Health inspection·October 11, 2024

California Code of Regulations, Title 22, Section § 72311 Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B)Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. Section § 72319. Nursing Service - Restraints and Postural Supports. (a) Written policies and procedures concerning the use of restraints and postural supports shall be followed. (b) Restraints shall only be used with a written order of a licensed healthcare practitioner acting within the scope of his or her professional licensure. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients. In accordance with Section 72317, there shall be no standing orders and in accordance with Section 72319(i)(2)(A), there shall be no P.R.N. orders for physical restraints. (c) The only acceptable forms of physical restraints shall be cloth vests, soft ties, soft cloth mittens, seat belts and trays with spring release devices. Soft ties means soft cloth which does not cause abrasion and which does not restrict blood circulation. (d) Restraints of any type shall not be used as punishment, as a substitute for more effective medical and nursing care, or for the convenience of staff. (1) Treatment restraints may be used for the protection of the patient during treatment and diagnostic procedures such as, but not limited to, intravenous therapy or catheterization procedures. Treatment restraints shall be applied for no longer than the time required to complete the treatment. Section § 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right, (24) To be free from psychotherapeutic drugs and physical restraints used for the purpose of patient discipline or staff convenience and to be free from psychotherapeutic drugs used as a chemical restraint as defined in Section 72018, except in an emergency which threatens to bring immediate injury to the patient or others. If a chemical restraint is administered during an emergency, such medication shall be only that which is required to treat the emergency condition and shall be provided in ways that are least restrictive of the personal liberty of the patient and used only for a specified and limited period of time. Code of Federal Regulations, Title 42 Section §483.10(e) Respect and Dignity.   The Patient has a right to be treated with respect and dignity, including:   §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the Patient's medical symptoms, consistent with §483.12(a)(2).   §483.12 The Patient has the right to be free from abuse, neglect, misappropriation of Patient property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the Patient’s medical symptoms.     F656 Section §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: — (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and On 8/26/20204, at 10:15 AM the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding patient abuse. As a result, CDPH determined, the facility failed to ensure Patient 1, who had moderately impaired cognition (thought process) and diagnosis of dementia (the loss of cognitive process) with combative behavior (aggressiveness/eagerness to fight) was free from physical restraints (any manual method, physical or mechanical device/equipment or material that limits a patient’s freedom of movement and cannot be removed by the patient) for purposes of discipline or convenience, by failing to:     1. Protect Patient 1 from physical injury on 8/20/2024, when Licensed Vocational Nurse (LVN) 1 restrained Patient 1‘s right and left arms by crossing Patient 1’s arms across the chest and above the head and “pull/drag” the Patient from the Patient’s room to the Nursing Station when Patient 1 exhibited episodes of mood swings [a sudden or intense change in a person's emotional state].   2. Implement Patient 1’s care plan interventions on “Dementia,” and “Communication Problem related to Language Barrier [a difficulty for people communicating because they speak different languages]” by establishing rapport and eye contact with the Patient, use appropriate words and gestures, listen carefully and attend to verbal/nonverbal expressions when LVN 1 physically restrained Patient 1’s left and right arms with both of her hands, while the Patient was exhibiting episodes of mood swings, anxiety and agitation on 8/20/2024.    3. Ensure the facility’s Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals for Patients) develop a comprehensive care plan when Patient 1 exhibited (showed) new behaviors manifested by combativeness, punching, scratching, and kicking, chasing staff, including touching the roommate (Patient 2) on 6/9/2024, 7/7/2024, and 8/18/2024, in accordance with the facility’s policy and procedure [P&P] titled “Person Centered Plan of Care.”    4. Develop care plan interventions on 8/22/2024, to address Patient 1’s combative behavior and agitation and identify the root cause (the fundamental reason for the occurrence of a problem) of the Patient’s behavior symptoms (combativeness and agitation) to prevent further injury to Patient 1.   5. Prohibit the use of physical restraints, in accordance with the facility’s policy and procedure titled “Physical Restraint Management,” when LVN 1 held Patient 1 down with both hands to prevent LVN 1 from being hit, kicked and spit on by Patient 1 and restrained Patient 1‘s right and left arms by crossing Patient 1’s arms across the chest and above the head and “pull/drag” the Patient from the Patient’s room to the Nursing Station, on 8/20/2024.   As a result, LVN 1 restrained Patient 1’s freedom of movement and the Patient sustained (continued over time) redness/bruising to the back of the left hand and verbalized pain to both hands and shoulders on 8/20/2024. On the same day, on 8/20/2024 timed at 7:48 PM, during a telemedicine (the use of electronic information and communications technologies to provide and support) visit with Psychiatrist 1, Patient 1 verbalized being “scared.” Patient 1 was unable to verbalize the reason for being “scared.”   These deficient practices placed other Patients with behavioral issues (acting in a way that causes harm) residing at the facility [24 Patients], at risk for staff abuse and restraints and cause psychosocial (covers a person's mental, emotional, social, and spiritual health) decline, physical (relating to the body) injuries, hospitalization, and death.   Findings: A review of Patient 1’s Admission Record [AR] indicated a 92 year old, female patient, admitted to the facility on 6/6/2024, with diagnoses that included dementia and encephalopathy (damage or disease that affects the brain).     A review of Patient 1’s History and Physical Examination (HPE, a comprehensive physician’s note regarding the assessment of the Patient’s health status) signed by the attending physician (Physician 1) on 6/7/2024, the HPE indicated Patient 1 had fluctuating (changing frequently) capacity to understand and make decisions.      A review of Patient 1’s “Post COC [Change in Condition]/SBAR [Situation, Background, Assessment, Recommendation]” notes dated 6/9/2024 timed at 1:20 PM, the Post COC indicated Patient 1 became combative towards the end of the shift and was brought back to bed several times.      A review of Patient 1’s Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) dated 6/12/2024, the MDS indicated the Patient had moderately impaired cognition (thought process).   A review of Patient 1’s Interdisciplinary Team [IDT] Conference Record dated 6/12/2024, indicated that Patient 1 did not present with any behavioral issues, needs encouragement to join activities of choice and enjoys music. The IDT Record indicated the facility did not use physical restraints and restraints were not recommended at this time for Patient 1.   A review of Patient 1’s care plans initiated in June 2024, the care plans indicated the following information:   -On 6/12/2024, the facility developed a care plan titled “[Patient 1] has a communication problem related to language barrier.” The care plan interventions included allowing adequate time to respond, face the Patient when speaking, making eye contact and reducing environmental noise, and monitoring for physical/nonverbal indicators of discomfort or distress.    -On 6/12/2024, the facility developed a care plan titled “[Patient 1] has diagnosis of dementia, at risk for decline in communication and activity participation...” The care plan interventions included establishing rapport and eye contact with the Patient, use appropriate words and gestures, listen carefully, and attend to verbal/nonverbal expressions, reducing environmental noise, and maintaining a calm, unhurried manner.    A review of Patient 1’s “SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Note” dated 7/7/2024 timed at 12:47 PM, indicated that on 7/7/2024 at about 8 AM, Patient 1 began to “swing fist (refers strictly to the action of throwing one's fist)” at the CNA when Patient 1 was reoriented by the CNA not to pull on her roommates' (Patient 2) gown. The SBAR indicated Physician 1 ordered Ativan (medication for anxiety) 0.5 milligrams [mg- unit of measurement) by mouth every 12 hours as needed for agitation for 14 days on 7/7/2024.    A review of Patient 1’s care plans, for July 2024, the care plan did not indicate documented evidence that a care plan for Patient 1’s agitation was developed on 7/7/2024, to specify the goals and care plan interventions the facility staff needed to implement to manage the Patient’s agitation.    A review of Patient 1’s Telephone Order (TO) dated 8/5/2024, indicated a physician’s telephone order to administer Depakote (medication to treat episodes of mania [extreme changes in mood]) oral tablet to 125 mg, one tablet by mouth one time a day for mood swings manifested by outbursts (uncontrolled feelings) of anger.   A review of Patient 1’s SBAR Communication Form and Progress Note dated 8/18/2024, timed at 3:22 PM, authored by LVN 3, the SBAR Form indicated Patient 1 attempted to touch Patient 2 and when Patient 1 was redirected, the Patient shook her head in denial and punched LVN 3. The SBAR form indicated Patient 1 began to chase facility staff down the facility hallway attempting to punch and kick staff. The SBAR Form indicated Patient 1 was combative, punching, scratching, and kicking staff. The SBAR Form indicated that LVN 3 called 911 emergency services, and a police officer spoke to Patient 1 in her primary/native language and the police officer was able to redirect the Patient to calm down and go back to her room.     A review of Patient 1’s “Progress Notes New” dated 8/19/2024, timed at 5:52 PM, the Progress Notes indicated the physician ordered to increase the Patient’s medication [Depakote] 120 mg from once a day to two times a day as a result of the behavior manifested by the Patient on 8/18/2024.   A review of Patient 1’s TO dated 8/19/2024, the TO indicated to administer Ativan oral tablet 0.5 mg, one tablet by mouth, every 12 hours to the Patient as needed for 14 days manifested by verbalization of nervousness.   A review of Patient 1’s Medication Administration Record [MAR], the MAR indicated to give the Patient one tablet of Ativan 0.5 mg starting 8/19/2024, by mouth every 12 hours for 14 days, as needed for anxiety manifested by verbalization of nervousness. The MAR did not indicate Ativan was administered as needed for anxiety, from 8/19/2024 or 8/20/2024. The MAR indicated an order to monitor behavior for anti-anxiety manifested by verbalization of nervousness and tally by hashmarks (a way to count and record count numerically), starting on 8/19/2024. The MAR did not indicate Patient 1’s anxiety manifested by verbalization of nervousness was monitored and counted by the licensed nurses from 8/19/2024 through 8/27/2024.   A review of Patient 1’s TO dated 8/19/2024, indicated Depakote oral tablets dosage was increased from the original dose that was ordered on 8/5/2024 from 125 mg, one tablet once a day to 125 mg, one tablet two times a day, for mood swings manifested by outbursts (uncontrolled feelings) of anger.   A review of Patient 1’s MAR in August 2024, the MAR indicated for the Depakote medication, Patient 1’s behavior issues of outbursts of anger was monitored and documented 16 days after the original order of the Depakote oral tablets was ordered on 8/5/2024 starting 8/21/2024.     A review of a Short Message Service [SMS - a text messaging service that allows users to send short text messages between mobile devices] sent via text message [TM] from LVN 1 to the Director of Nursing (DON) dated 8/20/2024 timed at 6:48 AM, the TM indicated Patient 1 keeps hitting other Patients and LVN 1 was unable to physically control the Patient. The TM indicated Patient 1 was very aggressive and LVN 1 had to hold Patient 1 to prevent Patient 1 from going back to Patient 1 and 2’s room and from hitting and kicking LVN 1. The TM indicated the DON asking LVN 1 “What prompted crossing her arms? Or dragging her [Patient 1] to the station with both arms/hands held?” LVN 1’s response indicated “She [Patient 1] did not want to stop. Where else should she go if not the station. Holding her hands so she [Patient 1] doesn’t hit me.” The TM indicated the DON stating that Patient 2 denied being hit by Patient 1 and Patient 1 sustained injuries/bruising to both the right and left hand.   A review of Patient 1’s “SBAR Communication Form and Progress Note” dated 8/20/2024 timed at 12:27 PM, the SBAR indicated “Patient 1 was allegedly hitting the roommate, Patient 2” on 8/20/2024. The SBAR indicated the charge nurse, LVN 1, reported that Patient 1 hit Patient 2. The SBAR indicated that upon interview of Patient 1, Patient 1 denied hitting Patient 2. The SBAR indicated Physician 1 was made