Health inspection·July 23, 2024

§ 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. 22 CFR § 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: (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. 22 CFR § 72515 Admission of Patients The licensee shall: (b) Accept and retain only those patients for whom it can provide adequate care. 22 CFR § 72501 Licensee--General Duties (f) If language or communication barriers exist between skilled nursing facility staff and patients, arrangements shall be made for interpreters or for the use of other mechanisms to ensure adequate communication between patients and personnel. 22 CFR § 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 6/10/2024, the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey at the facility. During staff interviews, the CDPH identified the facility did not have the resources and training necessary to communicate with Resident 107, who was deaf and communicated using American Sign Language (ASL, a language expressed by movements of the hands and face). Due to the facility’s inability to accurately assess and communicate with Resident 107, Resident 107 suffered a nine-pound ([lb.], a unit of measurement) weight loss from 4/12/2024 to 6/7/2024 and was transferred to general acute care hospital (GACH) 2 on 6/12/2024 due to abdominal pain. The facility failed to: 1. Ensure interpreter services were available for communication with Resident 107, prior to accepting and admitting Resident 107 to the facility from GACH 1. 2. Revise Resident 107’s care plan to reflect her preferred method of communication (ASL), when it was identified that use of other communication methods was ineffective. 3. Ensure all levels of staff used American Sign Language (ASL) when communicating with and conducting assessments of Resident 107. 4. Assess the cause of Resident 107’s poor oral intake starting on 6/8/2024. A review of Resident 107’s History and Physical (H&P) from general acute care hospital (GACH) 1, dated 4/8/2024, indicated Resident 107 had a history of deafness, visual impairment/blindness, and dementia (loss of memory, language, problem-solving and other thinking abilities). The H&P indicated history collection was limited due to Resident 107’s hearing and visual deficits. A review of Resident 107’s Admission Record indicated Resident 107, a 65-year-old female, was admitted to the facility on 4/12/2024. Resident 107’s admitting diagnoses included dementia, deaf nonspeaking, history of falling, and generalized muscle weakness. The Admission Record also indicated Family Member (FM) 1 was Resident 107’s responsible party and decision maker. A review of Resident 107’s H&P, dated 4/17/2023, indicated Resident 107 did not have the capacity to understand and make decisions. A review of Resident 107’s Minimum Data Set (MDS, a standardized care-planning and care-screening tool), dated 4/19/2024, indicated Resident 107 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 107 had highly impaired hearing, did not speak, and had moderately impaired vision requiring the use of corrective lenses. The MDS indicated Resident 107 was unable to respond when asked how often she needed to have someone help her read instructions or written material. The MDS indicated Resident 107 exhibited rejection of care necessary to achieve goals for health and well-being for one to three days over a period of seven days. The MDS indicated Resident 107 required partial to moderate assistance from staff for hygiene after toileting, dressing her upper body, personal hygiene activities, mobility while in bed, and transitioning between surfaces (bed to chair, getting on and off the toilet). The MDS indicated Resident 107 required verbal cues and/or touching/steadying assistance from staff when eating, brushing her teeth, dressing her lower body, putting on/taking off her shoes, and walking. A review of Resident 107’s Progress Note, dated 4/12/2024 at 10:59 p.m., indicated Resident 107 had an episode of aggressive behavior due to frustration from inability to communicate her needs. A review of Resident 107’s Admission Summary, dated 4/13/2024, indicated Resident 107 was admitted from GACH 1, was deaf and used ASL to communicate. The Admission Summary indicated due to frustration from being unable to talk, Resident 107 spat water at the nursing staff who were attempting to assess her. A review of Resident 107’s Progress Note, dated 4/14/2024 at 8:20 a.m., indicated Resident 107 was agitated, and displayed restlessness, walked up and down the hallway, and communicated that no one could understand her. The progress note did not indicate any attempts to assess Resident 107’s preferred method of communication, or staff attempts to communicate with the resident in her preferred method of communication. The progress note indicated Resident 107’s admission weight was 104 lbs. A review of Resident 107’s Progress Note, dated 4/15/2024 at 12:29 p.m., indicated Resident 107’s Family Member (FM) 1 notified facility staff that the effective way to communicate with Resident 107 was through ASL. A review of Resident 107’s Progress Note, dated 4/15/2024 9:29 p.m., indicated Resident 107 was agitated, restless, and communicating through hand gestures and no one could understand her. The progress note did not indicate any staff interventions to address Resident 107’s agitation, restlessness, or any attempts to communicate with Resident 107 in her preferred method of communication, to meet her needs. A review of Resident 107’s Dietary Progress Note, dated 4/17/2024 at 10:45 a.m., indicated Resident 107 was unable to answer questions verbally, and was asked by the Dietary Supervisor (DS) about her food and beverage preferences by writing with a pen and paper. The notes indicated Resident 107 responded by nodding her head. The progress note indicated Resident 107 requested to have coffee and the facility would honor her preferences. The progress note did not indicate that an ASL interpreter or other communication devices/methods were used to verify the accuracy of the interview. The progress note did not indicate Resident 107’s responsible party, (FM 1), was contacted for additional information related to Resident 107’s dietary restrictions or preferences. A review of Resident 107’s Progress Note, dated 6/6/2024 at 4:10 a.m., indicated on 5/15/2024, Resident 107’s weight was 100 lbs. A review of Resident 107’s Progress Note, dated 6/8/2024 at 12:23 p.m., indicated staff attempted to contact FM 1 to notify FM 1 of Resident 107’s weight change, inadequate eating patterns, and Resident 107’s behavior of pointing to her flank (the side of the body between the ribs and the hip). The progress note indicated Resident 107 had no complaints of pain or discomfort. The progress note did not indicate if a formal assessment was conducted, or an interpreter was used to assess Resident 107. A review of Resident 107’s COC, dated 6/8/2024 at 4:59 p.m., indicated Resident 107 had weight loss, and on 6/7/2024 Resident 107’s weight was 95 lbs. The COC indicated Resident 107 exhibited signs of inadequate food intake and was not eating or drinking at all. The COC indicated abdominal/gastrointestinal (relating to the stomach and the intestines) and pain status evaluations were “not clinically applicable to the change being reported”. The COC further indicated Resident 107 was unable to speak. The COC did not indicate that staff used an interpreter to perform any of the assessments. A review of Resident 107’s Progress Note, dated 6/8/2024 at 5:23 p.m., indicated FM 1 returned the facility’s call from 12:23 p.m. and was notified of Resident 107’s weight loss, and that Resident 107 had been pointing to her stomach. The progress note indicated FM 1 informed staff that Resident 107 had chronic problems with gastrointestinal discomfort and hyperacidity. The progress note indicated FM 1 informed staff that Resident 107 was not supposed to have acidic beverages, including coffee. A review of Resident 107’s Progress Note, dated 6/11/2024 at 8:30 p.m., indicated Resident 107 had a weight loss of nine (9) lbs. since admission on 4/12/2024. The progress note indicated Certified Nursing Assistant (CNA) staff reported Resident 107 ate less of her meals and sometimes pointed to her stomach. The progress note did not indicate that any further assessment was conducted to assess the cause of the decreased intake or why Resident 107 was pointing to her stomach. The progress notes indicated Resident 107’s primary physician (MD) was notified, and the MD gave an order for Resident 1 to be transferred to a GACH. A review of Resident 107’s Progress Note, dated 6/12/2024 at 3:15 p.m., indicated Resident 107 displayed facial grimacing, and pointed her hands to her stomach, back and shoulder. The progress note indicated FM 1 was contacted to assist with interpreting Resident 107’s gestures. The progress note indicated Resident 107’s covering MD ordered for Resident 107 to be transferred to a GACH for further evaluation. The progress note did not indicate that a formal assessment was conducted using interpreter services. A review of Resident 107’s COC, dated 6/12/2024 at 3:35 p.m., indicated Resident 107 had abdominal pain that started on 6/11/2024. The COC indicated 500 milligrams (mg, a unit of measurement) of Tylenol was administered for the abdominal pain. A review of Resident 107’s Progress Note, dated 6/12/2024 at 4:18 p.m., indicated Resident 107 had complained of severe abdominal pain since the evening of 6/11/2024. The progress note indicated Resident 107’s primary MD was on vacation and staff received orders from the facility’s Medical Director (MD 2) to transfer Resident 107 to a GACH. A review of Resident 107’s Progress Note, dated 6/12/2024 at 4:18 p.m., indicated Resident 107 was observed eating dinner and she was a “poor eater.” The progress note indicated staff encouraged Resident 107 to eat by pointing to the food. The progress note indicated Resident 107 ate 50% of her meal. The progress note did not indicate staff used an interpreter or alternative communication method to assess the cause of Resident 107’s poor intake, or to encourage Resident 107 to eat. A review of Resident 107’s Progress Note, dated 6/12/2024 at 10:10 p.m., indicated Resident 107 was transferred to GACH 2 due to intractable pain to her right lower abdomen and right shoulder. A review of Resident 107’s GACH 2 records, dated 7/9/2024, indicated Resident 107 was admitted to GACH 2 on 6/13/2024 and discharged from GACH 2 on 6/17/2024. The records indicated that upon arrival to GACH 2, Resident 107 was pointing to her lower abdomen and back, gesturing that she was in pain. The records indicated Resident 107 had tenderness to her abdomen when touched. Resident 107 received intravenous hydration (specially formulated liquids that are injected into a vein to prevent or treat dehydration) during her hospital admission and was diagnosed with gastro-esophageal reflux disease (A digestive disease in which stomach acid or bile irritates the food pipe lining). During an observation on 6/10/2024 at 10:10 a.m., in the doorway of Resident 107’s room, Resident 107 was observed sitting up at the right edge of her bed. Resident 107 did not respond to vocalized questions. Upon entering the room, Resident 107 vocalized unintelligible sounds, and pointed to her ears and eyes. No communication board, writing pad, or any other communication devices were observed readily available at Resident 107’s bedside. During an observation on 6/10/2024 at 10:13 a.m., in Resident 107's room, a Licensed Vocational Nurse (LVN) 1 entered Resident 107’s room holding a blood pressure machine. LVN 1 approached Resident 107, pointed at her (LVN 1’s) own arm, and told Resident 107 that she was to check the resident’s blood pressure. LVN 1 showed Resident 107 the machine. LVN 1 did not use any communication device to communicate with or explain the care to be provided to Resident 107. LVN 1 then directed Resident 107 to the bed using hand gestures and checked Resident 107’s blood pressure. During a concurrent observation and interview, on 6/10/2024 at 10:14 a.m., with LVN 1, in Resident 107’s room, LVN 1 was observed providing care to Resident 107. LVN 1 stated staff used hand gestures or wrote with pen and paper to communicate with Resident 107. LVN 1 told Resident 107 she was going to go through Resident 107’s belongings, then proceeded to go through Resident 107’s bedside dresser. Resident 107 frowned while LVN 1 went through her belongings. LVN 1 did not use any communication board, pen, paper, or any other communication device to explain her actions to Resident 107. LVN 1 exited the room and did not communicate further with Resident 107. During an observation on 6/10/2024 at 10:18 a.m., in Resident 107's room, Resident 107 was observed pacing at her bedside and pointing at her eyes and ears. During an observation on 6/11/2024 at 9:04 a.m., in Resident 107’s room, Resident 107 was observed sitting upright in bed, staring at the wall across from her bed. There were no communication boards, writing pads, or other communication devices readily observed at her bedside. During an interview on 6/11/2024 at 9:16 a.m., with the Director of Staff Development (DSD), outside of Resident 107’s room, the DSD stated there were no staff trained or certified in ASL. The DSD stated Resident 107 was one of the facility’s first residents with severe hearing impairment. When asked how Resident 107 communicated or expressed her needs, the DSD stated Resident 107 made gestures with her hands and arms. When asked how staff communicated with Resident 107, or explained the care provided, the DSD stated staff also used hand gestures. The DSD stated hand gestures were not a reliable method of communication. The DSD stated Resident 107 also had visual impairments. The DSD stated the Social Services Assistant (SSA) attempted to set up interpreter services for Resident 107 but was unsure of the outcome. During a concurrent observation and interview on 6/11/2024 at 9:20 a.m., at Resident 107’s bedside, with the DSD, the DSD was observed going through Resident 107’s bedside dresser. The DSD removed a printed communication board from the drawer. When the DSD was asked to demonstrate how the communication board was used to communicate with Resident 107, the DSD stated Resident 107 did not use the communication board. The DSD stated FM 1 previously informed the facility that Resident 107 used ASL. Resident 107 was observed attempting to communicate through hand gestures with the DSD. The DSD was observed attempting to understand what Resident 107 was trying to communicate by verbally asking Resident 107 what she needed, in an attempt to illicit a response from Resident 107. The DSD did not use a written communication method or communication device to communicate with Resident 107. Resident 107 rolled her eyes and continued to make hand gestures, then proceeded to grab the DSD’s arm and guided the DSD out of the room to the nurse’s station. At the nurse’s station, Resident 107 gestured to her stomach and the DSD stated Resident 107 was hungry. The DSD then redirected Resident 107 back to her room. The DSD did not communic