Other·June 7, 2024

Title 22 § 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. On 4/24/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding quality of care and allegation of falsification of record. The facility failed to report to the Department two incidents of an unusual occurrences that threatened safety or health of residents and/or staff within 24 hours of each incident occurrence. As a result, there was a delay of an onsite inspection by the Department to ensure the safety of the residents. 1. A review of the facility provided Police Department Investigative Report dated 12/23/2022, indicated the following: a. Date & Time of Occurrence: 12/23/2022 at 1:48 a.m. b. Date & Time Reported to Police Department: 12/23/2022 at 2:00 a.m. c. Type Property Stolen/Lost/Damaged: Front Door Glass d. Narrative information indicated that a suspect smashed the front door with unknown object and entered the facility before being stopped by workers and escorted out. During an interview with the Registered Nurse 1 (RN 1) on 4/25/2024 at 6:20 a.m., RN 1 stated that on 12/2022, unable to recall exact day; at around 1:00 a.m., RN 1 heard the sound of breaking glass. RN 1 stated that RN 1 rushed to the facility lobby where he found an intruder walking into the facility hallway. RN 1 stated that the intruder was aggressive. RN 1 stated that RN 1 gathered additional male facility staff to help stop the intruder. RN 1 stated that the intruder eventually exited the facility. RN 1 stated that RN 1 immediately called the local law enforcement (LLE), the Administrator (ADM) and the Director of Nursing (DON) and informed them of the incident. During a concurrent interview and record review with the ADM on 4/25/2024 at 9:57 a.m., the ADM reviewed the Police Department Investigative Report dated 12/23/2022. The ADM stated that the incident that occurred on 12/23/2022 was immediately reported to her by facility staff. The ADM stated that the ADM called the LLE but did not report the incident to the Department. The ADM stated that the incident on 12/23/2022 wherein an intruder entered the facility could potentially affect the safety of the residents. 2. A review of the facility’s Police Department Investigative Report dated 1/7/2023, indicated the following: a. Date & Time of Occurrence: 1/7/2023 at 1:40 a.m. b. Date & Time Reported to Police Department: 1/7/2023 at 8:20 a.m. c. Type Property Stolen/Lost/Damaged: Chicken d. Narrative information indicated that a suspect walked to the break room and selected chicken from the refrigerator, ate the chicken, and then left the location. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 4/25/2024 at 7:20 a.m., LVN 2 stated on 1/2023, unable to recall the exact day and time, LVN 2 found a stranger inside the employee breakroom looking for food inside the refrigerator. LVN 2 stated that LVN 2 was unsure how the stranger was able to enter the facility. During a concurrent interview and record review with the ADM on 4/25/2024 at 9:57 a.m., the ADM reviewed the Police Department Investigative Report dated 1/7/2023. The ADM stated that the incident that occurred on 1/7/2023 was immediately reported to her by facility staff. The ADM stated that the ADM called the LLE but did not report the incident to the Department. The ADM stated that the incident on 1/7/2023 wherein an intruder entered the facility and stole food from the employee breakroom could potentially affect the safety of the residents. A review of the facility’s policy and procedure (P&P) titled, “Unusual Occurrences Reporting”, last reviewed in 7/2023, indicated, “As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees, or visitors…. Unusual occurrence shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal or state regulations.” The facility failed to report to the Department two incidents of an unusual occurrences that threatened safety or health of residents and/or staff within 24 hours of each incident occurrence. As a result, there was a delay of an onsite inspection by the Department to ensure the safety of the residents. The above violation had a direct or immediate relationship to the health, safety, or security of the residents and staff at the facility.