Other·April 21, 2023

On 3/2/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint investigation related to accidents and quality of care for Resident 2. As a result of the investigation, CDPH determined that the facility failed to: 1. Provide behavioral management care and continuous 1:1 sitter (one person designated to always remain with the resident while assigned) monitoring and supervision to prevent accidents for Resident 2 who was on 5150 hold (a 72-hour long involuntary treatment hold in a hospital or mental health facility) for danger to others and gravely disabled (a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter) in accordance with the facility's policies and procedures titled "Behavior Management" revised on 1/16/2022 and "Resident Safety," revised on 4/15/2021. 2. Ensure Resident 2 received an accurate behavioral and mental evaluation after Resident 2 attempted to elope (a patient leaving a facility without notice), had aggressive behavior, and had a fall incident on 2/19/2023 in accordance with the facility's policies and procedures titled "Behavior Management" revised on 1/16/2022 and "Resident Safety," revised on 4/15/2021. 3. Notify the attending physician (MD 1-Medical Doctor), psychiatrist (MD 2), or the facility's medical director (MD) of Resident 2's aggressive and unmanageable behavior in a timely manner in accordance with the facility's policies and procedures titled "Behavior Management" revised on 1/16/2022 and "Resident Safety," revised on 4/15/2021. Resident 2 was not admitted to any General Acute Care Hospital (GACH) due to 5150 hold on 2/17/2023 and returned to the facility on 2/17/2023. 4. Facilitate transfer of Resident 2 to a facility that could provide the appropriate level of care in accordance with the facility's policies and procedures titled "Behavior Management" revised on 1/16/2022. 5. Conduct Interdisciplinary Team (IDT - a group of professionals with different functional expertise working toward a common goal) meeting to discuss plan of care regarding Resident 2 on 5150 hold and the Resident 2's aggressive behavior in accordance with the facility's policies and procedures titled "Behavior Management" revised on 1/16/2022 and "Resident Safety," revised on 4/15/2021. 6. Ensure that Resident 2's discharge planning was complete and appropriate, and that necessary information was communicated to the continuing care provider in accordance with the facility's policies and procedures titled "Discharge and transfer of Residents," revised on 2/2018. As a result, Resident 2 fell and hit his head on the concrete (floor) at the facility, sustaining a head injury, and was transferred to GACH 3 for further evaluation on 2/19/2023, where Resident 2 was diagnosed with a large left side subdural hematoma (a pool of blood collecting between the brain and its outermost covering), and an eight centimeter (cm- unit of measurement) right sided scalp (head) laceration (a pattern of injury in which blunt forces result in a tear in the skin and underlying tissue). Resident 2 was admitted in the intensive care unit (ICU- is a designated area of a hospital facility that is dedicated to the care of patients who are seriously ill), intubated (a tube inserted either through the mouth or nose and into the airway to aid with breathing), and connected to a ventilator (a respirator- a machine used to help a patient breathe). A review of Resident 2's Admission Record indicated the facility originally admitted Resident 2 on 1/10/2023 and re-admitted Resident 1 on 2/13/2023 with diagnoses including type 2 diabetes mellitus (a long term condition that causes an impairment in the way the body regulate and uses sugar), end stage renal disease (ESRD - a medical condition in which a person's kidneys stop functioning permanently), dependance on renal dialysis (a process of removing excess water solutes and toxins from the blood in people whose kidneys can no longer perform these functions naturally), history of falls, major depressive disorder( a mental condition characterized by a persistently depressed mood and long term loss of pleasure or interest in life), hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (weakness or the inability to move on one side of the body), and cerebral infarction (brain tissue death as of lack of circulation to the brain tissue from a clotted blood vessel) affecting the left side. A review of Resident 2's history and physical (H&P) completed by MD 1 dated 1/16/2023, indicated the facility admitted Resident 2 after a fall that resulted in left knee pain and a left femur fracture (break of the thigh bone), and Resident 2 had left lower extremity (LLE - left leg) brace (a device that supports or holds in correct position a part of the body). The H&P indicated Resident 2 had the capacity to understand and make decisions and the facility is to monitor laboratory results and obtain psychiatry (medical specialty devoted to the diagnosis, prevention, and treatment of mental conditions) consult for Resident 2. A review of Resident 2's Minimum Data Set (MDS - a standardized assessment) indicated the resident's ability to make decisions of daily living was moderately impaired. The MDS indicated Resident 2 did not have any physical or verbal behaviors directed towards staff and did not wander or attempt to leave the facility. The MDS indicated Resident 2 required extensive one person assist for bed mobility, dressing, toilet use and personal hygiene, used a wheelchair for mobility, and did not ambulate (walk). A review of Resident 2's at risk for fall assessment secondary to generalized weakness, gait (a manner of walking) problem, ... hemiplegia and hemiparesis, muscle weakness, and history of fall care plan initiated 2/7/2023, indicated Resident 2 had an actual fall on 2/6/2023 and 2/14/2023. The interventions included "to determine and address causative factors of fall and monitor/document/report ... change in mental status, new onset ... agitation times 72 hours to MD (medical Doctor)." A review of Resident 2's nursing progress notes dated 2/14/2023 timed at 9 p.m., indicated Licensed Vocational Nurse 1 (LVN 1) documented Resident 2 was agitated and attempted to hit staff members, was screaming and shouting "get out of my way, I'm leaving" the facility. Resident 2 was destructive, grabbed any available item to throw at staff, and did not listen to staff. A review of Resident 2's change in condition (COC) dated 2/14/2023 timed at 10:50 p.m., indicated Resident 2 had a witnessed fall, placed himself on the ground, was insisting to go home, ... "inability to walk and care for himself." The COC further indicated MD 1 was notified and an X-ray ordered for the right hip, right shoulder, sacrum (triangular bone in the lower back formed from fused bones between the two hip bones), coccyx (small triangular bone at the base of the spine). In addition, Resident 2 was to receive Ativan 0.5mg (milligrams- unit of measurement) one time only for aggressive behavior. A review of Resident 2's Xray request dated 2/14/2023, indicated Resident 2 refused the Xray to the right hip, right shoulder, sacrum, and coccyx on 2/15/2023 at 12:37 a.m. A review of Resident 2's at risk for elopement care plan initiated 2/15/2023, indicated Resident 2 verbalized wanting to go home, was yelling, throwing things, and refusing medications. Interventions included to monitor Resident 2's location every two hours and document behavior of trying to leave the facility. A review of Resident 2's nursing progress notes dated 2/15/2023 timed at 10 a.m., indicated the Director of Social Services (DSS) documented Resident 2's family member (FM 1) was notified of Resident 2's behavior and attempting to leave the facility. A review of Resident 2's physician order dated 2/15/2023 timed at 9:54 p.m., indicated to transfer Resident 2 to GACH 1 for aggressive behavior. A review of Resident 2's nursing progress note dated 2/15/2023 timed at 11:34 p.m., indicated LVN 1 documented Resident 2 was agitated, and the police were called because Resident 2 was attempting to hurt staff members. The nursing progress note indicated Resident 2 will be transferred to GACH 1 for mental evaluation per MD 1's order. A review of Resident 2's nursing progress note dated 2/16/2023 timed at 11:49 a.m., indicated MD 1 cancelled the transfer to GACH 1 and stated MD 2 would go to the facility and evaluate Resident 2. A review of Resident 2's physician progress note dated 2/16/2023, indicated MD 1 documented Resident 2 "gets easily agitated/anger/irritable, had poor coping skills, and paranoid ideations (thought processes involving persistent suspiciousness and beliefs of being persecuted, harassed, or treated unfairly by others) and to increase Lexapro (a medication used to treat certain mental/mood disorders) and start Seroquel (a medication used to treat certain mental/mood disorders)." A review of Resident 2's COC evaluation form dated 2/17/2023 timed at 7:30 a.m., indicated Resident 2 displayed aggressive behaviors evidenced by yelling and throwing items towards staff members, refused to take insulin (a medication that lowers blood sugar level in the blood) and morning medications and MD 1 was notified on 2/17/2023 at 8:10 a.m. MD 1 ordered to transfer Resident 2 to an unnamed GACH/health facility. A review of Resident 2's "Application for 72 hour Detention for Evaluation and Treatment" completed by a police officer dated 2/17/2023, indicated "at approximately 8:15 a.m., officers responded to a rapid call at ... regarding a male patient (Resident 2) very aggressive, throwing items at nursing staff. Upon arrival we (officers) observed subject (Resident 2) yelling and throwing items inside his room. Subject yelled that it was no need for him to stay at the above facility ... Subject must have dialysis x3 a week ... suffers from depression and his condition has been deteriorating. Based on ... mental condition, not realizing he needs ... officers placed subject on 5150 hold for danger to others and gravely disabled adult." A review of Resident 2's nursing progress note dated 2/17/2023 timed at 8:25 a.m., indicated LVN 2 documented Resident 2 was agitated, cursing at staff, and throwing objects toward staff. MD 1 was notified and ordered to transfer Resident 2 to GACH 1 on a 5150 hold. The nursing progress note indicated police were called, arrived, wrote a 5150 hold for Resident 2, and remained with Resident 2 until transportation arrived on 2/17/2023 at 10:20 a.m. Resident 2 was transferred to GACH 2. A review of Resident 2's physician order dated 2/17/2023 timed at 8:52 a.m., indicated to transfer Resident 2 on 5150 hold due to danger to others and danger to self. A review of Resident 2's nursing progress note dated 2/17/2023 timed at 11:30 a.m., indicated LVN 3 documented, she called report to GACH 1 regarding Resident 2. However, during the report call, LVN 3 was informed by GACH 1 staff that GACH 1 could not accept Resident 2 because Resident 2 was on a 5150 hold and LVN 3 informed MD 1. The nursing progress note further indicated MD 1's case manager contacted/communicated with LVN 3 and confirmed that Resident 2 should be transferred to GACH 2. Resident 2 was transferred to GACH 2 on 2/17/2023. A review of Resident 2's nursing progress note dated 2/17/2023 timed at 1:33 p.m., indicated LVN 3 documented, GACH 2 contacted and informed the facility that GACH 2 was not expecting Resident 2 and that Resident 2 will be returning to the facility. Resident 2 returned to the facility on 2/17/2023 at 2:25 p.m., was agitated, yelling, and continued to throw items at staff. A review of Resident 2's nursing progress note dated 2/17/2023 at 8:36 p.m., indicated LVN 7 documented, that LVN 7 met with FM 1 regarding Resident 2's behavior and that the facility assigned Resident 2 a 1:1 sitter for safety and supervision to prevent accidents for Resident 2 who was on 5150 hold. A review of Resident 2's nursing progress note dated 2/18/2023 at 10:28 a.m. and at 4:24 p.m., indicated LVN 4 documented, Resident 2 remained aggressive, tried to open the facility's hallway door but was stopped by staff. The Police were called because Resident 2 was a risk to harm self and others, and that MD 1 was informed. The nursing progress note did not indicate if MD 1 gave any orders or recommendations. A review of Resident 2's physician order dated 2/19/2023 timed at 1:29 p.m., indicated to transfer Resident 2 to GACH 4 due to severe backache and mental evaluation. However, Resident 2 refused to go. A review of Resident 2's nursing progress note dated 2/19/2023 timed at 6:57 a.m., indicated LVN 1 documented, "AGAIN!!!!" resident becomes more agitated trying to hurt staff screaming and shouting asking for the police." LVN 1 further documented "the sitter (1:1) could not handle the situation and please have this resident (Resident 2) out of this facility. We are in great danger there are three of us trying to stop this resident from hurting staff." The nursing progress note did not indicate if LVN 1 notified MD 1 or MD 2 of Resident 2's aggressive and unmanageable behavior. A review of Resident 2's nursing progress note dated 2/19/2023 timed at 4:47 p.m., indicated LVN 5 documented Resident 2 was at the nursing station sitting in a wheelchair yelling and throwing objects at staff. The nursing progress note further indicated Receptionist 1 (RCPT 1) left the facility through the front door and Resident 2 in his wheel chair, attempted to follow RCPT 1. Resident 2 began to kick the door and tried to exit the facility. Resident 2 threatened RCPT 1 and told RCPT 1 that he was going to kick RCPT 1 down the stairs when Resident 2 got up from his wheelchair. The nursing progress note indicated LVN 5 left to call 911 and upon return, found Resident 2 on the ground at the bottom of the steps outside the facility on 2/19/2023 at 4:53 p.m. LVN 5 documented Resident 2 was alert with moderate bleeding noted to the back side of his (Resident 2) head and LVN 3 applied a pressure (to stop bleeding) dressing. The paramedics arrived on 2/17/2023 at 4:59 p.m. and transported Resident 2 to GACH 3. A review of Resident 2's GACH "Department of Emergency (ED) Medicine Treatment record" dated 2/19/2023 timed at 7:49 p.m., indicated Resident 2 " ... sent over for trip and fall with confusion. He had a large bleeding laceration to his right occiput (back of head). Patient states he was in a bicycle accident. He is not clear as to what happened to him. He has no significant extremity (leg or arm) pain. Patient (Resident 2) sent over from" the facility ... "He has been combative and assaulting staff over the past several days, disruptive, and ... he fell down and hit his head ..." The ED notes indicated Resident 2's blood pressure (BP) on 2/19/2022 was recorded as follows: - 178/73 Mmhg (millimeters of mercury - unit to measure pressure). Reference range is between 90/60 Mmhg and 120/80 Mmhg) - 187/76 Mmhg at 7:22 p.m. The ED notes further indicated "He (Resident 2) is in acute distress and has bleeding laceration eight cm long and five millimeters (mm- unit to measure distance) to the right occipital region ... Patient (Resident 2) is awake and not oriented to date, time or place ..." The ED notes indicated emergent consent was obtained, skin repair (to laceration) was completed with sutures (stitches- is a medical device used to hold body tissues together and approximate wound edges after an injury or surgery) after administering bupivacaine 2.25% (anesthesia - medication causes a loss of feeling or awareness caused by drugs or other substances). The ED notes indicated computed tomography (CT- multiple x-rays of the head, including the skull, brain, eye sockets, and sinuses) brain result date of 2/19/2023, indicated post (after) traumatic hemorrhages (bleeding). The ED notes indicated Resident 2 received desmopressin (DDAVP - medication to treat diabetes insipidus [a rare disorder that causes the body to make too much urine]). The ED no