Health inspection·July 25, 2024

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 § 72517- Staff Development. (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: (1) Problems and needs of the aged, chronically ill, acutely ill and disabled patients. . . . (5) Accident prevention and safety measures. 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. 42 CFR §483.25(d) Free of Accident Hazards/Supervision/Devices The facility must ensure that – §483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. On 6/18/2024, at 1:30 PM, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding an accident involving Patient 1 on 6/17/2024. As a result of the investigation, the CDPH determined the facility failed to provide a hazard free environment to ensure the safety of the patients in the building by failing to screen Patient 1, who was severely impaired and needed supervision from the staff in doing most of his daily living activities, when the patient returned to the facility while Out-on-Pass (a request made by a patient to the treating team to leave the facility for a period of time, the place where they are going the time of return to the facility). The patient returned to the facility with contrabands (illegal items or weapons) such as cigarette lighter. This deficient practice resulted Patient 1 started a fire by using the lighter to light up a reading magazine in his room which triggered the smoke alarm to go on. The fire department intervened to put off the fire which exposed all patients and staff to dangerous smoke and the risk for injuries related to fire. A review of the facility’s Unusual Occurrence Report (a form used by the facility to report and document unusual occurrence), dated 6/17/24, indicated that at approximately 1:50 AM on 6/17/24, a Mental Health Worker (MHW) notified a Certified Nurse Assistant (CNA) that someone activated the call light. The CNA and the MHW smelled smoke while they were walking towards the room where the call light was triggered. When they opened the door of Patient 1’s room, they saw Patient 1 sitting on the floor with several pieces of burned magazine paper in front of him. The smoke came out from the room and activated the smoke alarm. During an observation on 6/18/24 at 1:50 PM, there were three patients occupying Patient 1’s room; that included Patient 1. The room had no significant fire damages other than burn marks on the floor beside the bed of Patient 1. A review of Patient 1’s Admission Record indicated that the facility initially admitted the patient on 1/30/15 and readmitted the patient on 5/20/19 with diagnoses that included paranoid schizophrenia (a serious mental health condition that affects how people think, feel, and behave, with paranoia [mistrust of other people] as one of its most dominant symptoms). A review of Patient 1’s Minimum Data Set (MDS - a standardized assessment and screening tool), dated 5/15/24, indicated that the patient’s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was severely impaired and the patient needed supervision from the staff in doing most of his daily living activities. A review of Patient 1’s care plan titled “At risk for injury related to smoking,” revised on 8/18/2021, indicated interventions that included the facility staff would provide supervision while resident is smoking, if resident is not able to smoke independently, and storage of smoking material which licensed nurses was required to monitor. A review of Patient 1’s “Pass Request” form indicated that Patient 1 requested to visit FAM 1 on 6/15/2024 at 11 AM, and planned to return the following day (6/16/2024) at 11 AM. A review of Patient 1’s Change in Condition (COC) Evaluation dated 6/17/2024 timed at 4:15 PM, indicated that on 6/17/2024 the “Resident admitted to burning piece of paper from his magazine.” The COC indicated that at approximately 1:50 AM, MHW noted smell of smoke in the hallway. The COC indicated the facility initiated a Code Red and all staff began checking rooms to look for the source of the fire. The COC indicated that upon opening Patient 1’s room, a large amount of smoke was observed, and patients were asked to evacuate from the room. Patient 1 was observed sitting on the floor beside his bed with a burned piece of paper from his magazine. Fire Department was called at 2:10 AM. The Fire Department arrived at 2:23 AM. Patient 1 and the roommates evacuated the room on 6/17/2024. During an interview on 6/18/24 at 1:55 PM, Patient 1 stated that he left the facility on 6/17/2024 to visit his family member (FAM 1) and brought a cigarette lighter from home when he came back to the facility. Patient 1 stated he put the cigarette lighter in his pocket. Patient 1 stated he tried to burn his magazine (inside his room) with his cigarette lighter but did not hurt himself during the process. During an interview and concurrent review of “Return from Pass Assessment” form dated 6/17/24 on 6/18/2024 at 2:40 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that she was the licensed nurse who screened Patient 1 when he came back to the facility from an Out-on-Pass on 6/17/2024. LVN 1 stated that the “Return from Pass Assessment” form dated 6/17/24 did not indicate that Patient 1 was assessed by LVN 1, including having possession of a contraband upon return to the facility on 6/17/24. The form indicated to circle “Yes or No” if the patient was found in possession of a contraband. The form did not indicate if LVN 1 assessed Patient 1 and left the question unmarked. During the interview, LVN 1 stated she should have thoroughly screened the patient when he returned to the facility and indicate the assessment in the” Return from Pass Assessment” form. During an interview on 6/18/2024 at 3 PM, Patient 1 stated that he took the cigarette lighter from FAM 1’s house and placed it in his pocket. Patient 1 stated he returned to the facility with the cigarette lighter still in his pocket. Patient 1 stated he was a smoker and could not remember if LVN 1 checked his pockets when he returned to the facility from being “Out on Pass” on 6/17/2024. During an interview on 6/18/2024 at 3:25 PM, the Administrator stated that licensed nurses must inspect the personal belongings of the patient and must conduct a body check when patients return to the facility from an “Out-on-Pass” to ensure that the patient does not have any contrabands in his possession. The ADM stated that the licensed nurse must indicate in a form titled, “Return from Pass Assessment,” if the patient had any contraband in his possession during the screening. The ADM stated that if the licensed nurse did not indicate that information on the form, the licensed nurse did not screen the patient. A review of the facility’s list of contrabands titled, “Contraband List,” revised on 7/3/2008, indicated that lighters and matches were contrabands that were not allowed in the facility. A review of the facility’s undated policy titled, “Smoking Policy – Patients,” revised in January 2024, indicated that the facility only allows “safety lighters” in the building while all other forms of lighters, including matches, are prohibited. A review of the facility’s undated policy titled, “Safety and Supervision of Patients,” revised in 12/2007, indicated that the facility strives to make the environment as free from accident hazards as possible where patient safety, supervision, and assistance to prevent accidents are facility-wide priorities. A review of the facility’s policy titled, “Day Program/Outings Policy and Procedure,” dated 12/8/14, indicated that upon the return of a patient from an Out-on-Pass, the licensed staff will inspect the bags and pockets of the patient for any contrabands. The facility failed to provide a hazard free environment to ensure the safety of the patients in the building by failing to screen Patient 1, who was severely impaired and needed supervision from the staff in doing most of his daily living activities, when the patient returned to the facility while Out-on-Pass. The patient returned to the facility with contrabands (illegal items or weapons) such as cigarette lighter. This deficient practice resulted Patient 1 started a fire by using the lighter to light up a reading magazine in his room which triggered the smoke alarm to go on. The fire department intervened to put off the fire which e exposed all patients and staff to dangerous smoke and the risk for injuries related to fire. The above violations had a direct or immediate relationship to the health, safety, or security of Patient 1 and other patients residing in the facility.