Health inspection·October 19, 2023

Title 22, California Code of Regulations § 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. § 72315. Nursing Service - Patient Care. (m) Patient call signals shall be answered promptly. § 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. D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. Title 42 Code of Federal Regulations: §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; § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices, §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. FINDINGS: On 8/18/2023, at 11:50 AM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate an anonymous complaint allegation regarding patient neglect, quality of care, and death. As a result of the investigation, CDPH determined that the facility failed to prevent a patient accident due to a fall and sustained injury by failing to: 1. Follow Patient 1’s ADL (Activities for Daily Living) care plans, and facility policy on “Nursing Clinical – Responding to call light” to ensure Patient 1, who was assessed at high risk for falls and had a recent history of fall in her room on 8/6/2023, was free from falls and injury when the patient sustained another fall on 8/12/2023, in her room, when Patient 1 got up unassisted and slipped on her feces on the floor. 2. Ensure facility staff immediately assisted Patient 1 when the patient call light (communication system that link facility staff to the needs of patient) was activated on 8/12/2023 as indicated in the facility’s policy on “Responding to Call lights,” and Patient 1’s care plan for “Risk for Falls” and “Actual Fall.” Patient 3, (Patient1’s roommate) reported Patient 1 activated the call light and facility staff did not come in the room to assist immediately on 8/12/2023. These deficient practices resulted in Patient 1 losing her balance, hitting the wall, and falling onto the floor on 8/12/2023, at 10:30 AM. Patient 1 vomited three times, then stopped responding to verbal commands (became non-responsive). 9-1-1 emergency services were called at 10:35AM by facility staff and chest compressions (the act of applying pressure to someone's chest to help blood flow through the heart in an emergency) were initiated. On 8/12/2023, at 10:50 AM (20 minutes after Patient 1 was found on the floor), Patient1 was pronounced dead. A review of Patient 1’s Admission Record indicated the patient was a 77-year-old female, admitted to the facility on 8/4/2023, with diagnoses that included urinary tract infection, abnormalities of gait (walking) and mobility, muscle weakness, and acute kidney failure (occurs when kidneys suddenly unable to filter waste products from the blood). A review of Patient 1’s Fall Risk Evaluation (an assessment tool to evaluate how likely an individual is likely to fall), dated 8/5/2023, indicated Patient 1 was evaluated at high risk for falls. The Fall Risk Evaluation indicated Patient 1 was disoriented x 1 (to time) and had a history of one to two falls for the past three months. The Fall Risk Evaluation indicated Patient 1 had balance problems while standing/walking, requires regular assistance with elimination, and had poor vision. A review of Patient 1’s care plan for Activities of Daily Living (ADL) self-care Performance Deficit, dated 8/5/2023, indicated Patient 1 required staff participation with transfers. The care plan indicated Patient1 required staff assistance to wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet and to use toilet. A review of Patient 1’s care plan for Risk for Falls dated 8/5/2023, indicated Patient1 needs a safe environment. The care plan indicated the goal of Patient 1 to be free from falls and will not sustain serious injury through the review date. The interventions included for facility staff to be sure the patient’s call light is within reach to encourage the patient to use the call light when calling for assistance. The interventions also included Patient 1 needing a safe environment and to ensure the floor was free from spills and clutter. A review of Patient 1’s care plan entitled “Actual Fall” with factors due to poor balance and unsteady gait, initiated 8/6/2023 and created 8/8/2023 indicated to continue interventions with previous “Risk for Falls” care plan dated 8/5/2023, reeducated the patient to call for assistance whenever help is needed, frequent visual checks every two hours for 72 hours, neuro-checks as ordered, and therapy consult for strength and mobility. A review of Patient 1’s updated Fall Risk Evaluation dated 8/8/2023, indicated Patient 1 continued to be a high risk for falls. The Fall Risk Evaluation indicated Patient 1 was disoriented x 3 (to time, place, person) and had a history of one to two falls in the past three months. The Fall Risk Evaluation indicated Patient1 had balance problems while standing/walking, had decreased muscular coordination/jerking movements, and required the use of assistive devices. A review of Patient 1’s Minimum Data Set (MDS; a standardized assessment and care screening tool) dated 8/9/2023, indicated the patient was severely impaired of cognition (thought process). The MDS indicated Patient 1 was assessed requiring one-person limited assistance (patient highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing support) with walking, including transfers from wheelchair to bed, vice versa, or to a standing position. The MDS indicated Patient 1 was assessed requiring extensive assistance with movement between locations inside her room, including self-sufficiency in the wheelchair. The MDS also indicated Patient 1 was occasionally incontinent (lack of involuntary control to urinate and bowel movement) of bowel and occasionally incontinent of bladder. A review of Patient 1’s Progress Notes dated 8/6/2023, at 10:14 AM, indicated Patient 1 was found on the floor and that Patient 1 complained of pain stating she hit her head on the floor. The Notes further indicated a bump was noted on the patient’s left frontal head (forehead). The Notes indicated the attending physician was at the facility during that time and was made aware. A review of Patient 1’s Progress Notes under Fall Committee Interdisciplinary Team (IDT) dated 8/7/2023, at 9:47 AM, indicated that on 8/6/23, during the morning shift, the charge nurse reported the patient bent down to pick up her cellphone when the patient fell on the floor and fell on her head. The Notes indicated Patient 1 complained of slight pain stating she (Patient 1) “hit her head on the floor.” The Progress Notes further indicated staff met and discussed Patient1’s fall incident and recommended interventions to reeducate the patient to call for assistance when help is needed, rehab (rehabilitation) department for safety training, and provide frequent visual checks every two (2) hours for 72 hours. A review of Patient 1’s Progress Notes dated 8/8/2023, at 3:21 PM, indicated Patient 1 reported waking up with blood on the pillowcase and to monitor Patient 1’s right ear bleed. The Progress Notes indicated the treatment nurse cleaned the wound with normal saline. The Progress Notes indicated the attending physician was made aware. A review of Patient 1’s Progress Notes dated 8/9/2023, at 9:58 PM, indicated for Patient1 to continue to be monitored from the previous fall. The Progress Notes indicated Patient1 was reminded to use call light when needing assistance. A review of Patient 1’s Progress Notes dated 8/12/2023, timed at 3:50 PM, and authored by Licensed Vocational Nurse (LVN) 1, indicated that at around 10:30 AM, LVN 1 was called to Patient 1’s room and that Patient 3 (Patient1’s roommate) stated Patient1 tried opening the curtain, defecated (had a bowel movement), and slipped on the feces. The Progress Notes also indicated Patient1 had three (3) episodes of emesis (vomiting). The Notes further indicated the patient was assessed by the Registered Nurse (RN) Supervisor; alert, responsive, able to move all limbs (arms and legs). The patient then, “stopped responding to verbal commands.” The Progress Notes indicated that at 10:35 AM, 9-1-1 emergency services were called and arrived at the facility at 10:40 AM. The Progress Notes indicated the patient was moved to the bed to begin chest compressions (the act of applying pressure to someone's chest to help blood flow through the heart in an emergency). The Progress Notes indicated at 10:50 AM, Patient 1 expired. During a random patient interview in the facility on 8/18/2023, at 12:20 PM, Patient 2 stated it would take 2 hours for the facility staff to come to her room and assist her when she pressed the call light for assistance for assistance needed for incontinent care. Patient 2 stated that facility staff does not come when she presses the call light. Patient 2 stated every time when she needed to have a bowel movement (BM), the facility staff does not come help. Patient 2 stated the facility staff leaves her soiled with BM for a long time. A review of Patient 2’s MDS dated 8/9/2023, indicated the patient was moderately impaired of cognition. The MDS indicated that Patient 2 required one-person limited assistance with bed mobility, transfer, walk in room, dressing, toilet use and personal hygiene. The MDS indicated Patient 2 was frequently incontinent (loss of bowel or bladder control) of bowel movement. A review of Patient 2’s care plan titled “ADL Self Care Performance Deficit” dated 8/9/2023, indicated interventions that included patient requiring staff participation with personal hygiene and requiring physical assistance with transferring. During an interview on 8/18/2023, at 12:37 PM, Patient 3 stated she feels uneasy and very upset when the facility staff does not attend to her promptly when she pressed her call light for assistance. Patient 3 stated facility staff “never” come on time to assist. Patient 3 stated it would take facility staff 30 minutes to come and help to change her. A review of Patient 3’s Admission Record, indicated the patient was admitted on 8/1/2023, with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) of the left side and muscle weakness. A review of Patient 3’s MDS, dated 8/7/2023, indicated the patient was moderately impaired of cognition. The MDS indicated Patient 3 did not have impaired communication and was able to understand others and be understood. The MDS indicated the Patient 3 required one-person extensive assistance with bed mobility, transfer, walk in room and corridor, locomotion (patient moves to and from) on unit, dressing, toilet use and personal hygiene. The MDS indicated Patient 3 was always incontinent of bladder and frequently incontinent of bowel movement. During the same interview, on 8/18/2023, at 12:37 PM, Patient 3 (Patient 1’s roommate) stated her roommate (Patient 1) “fell a few days ago” while waiting for facility staff to assist her. Patient 3 stated on 8/12/2023, at around 9:30 AM, she observed Patient 1 walk over to Patient 3’s bedside of the room trying to open the drapes (window curtain) when Patient 1 lost her balance. Patient 3 stated she saw Patient 1 fall back against the wall and the patient slipped on the bowel movement on the floor. Patient 3 stated she recalled after Patient 1 fell, she heard Patient 1 verbalized, “Oh God… I pushed the button, but no one came.” Patient 3 stated she also screamed and yelled for facility staff to come and assist Patient 1. Patient 3 stated Certified Nurse Assistant (CNA) 1 finally came to their room and attended to Patient1 “about an hour later” around 10:30 AM. Patient 3 stated Patient 1 was bleeding from her left elbow and the treatment nurse (TN1) took care of the patient’s elbow. Patient 3 stated “I was yelling my head off and no one came.” During the same interview, on 8/18/2023, at 12:37 PM, Patient 3 stated she saw the licensed nurses lay Patient 1 on the bed and performed cardiopulmonary resuscitation (CPR; an emergency lifesaving procedure performed when the heart stops beating). Patient 3 stated Patient 1 “died” shortly after 9-1-1 emergency services arrived in their room. Patient 3 stated she was very upset because she did not know what to do because she was screaming and yelling for facility staff, and no one came to assist. During another random patient interview on 8/18/2023 at 1:41 PM, Patient 5 stated it would take “a long time like 20 minutes” for facility staff to answer when she pressed her call light for facility staff assistance. Patient 5 stated she mostly calls for staff assistance to ask for help with incontinence care like “diaper change.” A review of Patient 5’s undated History and Physical, indicated the patient had the capacity to understand and make decisions. A review of Patient 5’s MDS, dated 6/18/2023, indicated the patient was moderately impaired of cognition. The MDS also indicated the patient required two-person extensive assistance with bed mobility and one-person extensive assistance with dressing and toilet use. The MDS indicated the patient was frequently incontinent of bowel and bladder movements. During an interview on 8/18/2023, at 2 PM, CNA 1 stated Patient 1 was supposed to be discharged home on 8/12/2023, when the patient had the fall. CNA 1 stated Patient 1 had tendencies of getting up without waiting for facility staff assistance. On 8/12/2023, CNA 1 stated she arrived in Patient 1’s room at around 10:30 AM to respond to the activated call light in the room. CNA 1 stated she was busy in another room attending to another patient prior to seeing Patient 1’s call light. CNA 1 stated she observed Patient 1 on the floor with feces on h