facility) side of the facility. Resident A again goes out of video view for a few minutes but is assumed to have entered the facility because commotion of the staff indicated the stabbing incident happened during the time Resident A is out of video view. On 1/24/2023 at approximately 9:30 a.m., during a view of the facility's surveillance video (close observation through a camera) of the stabbing incident on 1/20/2023, there were two different views of the stabbing incident as follows: View #1 Resident C was seen entering the "Annex" (name of area in the facility) side of the facility through a door near the Annex nursing station. Resident C walked around the Annex nursing station and proceeded down the hallway. Resident C was halfway down the hallway and Resident A abruptly stood up and quickly walked down the same hallway toward Resident C. When Resident A was next to Resident C, he (Resident A) pulled out an object, resembling a knife, and stabbed Resident C in his left side (flank/abdomen area). Resident C turned and ran back toward the facility's exit and through the door he had previously came in. After Resident A stabbed Resident C and Resident C ran, Resident A turned his attention to Resident B, who was sitting in a wheelchair along the wall in the hallway. Resident A lunged at Resident B making at least three thrusting/jabbing motions, stabbing Resident B while Resident B was trying to push away and/or hold onto Resident A. Resident B fell from the wheelchair to the floor. Resident A was restrained by LVN 2 and the facility's Marketer while the staff attended to Resident B's injuries and started performing Cardiopulmonary Resuscitation ([CPR] an emergency procedure to help save a person's life when breathing and/or the heart stops). View #2 Resident A was seen entering the "Annex" side of the facility through a door on the outside patio area. Resident A sat in a chair that was lined up along the wall in the hallway, next to another resident, and Resident A started fidgeting (movements, especially of the hands and feet through nervousness or impatience). Resident A was seen pulling a wrapped object from the pocket of his jacket and unwrapped the object and placed the object on top of his thigh covering the object with his hand. A certified nurse assistant (CNA 1) was seen standing at the end of the hallway, approximately 10 feet from Resident A. CNA 1 appeared