Health inspection·November 1, 2024

§483.40 Behavioral health services. Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (B)A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii)When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. 22 CCR § 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. 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 9/16/2024 the California Department of Health (CDPH) received a facility reported incident (FRI) regarding a resident (Resident 1) who was found hanging in the bathroom with a charging cord for a phone around his neck. On 9/16/2024, CDPH conducted an unannounced visit to the facility to investigate this FRI. The facility failed to ensure Resident 1, who had diagnosis of depression (mental health disorder characterized by persistently low mood or loss of interest in activities, causing significant impairment in daily life) and a history of suicidal ideation (thinking about or formulating plans for suicide) was provided with an appropriate care plan and supervision to prevent Resident 1 from committing suicide. The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN 1) initiated continuous monitoring of Resident 1's behavior through an assessment to ensure close monitoring of Resident 1's change in behavior, mood, cognition, presence of hallucinations delusions and suicidal ideation, when Certified Nursing Assistant (CNA 1) reported to LVN 1 that Resident 1 was observed sobbing (crying spells) and accusing CNA 1 of putting poison in his water pitcher on 9/14/2024 at 12:15 a.m. 2. Ensure a change of condition (COC) form was completed when on 9/14/2024 at 12:15 a.m., when Resident 1 was having crying spells, shaking hands, anxious, and verbalizing being scared and that someone was trying to kill him. 3. Ensure staff followed Resident 1's care plan titled, "Resident uses antidepressant related to depression" initiated on 9/12/2024, which included interventions to monitor, document, and report as necessary changes in Resident 1's behavior, mood, cognition, hallucinations, delusions, suicidal thoughts, and withdrawal and notify the physician of COC. 4. Ensure Resident 1's primary care physician was notified when Resident 1 experienced a COC, when Resident 1 was observed crying and accusing CNA 1 of putting poison in his water pitcher on 9/14/2024 at 12:15 a.m. 5. Ensure Social Services Director (SSD) reviewed and assessed Resident 1's history of suicidal ideations on 2/29/2024 as documented in Resident 1's medical record from Resident 1's previous admissions to the facility. 6. Ensure SSD assessed Resident 1 upon admission to the facility on 9/10/2024 and gather information to complete Resident 1's Patient Health Questionnaire ([PHQ 9- a validated interview that screens for symptoms of depression) on the 7th day after admission. 7. Ensure nursing staff followed the facility's policy and procedure (P&P) titled, "Resident Safety," which indicated the residents will be evaluated whenever there is a COC, to identify circumstances that pose a risk for the safety and wellbeing of the resident. 8. Properly assess and review previous admission records to ensure Resident 1's room was free of objects that could be used to cause harm to a resident with a history of suicidal ideation. As a result, Resident 1 was found hanging in the bathroom with a charging cord from a phone around his neck, on 9/14/2024 at 4:40 a.m. The resident was lowered to the floor, cardiopulmonary resuscitation ([CPR]-an emergency procedure that can save a person life if their breathing or heart stops) was initiated and 911 (emergency services) was called. The Emergency Medical Services ([EMS]- medical professionals providing emergency medical care) arrived at the facility and pronounced Resident 1 dead on 9/14/2024 at approximately 5:25 a.m. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on 9/10/2021 and re-admitted 3/10/2024. On 4/2/2024 Resident 1 was discharged home and readmitted back to the facility on 9/10/2024 with diagnoses including depression, cerebral infarction (damage to the brain from interruption of its blood supply) with right sided hemiplegia (paralysis of one side of the body and right hemiparesis (weakness of one side of the body), and failure to thrive (a syndrome that describes a decline in an older adult's health that can include weight loss, poor nutrition, and inactivity). A review of Resident 1's History & Physical (H&P) dated 9/11/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Minimum Data Set ([MDS] dated 3/15/2024, indicated Resident 1 had intact cognitive skills (ability to think, understand, learn, and remember) for daily decision making and required supervision or touching assistance (helper provides verbal cues) with bed mobility, transfer from chair/bed-to-chair transfer (ability to transfer to and from a bed to chair or wheelchair), walking 10 feet (ability to walk at least 10 feet in a room, corridor or similar space once standing) and personal hygiene. A review of Resident 1's MDS dated 9/14/2024, indicated Resident 1 had an active diagnosis of depression and was taking anti-depressant (prescription medications that can help treat depression and other mental health conditions) medication (Lexapro). A review of Resident 1's baseline care plan (a document that provides instructions for a resident's care in a nursing home), dated 9/10/2024, indicated under Social Services, Resident 1 was being monitored for depression, and "Social Service Director (SSD) to complete Patient Health Questionnaire ([PHQ 9- a validated interview that screens for symptoms of depression)." A review of Resident 1's Informed Consent (the process in which a healthcare provider educated a patient about the risks, benefits, and alternatives of a given procedure, treatment, or intervention), dated 9/10/2024, indicated Resident 1 was prescribed Lexapro (medication used to treat depression) for depression and persistent verbalization of sadness. A review of Resident 1's Care Plan titled, "Resident 1 uses antidepressant medication Lexapro related to depression" initiated on 9/12/2024, indicated a goal for Resident 1 to decrease the resident's episodes of signs and symptoms of depression. The Care Plan's interventions included to administer antidepressant medications as ordered by the physician, monitor, document, report as needed changes in the resident's behavior/mood/cognition (mental process involved in knowing, learning, and understanding things), presence of hallucinations (false perception of reality), delusions, social isolation (no relationships with other), suicidal thoughts, and withdrawal. A review of Resident 1's initial Psychiatric Evaluation (a comprehensive examination of a person's mental, emotional, and behavioral health), dated 9/13/2024, the initial Psychiatric Evaluation indicated Resident 1 was oriented to person, place, and time. The initial Psychiatric Evaluation, under the treatment plan, indicated "to observe the resident for deterioration in function, resident was educated to report worsening of symptoms and to report if noted with changes in mood and behavior. Gradual dose reduction ([GDR] a step in tapering a dose of a medication), of Lexapro was contraindicated at this time as it may exacerbate (to make something worse) resident symptoms (not specified)." A review of Resident 1's Nurses Progress Notes, dated 2/8/2024, indicated Resident 1 was on monitoring due to hallucination episode. Nurses progress notes indicated Resident 1 could not sleep because he was experiencing strange things in the room during the night such as pages of a book in his closet flipping by themselves. A review of Resident 1's PHQ-2-9 questionnaire, dated 2/25/2024, indicated a score of 10 (a score of 10-14 represented moderate depression). A review of Resident 1's Nurses Progress Notes, dated 2/29/2024, indicated a Social Worker met with Resident 1 for "verbalization of wanting to die" and Lexapro was increased to 20 milligrams ([mg]-unit of measurement). A review of Resident 1's Nurses Progress Notes, dated 3/3/2024, indicated Resident 1 was being monitored (unspecified) for episodes of verbalization of wanting to die. A review of Resident 1's Nurses Progress Notes, dated 3/22/2024, indicated Resident 1 was being monitored for panic attacks (a sudden episode of intense fear or discomfort that can cause physical and mental symptoms) and tachycardia (a heart rate that is faster than 100 beats per minute). A review of Resident 1's Nurses Progress Notes dated 9/14/2024 timed at 12:51 a.m., indicated on 9/14/2024 at around 12:15 a.m., CNA 1 called Resident 1's assigned charge nurse (LVN 1) to the bath resident's room. The Nurses Progress Notes indicated LVN 1 entered Resident 1's room and found Resident 1 sitting on the side of his bed appeared worried and stated someone was trying to poison him pointing to his water pitcher/cup. The Nurses Progress Notes indicated Resident 1's blood pressure was 171/89 millimeters of mercury (mm/Hg unit of measurement [reference range for normal blood pressure is less than 120/80], the resident had a headache rated four out of 10 on a pain scale (tool to measure pain intensity by asking patient to rate their pain on a scale of 0 to 10, where zero is no pain and 10 is the worse pain possible). The Nurses Progress Notes indicated at 12:18 a.m. Resident 1 received Tylenol (medicine used to relieve pain) and at 12:38 a.m. Resident 1 received Clonidine (medicine used to lower blood pressure) for high BP. The Nurses Progress Notes indicated on 9/14/2024, at around 4:40 a.m. CNA 3 entered the Resident 1's bathroom and found Resident 1 kneeling on the floor facing the wall with a red cord (cord to charge a phone) around his neck, and the cord was tied around the handrail. The Nurses Progress Notes indicated Resident 1 was unresponsive, not breathing and staff was unable to obtain a blood pressure reading. The Nurses Progress Notes indicated Resident 1's pulse rate was 186 beats per minute (reference range for adult pulse is 60 to 90 beats per minute). The Nurses Progress Notes indicated a facility staff (unknown) called 911 (emergency services) and initiated CPR. At 5:01 a.m. paramedics (Emergency Medical Services) arrived and continued CPR. Resident 1 was pronounced dead around 5:25 a.m. During an interview on 9/16/2024 at 2:50 p.m., with Resident 1's roommate (Resident 2), Resident 2 stated on the night of 9/13/2024, he could not sleep well as Resident 1 was not sleeping and crying a lot. Resident 2 stated a staff member (unknown) came into the room to calm Resident 1 down on 9/14/2024 at 3:00 a.m., and after staff member left Resident 1 began crying again. Resident 2 stated around 4 a.m. he heard Resident 1 struggling to walk to the bathroom, as he was holding onto the walls while walking. Resident 2 stated after that he went back to sleep and did not hear anything until someone told him the next day what happened to Resident 1 (committed suicide). During an interview on 9/17/2024, at 6:25 a.m., CNA 1 stated on 9/14/2024 at 12:00 a.m., Resident 1 was restless standing up next to his bed crying. CNA 1 stated she informed LVN 1 that Resident 1 was restless and crying. CNA 1 stated Resident 1 continued to cry when he was assisted back to bed. CNA 1 stated it was important to report to the charge nurse any changes in a resident's behavior so the charge nurse can check on the resident and assess the behavior. CNA 1 stated she returned to check on Resident 1 at 1:00 a.m. and observed Resident 1 was awake lying in bed. CNA 1 stated at 4 a.m. she saw Resident 1 standing up next to his bed talking with CNA 3 and LVN 1. CNA 1 stated when Resident 1 saw her he pointed at her and stated, "that was her, she was trying to kill me, you poisoned the water," while pointing to his water pitcher. During an interview on 9/17/2024, at 6:45 a.m., LVN 1 stated CNA 3 informed her that Resident 1 appeared worried and concerned and was telling CNA 3 someone was trying to poison him. LVN 1 stated she went to assess him, and Resident 1 was alert and oriented and did not appear to be confused. LVN 1 stated Resident 1 calmed down after she explained to him that the CNAs were delivering the new water pitchers and offered to get him a new CNA but Resident 1 declined. LVN 1 stated she felt there was a "misunderstanding" between her (LVN 1) and Resident 1 and not a change in resident's condition, and that was the reason she did not call Resident 1's the doctor to inform of the resident's behavior. During an interview on 9/17/2024, at 7 a.m., CNA 3 stated when she was passing out water pitchers at approximately 12:00 a.m. on 9/14/2024, Resident 1 verbalized to CNA 3 that another CNA (unknown) was trying to poison him. CNA 3 stated Resident 1 appeared nervous, scared, his hands were shaking, and verbalized repeatedly that a lady was trying to poison him. CNA 3 stated she stayed with Resident 1 to listen to his concerns and then reported his behavior to LVN 1. During a concurrent interview and record review on 9/17/2024, at 7:25 a.m., with LVN 1, Resident 1's medication administration record (MAR) was reviewed. LVN 3 stated she gave Resident 1 Tylenol for his headache at 12:18 a.m. and Clonidine at 12:30 a.m. LVN 1 stated it was difficult to obtain Resident 1's blood pressure because he was moving a lot and was pointing at his water pitcher. LVN 1 stated Resident 1 had depression and high blood pressure, and when Resident 1 was stating someone was trying to poison him it could have been related to his depression. LVN 1 stated Resident 1 was taking Lexapro for his depression for targeted behaviors of persistent verbalization of sadn