Health inspection·March 2, 2023

F919 CFR §483.90(g) Patient Call System. The facility must be adequately equipped to allow patients to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from- §483.90(g)(1) Each resident’s bedside; and §483.90(g)(2) Toilet and bathing facilities. T22 - §72631- Signal Systems (a) A nurses' signal system shall be maintained in operating order as required by Section E702-30 of Title 24. (b) Detachable extension cords shall be readily accessible to patients at all times. T22 Section 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 12/15/2022, the California Department of Public Health (CDPH, the Department) conducted a complaint investigation regarding quality of care and call bells not functioning. The facility failed to provide a working patient call system for Patients 3, 7, 8 and 9. a. For Patient 3, facility’s staff (in general) did not respond promptly to the call bell when Resident 3 called for help. b. For Patients 7, 8 and 9, facility’s staff did not provide the call bells for the patients to utilize to call staff for assistance when the electronic call light system was not working. These deficient practices violated Patients 3’s, 7’s, 8’s and 9’s rights, and had the potential for the patients not receiving needed nursing care and services due to the patients’ inability to call staff for assistance. During a facility tour on 12/15/2022, from 12:50 pm to 2:28 pm, Rooms A, B, C, D, E, F, G, H, I and J were observed without call lights for patients to utilize to alert staff when they needed staff assistance for care and services. 1. A review of Patient 3’s Admission Record indicated Patient 3 was an 84 years old male patient, who admitted to the facility on 11/22/2022 with diagnoses that included hemiplegia (the loss of the ability to move one side of the body), and muscle wasting and atrophy (wasting of body tissue). A review of Patient 3’s Minimum Date Set (MDS, a patient assessment and care-screening tool), dated 11/25/2022, indicated Patient 3’s cognition (ability to understand) was intact. A review of Patient 3’s Care Plan titled, “At risk for falls due to Injury,” revised on 11/22/2022, indicated for Patient 3’s call light to be within reach and for staff to answer the call light promptly as part of the facility’s interventions. During an observation of Patient 3’s room and concurrent interview with Patient 3 on 12/15/2022 at 1:10 pm, Patient 3 was in bed with a call bell next to him. Patient 3 stated the call light system has not been functioning for a few weeks (could not remember specific dates). The patient stated he would manually use the call bell for “about one hour prior to getting assistance,” Patient 3 stated, “I get tired of ringing the bell constantly; the facility should really get that system working.” 2. A review of Patient 9’s Admission Record indicated Patient 9 was a 73 years old female who admitted to the facility on 10/5/2022 and re-admitted on 12/14/2022 with diagnoses that included muscle weakness and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). A review of Patient 9’s MDS dated 10/12/2022, indicated Patient 9’s cognition was moderately impaired. The MDS indicated Patient 9 needed extensive assistance (staff provide weight bearing support) with two-person assist with bed mobility (moved or turns from side to side) and transfers and with one-person support for toilet use and personal hygiene. A review of Patient 9’s Care Plan titled, “At risk for falls due to injury,” revised on 12/14/2022, indicated for Patient 9’s call light to be within reach and for staff to answer the call light promptly as part of the facility’s interventions. During an observation of Patient 9’s room on 12/15/2022 at 1:36 pm, Patient 9’s was lying in bed. The call light was not around Patient 9. When the wall call light was pressed, there was no indication (light or sound) noted in the patient’s room, hallway, or nurse station. A review of Patient 7’s Admission Record indicated Patient 7 was a 59 years old male who admitted to the facility on 11/7/2022 with diagnoses that included End Stage Renal Disease (ESRD - kidney impairment that is irreversible), respiratory failure (a condition when the lungs cannot get enough oxygen into the blood), and muscle weakness. A review of Patient 7’s MDS dated 11/25/2022, indicated Patient 7’s cognition was intact. The MDS indicated Patient 7 needed extensive assistance (staff provide weight bearing support) with two-person assist for bed mobility (moved or turns from side to side) and one-person support for toilet use and personal hygiene. A review of Patient 7’s Care Plan titled, “At risk for falls due to injury,” revised on 11/7/2022, indicated for Patient 7’s call light to be within reach and for staff to answer the call light promptly as part of the facility’s interventions. During an observation of Patient 7’s room and a concurrent interview with Patient 7 on 12/15/2022 at 1:51 pm, Patient 7 was lying in bed. Patient 7 did not have a call bell. Patient 7 stated the electronic call light system did not work and he never received a call bell from staff. Patient 7 stated when he need help, he just yell “nurse” to get the staff’s attention. A review of Patient 8’s Admission Record indicated Patient 8 was a 79 years old female who admitted to the facility on 10/14/2021 with diagnoses that included respiratory failure. A review of Patient 8’s MDS dated 10/15/2022, indicated Patient 8’s cognition was intact. The MDS indicated Patient 8 needed limited assistance (staff provided guided maneuvering) with one-person assist for bed mobility (moved or turns from side to side,) toilet use and personal hygiene. A review of Patient 8’s Care Plan titled, “At risk for falls due to injury,” revised on 11/4/2022, indicated for Patient 8’s call light to be within reach and for staff to answer the call light promptly as part of the facility’s interventions. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 12/15/2022 at 2:00 pm, LVN 2 stated some patients assigned to Rooms A, B, C, D, E, F, G, H, I and J did not have call bells. In a concurrent observation, LVN 2 pressed the electronic call light and stated there was no light or sound can be seen or heard in the patient’s rooms, hallways, and nurse stations. LVN 2 stated the call bells were given to the patients to use to call staff for assistance. LVN 2 stated it was important for each patient to have a bell “to get good care and not place the patient in danger.” During an observation of Patient 8’s room and a concurrent interview with Patient 8 on 12/15/2022 at 2:25 pm, Patient 8 was lying in bed. Patient 8 did not have a call bell. Patient 8 stated the call light system has not been working for a while (could not remember exact date). Patient 8 stated “I never got a bell; they did not give me one.” During an observation on 12/15/2022 at 2:30 pm, multiple Certified Nurse Assistants (CNAs) were observed going into patient rooms, ensuring each patient had a bell and distributing call bells to whomever needed it. During an interview with the facility’s Maintenance Supervisor (MS), on 12/15/2022 at 2:35 pm, The MS stated the facility is currently working on its electronic call light system. The MS stated worked with both the facility’s vendor and facility’s monitoring system company to find the solution. The MS stated the facility’s intervention regarding the nonfunctioning electronic call light system was to give call bells to each patient. During an interview with Certified Nurse Assistant 1 (CNA 1) on 12/15/2022 at 2:46 pm, CNA 1 stated the electronic call light system has not been functional “for about one month.” CNA 1 stated it was important to give each patient a call bell in case the patients needed something and in case of an emergency, the patient could call staff to help. During an interview with CNA 2 on 12/15/2022 at 3:16 pm, CNA 2 stated the wall call light system has not been working for a couple of weeks. CNA 2 stated call bells were distributed to the patients to call for assistance. CNA 2 stated every patient had to have a call bell because the electronic call light system was not working. CNA 2 stated patients could use the call bells to let the staff know when they needed help. During an interview with the facility’s Administrator (ADM) on 12/15/2022 at 3:45 pm, the ADM stated the facility was in the process of fixing the electronic call light system. The ADM stated the call bells were distributed to the patients to alert staff when they needed assistance. The ADM stated it was important to have a functional call light system to ensure the patients’ needs were meet and for the patients’ safety. During an interview with the Director of Staff Development (DSD) on 12/15/2022 at 4:26 pm, The DSD stated every patient should have a call bell accessible to them. The DSD stated patients needed to have a functional call system so they can call staff for help. The DSD stated functioning call light system could be used to prevent the patient from falling or any unforeseen circumstances. A review of the facility’s Policy and Procedure (P&P) titled, “Answering the Call Light,” revised on 3/2021, indicated for staff to ensure timely responses to the patient’s request and needs and ensure that the call light is plugged in and functioning at all times. A review of the facility’s P&P titled, “Accommodation of Needs,” revised on 1/2021, indicated the facility’s environment and staff behaviors are directed towards assisting the patient in maintaining and/or achieving safe independent functioning, dignity, and wellbeing. A review of the facility’s undated P&P titled, “Safety and Supervision of Patients,” indicated for the facility to provide an environment as free from accident hazards as possible. Patient safety, supervisions, and assistance to prevent accidents are facility wide priorities. The facility failed to provide a working patient call system for Patients 3, 7, 8 and 9. a. For Patient 3, facility’s staff did not respond promptly to the call bell when Resident 3 called for help. b. For Patients 7, 8 and 9, facility’s staff did not provide the call bells for the patients to utilize to call staff for assistance when the electronic call light system was not working. These deficient practices violated Patients 3’s, 7’s, 8’s and 9’s rights, and had the potential for the patients not receiving needed nursing care and services due to the patients’ inability to call staff for assistance. These violations jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patients 3, 7 ,8 and 9.