Health inspection·October 10, 2023

42 CFR §483.25(d) Free of Accident Hazards/Supervision/Devices The facility must ensure that – (1) The resident environment remains as free of accident hazards as is possible; and 2) Each resident receives adequate supervision and assistance devices to prevent accidents. 42 CFR §483.21(b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident. 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. (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. 22 CCR § 72313 Nursing Service--Administration of Medications and Treatments (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed 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 8/28/2023, the California Department of Public Health (CDPH) received a facility reported incident (FRI) indicating on 8/26/2023, at 12:15 p.m., Resident 1 became unresponsive in the dining room, cardiopulmonary resuscitation ([CPR] an emergency procedure to restart a person’s heart and breathing after one or both suddenly stop) was initiated, and Resident 1 was pronounced dead at 1:02 pm. On 8/29/2023, the CDPH conducted an unannounced visit at the facility to investigate the FRI regarding Resident 1’s death. The facility failed to: 1. Ensure Resident 1’s environment remained free of hazards and that Resident 1 received adequate supervision and assistance because Resident 1 was served a meal tray with no 1:1 supervision (one staff supervising one resident only). 2. Implement the facility’s policy and procedure (P&P), titled “High Risk Safety Monitoring,” which indicated the assigned staff for residents on 1:1 monitoring, will be within two feet from the resident. 3. Develop and implement a comprehensive person-centered care plan addressing Resident 1’s eating behaviors identified as eating too fast and not chewing foods thoroughly. 4. Follow the Registered Dietitian’s (RD) recommendation, dated 8/12/21, which indicated to provide Resident 1 with 1:1 supervision during dining. 5. Provide care as prescribed in the Physician’s Order dated 6/14/23, which indicated to provide 1:1 supervision to Resident 1, during mealtimes. 6. Implement the facility’s P&P titled, “Care Plans-Comprehensive,” which indicated an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident’s needs was developed for each resident. As a result of these failures, on 8/26/2023, Resident 1 choked and became unresponsive, while eating in the dining room. Resident 1 did not have 1:1 supervision during meal, and CPR was initiated, by staff. The paramedics suctioned heavy vomitus from Resident 1, performed CPR for 22 minutes, and pronounced the resident dead on 8/26/2023 at 1:02 p.m. A review of Resident 1’s face sheet (admission record) indicated, Resident 1 was a 58-year-old female originally admitted to the facility on 10/24/2019 and readmitted on 12/30/2020, with diagnoses including schizophrenia (a disorder that affects a person’s ability to think, feel, and behave clearly), type 2 diabetes (abnormal blood sugar), tachycardia (fast heart rate), and hypertension (high blood pressure). The face sheet indicated Resident 1 expired on 8/26/2023. A review of Resident 1’s Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 8/11/2023, indicated Resident 1 usually understood and was usually able to be understood by others. The MDS indicated Resident 1 was independent with eating, locomotion (moving from one location to another), dressing and toileting. A review of Resident 1’s Registered Dietitian’s (RD) note dated 8/7/2021, indicated Resident 1 was observed eating too quickly and not chewing meals thoroughly. The RD note indicated to provide close monitoring at all mealtimes to encourage Resident 1 to chew foods thoroughly before swallowing and provide meal portions in a few small containers to encourage slower eating. A review of Resident 1’s RD’s Follow-Up Note dated 8/12/2021, indicated on 8/12/2021, the RD observed Resident 1 had “risky eating behaviors.” The resident was observed eating quickly, not clearing mouth between bites, and eating chicken without pulling the meat away from the bones then spitting out the bones. The RD recommendations included 1:1 supervision during meals and a diet order change to small portions with all meals, mechanical soft and finely chopped diet. A review of Resident 1’s care plan titled “Altered nutritional status related to history of skipping meals,” dated 5/25/2023, indicated staff will monitor Resident 1’s meal intake, and provide supervision to Resident 1 during meals. A review of Resident 1’s Medication Review Report (physician orders), dated 6/14/2023, indicated mechanical soft finely chopped textured diet and 1:1 supervision during meals. A review of Resident 1’s change in condition (COC) report, dated 8/26/2023, indicated on 8/26/2023, at approximately 12:15 p.m., Resident 1 was observed unresponsive sitting in a chair in the dining room, leaning to her right side, with no palpable pulse and no breath sounds. The report indicated CPR was initiated and 911 (an emergency alert system) was called. The report indicated Resident 1 was pronounced dead on 8/26/2023, at 1:02 p.m. A review of the Los Angeles County Fire Department incident summary for Resident 1, dated 8/26/2023 indicated Resident 1 was eating food when staff witnessed Resident 1 slump over. The summary indicated Paramedics suctioned Resident 1’s oropharynx (middle part of the throat) due to heavy vomitus. The summary indicated Paramedics declared Resident 1 dead at 1:02 p.m. During a concurrent interview and record review with Licensed Vocational Nurse (LVN 2) on 8/30/2023 at 2:15 p.m., Resident 1’s dietary care plan titled “Resident has altered nutritional status related to history of skipping meals, obesity (excess body fat), diabetes, and hypertension,” dated 5/25/2023 was reviewed. LVN 2 stated the care plan did not include the RD’s recommendations for Resident 1 to be on 1:1 supervision during meals. LVN 2 stated when a resident’s diet was changed, licensed nurses were supposed to develop a new care plan based on the current diet order and the RD’s recommendations. LVN 2 stated Resident 1 did not have a care plan to address the RD’s recommendations dated 8/12/2021, for Resident 1 to be supervised during meals. During a concurrent interview and record review with the DON on 8/30/2023 at 4:19 p.m., Resident 1’s physician’s orders were reviewed. The DON stated Resident 1’s Physician’s orders indicated mechanical soft finely chopped textured diet and 1:1 supervision during meals for safety. The DON stated Resident 1 did not have an assigned staff member for 1:1 supervision when she choked on 8/26/23. The DON stated no care plan was developed to address the RD’s recommendations on 8/7/2021, and 8/12/21, which indicated Resident 1 should have a 1:1 supervision during mealtimes. During a phone interview on 8/31/2023 at 11:26 a.m. with Licensed Vocational Nurse (LVN) 1 stated on 8/26/2023, at approximately 12:15 p.m., she (LVN 1) was busy assisting other residents and not within two feet of Resident 1, when she observed Resident 1 slumped over. LVN 1 stated she did not see a staff member sitting next to Resident 1. LVN 1 stated Resident 1 did not have an order for 1:1 supervision with meals. LVN 1 stated she did not see Resident 1’s physician’s orders dated 6/14/2023 which indicated Resident 1 should be supervised during meals. LVN 1 stated it was her responsibility to verify and carryout all physician’s orders. LVN 1 stated, she assumed Resident 1 did not require 1:1 supervision and was not supervised during meals when she choked and died. During a concurrent interview and video footage review on 9/2/2023 at 2:27 p.m., with the Director of Nursing (DON) and Administrator (ADM), the facility’s video surveillance of the north dining area dated 8/26/2023, was reviewed. The ADM stated, on 8/26/2023 at 12:17 p.m., LVN 1 served Resident 1 a lunch tray., and walked away to serve other residents. LVN 1 was observed walking out of the room. The ADM stated 12:24 p.m., while Resident 1 was eating, staff continued to pass meal trays to other residents and Resident 1 was not supervised (1:1). The ADM stated at 12:26 p.m., LVN 1 noticed Resident 1 slumped over and rushed to Resident 1’s side. The ADM stated at 12:27 p.m., LVN 1 performed the Heimlich maneuver (a method for forcing an object out the airway of a choking person) on Resident 1. A review of the facility’s P&P, titled “High Risk Safety Monitoring,” dated 2020, indicated the facility closely monitored the status of residents at risk for unsafe behavior, to observe for a significant change in their behavior or physical or mental condition. The P&P indicated its purpose was to ensure the safety and wellbeing of residents at risk for unsafe behaviors were monitored appropriately. The P&P indicated assigned staff for residents on 1:1 monitoring, will be within two feet from the resident. A review of the facility’s P&P titled “Physician Orders,” dated 2020, indicated Physician orders must be given and managed in accordance with applicable laws and regulations. A review of the facility’s P&P titled, “Care Plans-Comprehensive,” dated 2020, indicated an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident’s medical, nursing, mental, and psychological needs was developed for each resident. The P&P indicated each resident’s care plan had been designed to incorporate risk factors associated with identified problems and aided in preventing or reducing declines in the resident’s functional status and or functional levels. A review of the facility’s P&P titled, “Care Plan Goals and Objectives,” dated 2020, indicated goals and objectives were reviewed and or revised when there had been a significant change in the resident’s condition. A review of the facility’s P&P titled “Mealtime Supervision,” dated 2022, indicated all residents will be observed during mealtime to monitor meal acceptance and safety of the residents. The P&P indicated observations will be noted and referrals made as needed to the appropriate staff, for residents with difficulty chewing, swallowing, using utensils and self-feeding. The facility failed to: 1. Ensure Resident 1’s environment remained free of hazards and that Resident 1 received adequate supervision and assistance because Resident 1 was served a meal tray with no 1:1 supervision. 2. Implement the facility’s policy and procedure (P&P), titled “High Risk Safety Monitoring,” which indicated the assigned staff for residents on 1:1 monitoring, will be within two feet from the resident. 3. Develop and implement a comprehensive person-centered care plan addressing Resident 1’s eating behaviors identified as eating too fast and not chewing foods thoroughly. 4. Follow the RD’s recommendation, dated 8/12/21, which indicated to provide Resident 1 with 1:1 supervision during dining. 5. Provide care as prescribed in the Physician’s Order dated 6/14/23, which indicated to provide 1:1 supervision to Resident 1, during mealtimes. 6. Implement the facility’s P&P titled, “Care Plans-Comprehensive,” which indicated an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident’s needs was developed for each resident. As a result of these failures, on 8/26/2023, Resident 1 choked and became unresponsive, while eating in the dining room. Resident 1 did not have 1:1 supervision during meal, and CPR was initiated by staff. The paramedics suctioned heavy vomitus from Resident 1, performed CPR for 22 minutes, and pronounced the resident dead on 8/26/2023 at 1:02 p.m. These violations, jointly, separately or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and were a direct proximate cause of death for Resident 1.