Health inspection·October 11, 2024

F689 §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR §72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 8/27/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its annual recertification survey and investigate a facility reported incident regarding resident safety. The facility failed to ensure Resident 216, who had a behavior of ingesting foreign objects (when a person swallows objects that may be inserted/ingested into the body accidentally or intentionally that is not meant to be eaten such as batteries, paper clips, nails, pins, screws, coins, plastic, pens), was supervised to prevent ingesting a paper clip and batteries by failing to: 1. Monitor and supervise Resident 216 to ensure the resident did not have episodes of self-harm behavior (the resident ingested a paper clip on 8/19/2024 and ingested batteries on 8/25/2024) in accordance with the care plan focusing on risk for injury. 2. Notify the Primary Medical Doctor (PMD) on 8/19/2024 that the ordered STAT (to do something immediately or without any delay) abdominal x-ray (AXR - imaging test that looks at organs and structures in the abdomen) was not done immediately (after the resident had ingested a paperclip) as ordered by the physician for Resident 216 due to insurance eligibility issues. 3. Revise the care plan focusing on risk for injury after Resident 216 ingested a paper clip on 8/19/2024, and after Resident 216 ingested batteries on 8/25/2024, to ensure interventions are in place to prevent the resident from self-harm behaviors like ingesting foreign objects. As a result, Resident 216 was placed at increased risk for serious injury, serious harm, intestinal hemorrhage (bleeding), bowel obstruction (a serious condition that occurs when the small intestine or large intestine becomes blocked that keeps food or liquid from passing through), gastrointestinal (GI) erosion (a sore or raw area in the stomach lining), serious impairment, or death. Resident 216 was transferred to the General Acute Care Hospital (GACH) for further evaluation and management on 8/20/2024 after ingesting the paper clip. On 8/25/2024, Resident 216 ingested batteries and was transferred to the GACH on 8/26/2024 at 3:14 p.m. for further evaluation and management. Resident 216 has not returned to the facility as of 8/31/2024. A review of Residents 216's Admission Record indicated the facility admitted Resident 216, a 39-year-old female, on 8/16/2024 with diagnoses including schizophrenia (mental disorder which leads to hallucinations [experiences of hearing, seeing or smelling things that are not there], irrational thought patterns or behaviors [patterns of thinking or behaviors that are illogical or not based on reality]), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). A review of Resident 216's Minimum Data Set (MDS - a standard assessment and care screening tool), dated 8/22/2024 indicated Resident 216 was cognitively intact (has the capacity to think, learn, remember, use judgment, and make decisions). The MDS indicated Resident 216 required supervision or touch assistance from staff for toileting, shower, and personal hygiene. A review of Resident 216's Situation Background Assessment and Recommendation (SBAR - a structured communication framework that can help facility staff share information about the condition of a resident) form dated 8/19/2024, indicated Registered Nurse Supervisor 1 (RNS 1) documented that Resident 216 claimed to have swallowed a paper clip (time of incident not specified). A review of Resident 216's Physicians Orders dated 8/19/2024, timed at 9:40 p.m., indicated to obtain a STAT abdominal x-ray. A review of Resident 216's AXR results, dated 8/20/2024, indicated "Impression: metallic (metal) radiodensity (portions that appear light whereas other parts are dark) in the antrum (antral region, lowermost part of the stomach) of the stomach measuring 97 millimeters (mm -units of measure) by 2 mm. This may represent a swallowed paperclip." A review of Resident 216's nursing note, documented by RNS 1, dated 8/20/2024 and timed at 5:15 p.m., indicated that Resident 216 was made aware of the AXR results. The nursing note indicated Resident 216 insisted to go to the hospital. The nursing notes further indicated that the doctor ordered to transfer Resident 216 to the hospital per resident's request. A review of Resident 216's nursing note, documented by RNS 1, dated 8/20/2024 and timed at 10:08 p.m., indicated the ambulance arrived to transfer Resident 216 to the GACH. A review of Resident 216's care plan, with initiation date of 8/19/2024, indicated Resident 216 was at risk for injury and claimed to have swallowed a paperclip. The goal was for Resident 216 not to have any episodes of self-harm behavior. The care plan interventions included to obtain abdominal x-ray as ordered and to notify the doctor for any significant change. Resident 216's care plan did not include interventions related to supervision. A review of Resident 216's Physicians Orders, dated 8/26/2024 and timed at 10:00 a.m., indicated to obtain STAT x-ray of the stomach due to Resident 216's claim of swallowing two double A batteries on 8/25/2024 at 5:00 p.m. A review of Resident 216's AXR results, dated 8/26/2024, indicated "Findings: consistent with two small triple or double A sized batteries appear to be located in the region of the antrum of the stomach." A review of Resident 216's Physicians Orders, dated 8/26/2024 and timed at 1:48 a.m., indicated to transfer Resident 216 to GACH for further evaluation. A review of Resident 216's Transfer Form, dated 8/26/2024 at 3:15 p.m., the Transfer Form indicated that Resident 216 was sent to GACH due to swallowing two batteries. During an interview on 8/29/2024 at 1:43 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated that Resident 216 needed to be monitored closely "at least every 30 minutes" because Resident 216 had swallowed a paper clip before and Resident 216 eats strange stuff that is not food. CNA 1 stated he (CNA 1) was assigned to Resident 216 on the day of the incident (8/25/2024), however, CNA 1 was unable to "watch her (Resident 216) every 30 minutes because I had nine other residents." During an interview on 8/29/2024 at 4:13 p.m. with RNS 1, RNS 1 stated that on 8/19/2024 at around 9:30 p.m., Resident 216 came to the nursing station and told her (RNS 1) that earlier in the day around 3:00 p.m., her (Resident 216's) roommate kept going through her (Resident 216) stuff, she (Resident 216) got upset, went to the patio, found a paperclip and she (Resident 216) swallowed it. RNS 1 stated Resident 216 "wanted to go to the hospital so I called the doctor for an x-ray, and it was ordered STAT." RNS 1 stated that on 8/19/2024 at 11:00 p.m., when RNS 1 was leaving the facility, Resident 216's x-ray had not been done "because the x-ray technician said they needed to check for insurance eligibility first." RNS 1 stated she did not notify Resident 216's doctor about the delay. RNS 1 stated, "I only told the night shift that they (diagnostic laboratory [DL]) needed to check Resident 216's eligibility for the STAT x-ray before they can do it." RNS 1 stated, "I should have called the doctor and let him know that the STAT x-ray was not done and that they (DL) were waiting for a referral before they could do it (x-ray)." RNS 1 further stated potential adverse outcomes of swallowing a paperclip were "bleeding from the puncture because it is a metal." RNS 1 stated she worked the next day (8/20/2024), RNS 1 work shift started at 3:00 p.m. Resident 216 was still in the facility and her (Resident 216) x-ray results came back that afternoon. RNS 1 stated she notified the doctor of the x-ray results which showed a paperclip in the stomach. RNS 1 stated that the doctor stated "she (Resident 216) was not in danger, it (paperclip) will pass." RNS 1 stated Resident 216 left (transferred) for GACH " at around 10:30 p.m., because Resident 216 weigh 300 pounds (lbs. - unit of measure), I could not find an ambulance that could take her." RNS 1 stated Resident 216 returned to the facility on 8/21/2024 and there were no changes made to the resident's orders. RNS 1 stated that upon Resident 216's return from GACH to the facility, Resident 216 "did not have a one-on-one staff" (one facility staff assigned to one resident for continuous supervision or observation) to watching her (Resident 216). RNS 1 stated Resident 216 was transferred to GACH the next day (8/26/2024) after the x-ray results showed that Resident 216 had batteries in the stomach. RNS 1 was asked what the potential adverse outcomes of ingesting a foreign object such as batteries were, RNS 1 declined to respond to the question. During a concurrent interview and record review, on 8/29/2024 at 5:38 p.m., with the Interim Director of Nursing (IDON), Resident 216's care plan focusing on resident's risk for injury, initiated on 8/19/2024 and revised on 8/26/2024 was reviewed. The care plan goal included to "closely monitor patient." The IDON stated, closely monitor patient meant providing one-on-one sitter (a caregiver who provides one-on-one supervision to the resident) for the resident. The care plan interventions/tasks included to provide one-to-one bedside monitoring if recommended by the IDT or attending physician/psychiatrist. The IDON stated potential adverse outcomes of ingesting foreign objects such as paper clip and batteries were difficulty breathing, nausea (a feeling of sickness or discomfort in the stomach that may come with an urge to vomit), vomiting, obstruction, internal bleeding, hypotension (low blood pressure), altered consciousness (a change in one's normal mental state), respiratory distress (a condition that occurs when the body has difficulty getting enough oxygen), possibly infection, poisoning, and death. The IDON stated ingestion of a paperclip and batteries is an emergency and "we have to call 911 right away." During an interview on 8/30/2024 at 1:21 p.m., with the Medical Director (MD), the MD stated that he (MD) spoke with the Administrator (ADM) and was aware that Resident 216 had swallowed a paper clip and batteries. The MD stated that a resident who ingests a foreign object needs to go and get evaluated at the hospital right away. The MD stated that it is an emergency and that ingesting batteries may result in adverse outcomes such as potential leak of toxic chemicals from the battery which cause affect the kidneys, stomach, brain or even cause perforation (hole) of the stomach. A review of the facility's policy and procedures (P&P) titled, "Safety and Supervision of Residents," last revised in 12/2007, indicated "Policy Statement: Our facility strives to make the environment as free from accidents hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility wide priorities ..." "Facility oriented approach to safety ... 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; Quality Assurance and Analysis (QA &A) review of safety and incident/accident reports; and a facility-wide commitment to safety all levels of the organization ... Resident oriented approach to safety: 1. Our resident-oriented approach to safety addresses safety and accident hazards for individual residents ... 3.The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazard or risk for that resident. The care team shall target interventions to reduce the potential for accidents." A review of the facility's (P&P) titled, "Hazardous Areas, Devices and Equipment," last revised in 7/2017, indicated "Policy Statement: All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible ... Identification of Hazards ... 1.A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of sentimental hazards include, but are not limited to the following: c. sharp objects that are accessible to vulnerable residents; ... g. access to toxic chemicals;" A review of the facility's P&P, titled, "Transfer or Discharge, Emergency," revised in 8/2018, indicated "Policy Statement: Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s)." A review of the undated Duracell (brand name of batteries) "Safety Data Sheet," indicated "Section 4: First Aid and Measures... Swallowed: If battery contents are swallowed, do not induce vomiting ...Seek immediate medical attention." The facility failed to ensure Resident 216, who had a behavior of ingesting foreign objects was supervised to prevent ingesting a paper clip and batteries by failing to: 1. Monitor and supervise Resident 216 to ensure the resident did not have episodes of self-harm behavior in accordance with the care plan focusing on risk for injury. 2. Notify the PMD on 8/19/2024 that the ordered STAT abdominal x-ray was not done immediately as ordered by the physician for Resident 216 due to insurance eligibility issues. 3. Revise the care plan focusing on risk for injury after Resident 216 ingested a paper clip on 8/19/2024, and after Resident 216 ingested batteries on 8/25/2024, to ensure interventions are in place to prevent the resident from self-harm behaviors like ingesting foreign objects. As a result, Resident 216 was placed at increased risk for serious injury, serious harm, intestinal hemorrhage, bowel obstruction, gastrointestinal (GI) erosion (a sore or raw area in the stomach lining), serious impairment, or death. Resident 216 was transferred to the GACH for further evaluation and management on 8/20/2024 after ingesting the paper clip. On 8/25/2024, Resident 216 ingested batteries and was transferred to the GACH on 8/26/2024 at 3:14 p.m. for further evaluation and management. Resident 216 has not returned to the facility as of 8/31/2024. The above violations had direct or immediate relationship to the health, safety, or security of Resident 216.