Health inspection·December 18, 2023

§ 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. The facility failed to report a Coronavirus 2019 (COVID-19, an infectious disease) outbreak in the facility, within 24 hours of occurrence of the incident, to the California Department of Public Health in accordance with the facility’s policy and procedure. This failure had the potential to threaten the welfare, safety, or heath of the patients, personnel, or visitors due to the spread of the infectious disease. As a result, the California Department of Public Health was not aware of the incident and could not conduct a timely on-site investigation to ensure the facility was taking proper precautions to ensure the welfare of the patients and staff during this outbreak. On 12/08/2023 at 8:00 a.m., an unannounced complaint investigation was conducted regarding a COVID- 19 outbreak at the facility that started on 11/25/2023. A review of Patient 1s Admission Record indicated admission to the facility admitted a 78 year old Female on 09/09/2023, with diagnoses of cirrhosis of the liver (a type of liver damage where healthy cells are replaced by scar tissue), atrial fibrillation (an irregular and often very rapid heart rhythm, can lead to blood clots in the heart), and encephalopathy (disturbance of brain function, it causes confusion, memory loss and coma in severe cases). A review of Patient 1s History and Physical dated 9/20/23, indicated Patient 1 had the capacity to understand and make decisions. A review of Patient 1s Minimum Data Set (MDS: a standardized assessment and care planning screening tool) dated 9/25/2023 indicated Patient 1s brief interview of mental status (BIMS, brief screener that aids in detecting cognitive impairment) score was 13 (a score of 13-15 indicated cognitive skills for daily decision making was intact). A review of Patient 1s Physician Order Report (POR) dated 11/25/23 and timed at 2:06 PM, the POR indicated place Patient 1 to contact and droplet precaution due to positive for COVID 19. A review of Patient 2s Admission Record indicated the facility admitted a 70 year old female on 09/18/2023, with diagnoses of diabetes mellitus (blood sugar levels abnormally high, It can also increase your risk of getting serious problems with your eyes, heart and nerves), chronic kidney disease (kidneys are damaged and can't filter blood the way they should, and can lead to other health problems, such as heart disease), and hypothyroidism (thyroid gland is underactive and fails to secrete enough hormones into the bloodstream, this causes the person’s metabolism to slow down). A review of Patient 2s History and Physical dated 9/20/23, indicated Patient 2 had the capacity to understand and make decisions. A review of Patient 2s Minimum Data Set (MDS: a standardized assessment and care planning screening tool) dated 9/25/2023 indicated Patient 2s brief interview of mental status (BIMS, brief screener that aids in detecting cognitive impairment) score was 15 (a score of 13-15 indicated cognitive skills for daily decision making was intact). A review of Patient 2s Physician Order Report dated 11/25/23 and timed at 1:58 PM, the report indicated to place Patient 1 on contact and droplet precaution due to positive for COVID 19. During an interview on 12/8/223 at 8:45 AM with infection preventionist nurse (IP), IP stated, the facility’s Covid outbreak began with two patients (Patient 1 and Patient 2) testing positive for COVID on 11/25/2023. IP stated, she reported the covid outbreak to Acute Communicable Disease Control Program (ACDC) (program for the surveillance and investigation of most communicable diseases) and Redcap (a platform to report COVID-19 data and other information to DPH) on 11/26/2023 but did not report to California Department of Public Health (CDPH) licensing/enforcement because she did not know she is supposed to report it. IP stated, she will refer to the facility’s policy on reporting outbreak. During an interview on 12/8/223 at 12:33 PM with the administrator (ADM), ADM stated, reporting to Redcap was only required and that it was not necessary to report the COVID-19 outbreak to the California Department of Public Health Licensing and Certification District office. ADM stated the facility should have reported the COVID-19 outbreak to the Department within 24 hours. During a concurrent interview and record review on 12/8/223 at 2:30 PM with the ADM, in the presence of the Director of Nurses (DON), the facility’s policy and procedure for unusual occurrence was reviewed. The ADM stated, the facility should have followed the state regulation about reporting unusual occurrences/outbreak as per policy and State Licensing requirement. A review of the facility’s undated Policy and Procedure (P&P) titled, “Incident Reporting for Patients or Visitors”, indicated, all accidents and unusual occurrences involving a patient or visitor will be documented and reported so as to meet all regulatory (JCAHO, state, and federal) and insurance requirements. The P&P indicated, definitions of event included any event reportable to federal and state agencies as defined by those agencies. The P&P indicated, The Administrator or Director of nursing must notify the appropriate state agency as required by state regulations and the exact date, time, and name of contact at the state agency must be recorded on the appropriate investigation form. The facility failed to report a Coronavirus 2019 (COVID-19, an infectious disease) outbreak in the facility, 24 hours of occurrence of the incident, to the California Department of Public Health. This failure had the potential to threaten the welfare, safety, or heath of the patients, personnel, or visitors due to the spread of the infectious disease. As a result, the California Department of Public Health was not aware of the incident and could not conduct a timely on-site investigation to ensure the facility was taking proper precautions to ensure the welfare of the patients and staff during this outbreak. This violation had a direct relationship to the health, safety, and security of Patient 1 and Patient 2, and all patients residing in the facility.