Other·November 15, 2023

LOS ANGELES STATE DISTRICT OFFICE "A" CITATION Sherman Oaks Health & Rehabilitation Complaint# CA00804958 Provider #056250 Zelma Brie Brenetta Dean, HFEN #38593 22 CCR § 72321. Nursing Services-Patients with Infectious Diseases (b) The facility shall adopt, observe, and implement written infection control policies and procedures. These policies and procedures shall be reviewed at least annually and revised as necessary. The Department determined that facility was in violation of the above regulation when the facility failed to ensure two patients, Patient 1 (P1) and Patient 2 (P2) were protected and safe from the Coronavirus Disease - 19 (COVID-19 [C-19], an illness caused by a virus which spreads from person to person) by failing to ensure another patient, Patient 3 (P3) had a negative C-19 test result before moving P3 into the room with P1 and P2, as required by the facility's policies and procedures. As a result, P1 and P2 contracted C-19 and died, with C-19 identified as a contributing factor in their deaths. A review of P1's Admission Record indicated P1 was admitted to the facility on 8/3/2018 with an original admission date of 5/18/2012. P1 was admitted with multiple diagnoses including encephalopathy (a brain disease), dementia (loss of memory, judgment, and daily functioning), cerebral infarction (loss of blow flow to brain), kidney failure (the pair of body organs moving urine from the body stop working), hemiplegia (one side of the body does not move), hemiparesis (muscle weakness on one side of the body), cataracts (causing cloudy appearance of the eye), and a principal admitting diagnosis of adult failure to thrive (adults with multiple ongoing sickness resulting in decreased functioning). A review of Patient 1's Minimum Data Set (MDS, assessment and care screening tool), dated 5/13/2020, indicated, Section C-Cognitive (mental ability to process thoughts, experiences, and the senses) was severely impaired. Section I-Diagnosis indicated P1 had multiple diagnoses including dementia. A review of P2's Admission Record indicated P2 was admitted to the facility on 4/20/2020 with an original admission date of 2/4/2013. P2 was admitted with multiple diagnoses including encephalopathy, adult failure to thrive, altered mental status (changes in thinking and behavior), and a principal admitting diagnosis of gastrostomy (a tube placed into the stomach for feeding and medicine). A review of P2's MDS dated 7/31/2020, Section C- Cognitive indicated a score of 2 on the Brief Interview for Mental Status (BIMS, a screening tool used to determine cognitive ability). A score of 0-7 indicated severely impaired cognitive ability. Section I-Diagnosis indicated P2 had multiple diagnoses including dementia. A review of P3's Admission Record indicated P3 was admitted to the facility on 6/30/2020 with an original admission date of 7/3/2018. P3 was admitted with multiple diagnoses including encephalopathy, dementia, and a principal diagnosis of sepsis (infection in the bloodstream). A review of P3's MDS dated 7/6/2020, indicated P3 had a score of 1 on the BIMS. A score of 0-7 indicated severely impaired cognitive ability. Section I-Diagnosis indicated P3 had multiple diagnoses including dementia. During an interview and concurrent record review with the Director of Nursing (DON), on 10/6/2022, at 10:15 a.m., the DON reviewed documents for P1 and P2 titled CoV2 Patient Reports as laboratory (Lab) reports providing C-19 test results. The DON stated the dates on the report indicated when the samples were collected (7/23/2020), the date received (7/27/2020) and the date the test result was reported and recorded (7/28/2020). The DON verified both Patients had negative test results and were roommates on 7/23/2020 in the green zone (an area of the facility without residents with C-19 or for those who have tested negative on C-19 test) in beds 11B and 11C as indicated on the facility census for those dates. During an interview and concurrent record review with the DON on 10/6/2022, at 10:22 a.m., the DON reviewed the Lab report for P3 and stated P3 was tested for C-19 on 7/23/2020 as indicated on a C-19 test Lab report. The DON stated P3 was moved to room 11A on 7/26/2020. The DON stated the C-19 test results for P3 were reported positive on 7/29/2020 as indicated on the C-19 Lab report. The DON stated at this time P3 had already been in the room with 11B and 11C for 3 days. Surveyor asked the DON why not wait for the C-19 test results before moving P3. The DON stated being unsure at this time but should have waited for the results before moving P3 into the room with 11B and 11C. During an interview and concurrent record review with the DON on 10/6/2022, at 10:43 a.m., the DON reviewed the facility census dated 7/29/2020 and stated both Patients, P1 and P2, were without symptoms and moved together into a room in the yellow zone (area of the facility for patients exposed to C-19) as indicated on the facility census for that date. A review of a document titled, Change of Condition, dated 8/3/2020, at 9:45 p.m., indicated P1 had a medical event requiring a transfer to an acute hospital. P1 was transferred via ambulance to an acute hospital on 8/3/2020. Records obtained from the acute hospital dated 8/3/2020, at 11:23 p.m., indicated P1 had tested positive on the SARS-CoV2 Antigen test (a test for C-19). P1 remained at the acute hospital until P1 died on 8/30/2022. P1's death certificate indicated C-19 as contributing to the death of P1. A review of a C-19 Lab test for P2 indicated P2 tested positive on 8/6/2020. A license nurse progress note dated 8/30/2020, at 4:28 p.m., indicated P2 was placed on hospice (end of life care). P2 died on 9/13/20. A review of a document titled, "Job Description" for the Director of Nursing prepared 8/18/2011 and approved by the Quality Assurance Team on 8/23/2011, indicated "The DON administered the nursing program to maintain a standard of resident care. The standard of care included advising medical staff and providing safe, dignified, and a healthy environment." The facility's policy and procedures titled, "Covid-19 Preparedness" dated 9/4/20, indicated, "The green cohort is an area reserved for residents who do not have covid19 or have tested negative." The facility failed to ensure two patients, P1 and P2 were protected and safe from C-19 by failing to ensure another patient, P3 had a negative C-19 test result before moving P3 into the room with P1 and P2, as required by the facility's policies and procedures. As a result, P1 and P2 contracted C-19 and died, with C-19 identified as a contributing factor in their deaths. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.