Health inspection·February 13, 2024

The following reflects the finding of the California Department of Public Health during the investigation of Complaint # 877793 Survey Re-licensing EVENT ID: V7E911 Representing the Department, HFEN # 47362 State Citation B was written. F689 (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) §483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. § 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The facility failed to ensure the safety and supervision for Patient 1 in accordance to the facility’s policy and procedure (P&P), on Safety and Supervision of Patients. As a result, Patient 1 obtained paint from the facility’s activity cart and ingested the paint. On 1/4/2024 at 10:30 AM, an unannounced facility reported investigation was conducted regarding accidents. A review of Patient 1’s Admission Record indicated the facility admitted a 78 year old female on 10/17/2022 with diagnosis which include history of falling, Alzheimer disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), anxiety (a feeling of fear, dread, and uneasiness). A review of Patient 1’s Minimum Data Set (MDS, standardized care and screening tool), dated 10/13/2023, indicated Patient 1 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Patient 1 required partial/ moderate assistance (helper does less than half the effort, helper lifts, hold or supports trunk or limb, but provide less than half the effort) for toileting hygiene, shower, upper body dressing, lower body dressing, putting on and taking off footwear and personal hygiene. Patient 1 required supervision or touching assistance (helper provide verbal cues and/or touching steadily and /or contact guard assistance as patient completes activity) with eating and oral hygiene. A review of Patient 1’s Care Plan for At Risk for Wandering, revised on 12/19/23, indicated interventions to monitor Patient 1 while in the activity room. During concurrent observation and interview in the facility hallway with the medical records (MR) on 1/4/2024 at 12:00 p.m., MR stated Patient 1 was always walking and wandering around in the facility hallways. MR stated Patient 1 was always confused and required redirection. During a concurrent observation of the facility surveillance camera and interview with the Administrator (ADM) on 1/4/24 at 5:00 pm, Patient 1 was observed in the activity room. The ADM stated Patient 1 was in the facility’s activity room with certified nurse assistant (CNA) 2 present to supervise patients. The ADM stated Patient 1 obtained a paint from the activity cart located near CNA2 and proceeded to ingest the paint. The ADM stated CNA2 was on her cellphone, therefore, was not supervising and monitoring Patients in the facility’s activity room. A review of the facility’s policy and procedure (P&P), titled Safety and Supervision of Patients, revised 7/2017, indicated patient safety and supervision and assistance to prevent accidents were facility-wide priorities. The P&P indicated for individualized, patient-centered approach to safety to address safety and accident hazards for individual patients, and to reduce accidents risks and hazards, the facility ensures interventions are implemented. During a review of facility policy and procedure (P&P) titled “Job Description” revised date 1/27/2022 indicated: “Job Title: Activity Assistant. Summary: Assist activity director in planning coordinating, conducting, and implementing a therapeutic activity program to meet both group and individual patients needs and interest. Assist in providing a clean, safe, dignified, happy, and healthy environment for patients by performing the duties as described”. The facility failed to ensure the safety and supervision for Patient 1 in accordance to the facility’s policy and procedure (P&P), on Safety and Supervision of Patients. As a result, Patient 1 obtained paint from the facility’s activity cart and ingested the paint. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.