Health inspection·May 23, 2023

F740 Behavioral health services. Each Patient must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a Patient’s whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. T22 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 4/24/2023 at 1:45 pm, The California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate multiple complaints regarding abuse. The facility failed to provide Patient 1 with behavioral health care and services for the treatment of Patient 1's emotional, mental, and drug abuse (a disease that affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medication) by failing to: 1. Identify goals and nursing interventions when Patient 1 had cannabis (marijuana, a mind-altering drug), sedative (a category of drugs that slow brain activity) abuse, anxiety (nervousness), and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) would leave the facility on out on pass (OOP, temporary permission of a Patient to leave the facility in a specified time) unsupervised, without OOP orders from Patient 1's Physician (MD 1) and would return to the facility with aggressive behaviors toward staff . These deficient practices resulted in Patient 1 being involved in a motor vehicle accident (MVA) on 4/10/2023, and the Police Officer (PO 1) identified Patient 1 as a "drunk homeless" and picked Patient 1 up at the City Hall on 4/13/2023 while Patient 1 was OOP. Patient 1 continued to go OOP unsupervised and without MD 1's orders had the potential to result in serious injury, harm, impairment, or death of Patient 1. 2. Ensure Patient 1 did not go to unauthorized areas in the facility and video record Patients 2 and 4 without Patients 2 and 4's consent. These deficient practices violated Patients 2 and 4's rights and created an uncomfortable environment for Patients 2 and 4. 3. Ensure Patient 3 (Patient 1's roommate) did not experience Patient 1's aggressive behavior towards staff. This deficient practice violated Patient 3's rights and created an uncomfortable environment for Patient 3. a. A review of Patient 1's General Acute Care Hospital 1 (GACH 1) Care Coordination Transition forms dated 10/11/2022, indicated Patient 1 was not safe at home. The form indicated Patient 1 needed a mental evaluation and a Skilled Nursing Facility (SNF) placement. The form indicated Patient 1 had threatened Patient 1's Care Giver (CG) at home and the CG could no longer care for Patient 1. A review of Patient 1's GACH 1 History and Physical (H&P) dated 10/11/2022, indicated Patient 1 was diagnosed with acute encephalopathy (mental status change due to medications, illegal drugs, or toxic [poisonous] chemicals), due to benzodiazepine (medication used to sedate) and Tetrahydrocannabinol (THC, substance responsible for the effects of marijuana) use. The H&P indicated Patient 1's drug screen (a drug test looks for signs of one or more illegal or prescription drugs in a sample of the urine, blood, or saliva) was positive for benzodiazepine and cannabis. A review of Patient 1's Admission Record indicated the facility admitted a fifty-six-year-old-female on 10/15/2022 with diagnoses including toxic encephalopathy, cannabis abuse, sedative, hypnotic (tending to produce sleep) or anxiolytic (a medication or other intervention that reduces nervousness) abuse, anxiety, and depression. A review of Patient 1's Initial History and Physical dated 10/19/2022, indicated Patient 1 could understand and make decisions. A review of Patient 1's Psychiatric Progress Note dated 2/10/2023, indicated Patient 1's psychiatric (mental) condition was "fluctuating (changing)" The note indicated Patient 1 had a mood disorder (a group of mental conditions characterized by a persistent disturbance of mood), anxiety disorder, major depressive disorder, generalized anxiety, and sleep disorders (being unable to fall asleep and stay asleep). The note indicated the plan was to "monitor and continue the current regimen." A review of Patient 1's untitled care plan dated 2/14/2023, indicated Patient 1 had a behavior of yelling at staff (unidentified), getting close to staff's faces, and recording staff without staff's consent. The care plan did not have interventions to address Patient 1's behavior. A review of Patient 1's untitled care plan dated 3/22/2023, indicated Patient 1 would set up her (Patient 1's) own doctor appointments and transportation. The nursing interventions indicated follow-up with Patient 1 to ensure Patient 1's needs were met. A review of Patient 1's Social Services Progress Notes dated 4/10/2023 at 4:30 pm, indicated on 4/10/2023 at 1:20 pm, Patient 1 called the facility (SNF) to report she (Patient 1) was in a car accident. The notes indicated Patient 1 refused to disclose her location and hung up the phone. The notes indicated the Social Services Director (SSD) called the transportation company (unidentified) who reported dropping Patient 1 off at the facility on 4/10/2023 at 11:50 am. The notes indicated Patient 1 called the facility back on 4/10/2023 at 2:36 pm requesting a list of Patient 1's current medications to provide to GACH 2. The notes indicated the facility staff (unidentified) informed Patient 1 that medical information could not be given over the phone and Patient 1 hung up the phone. The notes indicated the facility called local hospitals and located Patient 1 at GACH 2's Emergency Room (ER). The notes indicated the facility's staff (unidentified) notified MD 1 and MD 1 ordered an absent without official leave (AWOL, absent often without notice or permission) since Patient 1 did not check back in with the facility at 11:50 am when the transportation company dropped Patient 1 off at the facility. A review of Patient 1's GACH 2's Emergency Documentation, dated 4/10/2023, timed 2:10 pm, indicated Patient 1 was involved in an MVA, rear-ended, and complained of head pain. A review of Patient 1's Social Services Progress Notes dated 4/12/2023, timed at 9 am, indicated the SSD called the local police department to file a report against Patient 1 for using her rollator device (walker, a type of mobility aid that offers stability and support while walking) to ram against the SSD twice. A review of Patient 1's Nurses Progress Notes dated 4/13/2023 at 7:22 am, indicated Patient 1 left the facility for an appointment at 7 am. A review of Patient 1's Nurses Progress Notes dated 4/13/2023 at 4:40 pm, indicated the local police officer (PO 1) dropped Patient 1 at the facility on 4/13/2023, at 4:30 pm. The notes indicated PO 1 stated Patient 1 was at the City Hall, from a neighboring city, yelling and screaming. PO 1 stated the City Hall's staff member (unidentified) called the police department stating a "drunk homeless," person (Patient 1) was causing a scene. The notes indicated PO 1 picked Patient 1 from the City Hall. The notes indicated Patient 1 told PO 1 that she (Patient 1) needed a ride to pick up her car at a mobile home located in a neighboring city. The notes indicated PO 1 identified the car was registered to Patient 1's CG who had an active restraining order (a court order that can protect someone from being physically abused or threatened) against Patient 1. A review of Patient 1's Minimum Data Set (MDS- standardized data collection tool used to assess cognitive and functional status) dated 4/14/2023, indicated Patient 1 could think and process information. A review of Patient 1's untitled care plan dated 4/19/2023, indicated Patient 1 went to unauthorized areas in the facility and the nursing interventions were to address Patient 1's behavior, educate and provide redirection. A review of Patient 1's Social Services Progress Note dated 4/24/2023 at 9:37 am, indicated Patient 1 informed a staff (unidentified) that she (Patient 1) had a doctor's appointment on 4/24/2023. The note indicated the SSD called the medical provider's office to confirm Patient 1's appointment and the medical provider's office told the SSD that Patient 1 did not have an appointment for a wellness check. The note indicated Patient 1 left the facility at 9 am. During a telephone interview on 4/24/2023 at 12 noon, Patient 1 stated she walked out of the facility earlier on 4/24/2023 and walked up a main road to a mental health wellness center (2 miles from the facility). Patient 1 stated she fell to the floor while passing a freeway off-ramp after she left the facility. Patient 1 stated she had "cannabis in my purse, alcohol, almond extract, tinctures (a medicine made by dissolving a drug in alcohol) with alcohol in them, some herbs, liver cleanser supplements." Patient 1 stated she bought Benadryl (medication to treat the symptoms of allergies and allergic reactions) on the way to the mental health wellness center. Patient 1 stated the cannabis was given to her for free at a farmer's market but would also buy cannabis at a local dispensary. Patient 1 stated she consumed alcohol periodically for years. A review of Patient 1's Nurses Progress Note dated 4/24/2023 at 12:13 pm, indicated a police officer (PO 2) arrived at the facility due to Patient 1 going to a local Mental Health Wellness Center and reported feeling unsafe at the facility. During an interview on 4/24/2023 at 2 pm, the ADM stated Patient 1 was OOP at the time of the interview. The SSD joined the interview visibly upset and crying. The SSD stated two weeks prior (did not state the date) Patient 1 "rammed," the SSD twice with the Patient's walker. The SSD stated the last time a psychiatrist assessed Patient 1 was in February 2023. The SSD stated Patient 1 scheduled her own appointments and transportation and would often not tell the facility's staff when or where she (Patient 1) was going. The SSD stated, "We can't stop her from going." During an interview on 4/24/2023 at 2:45 pm the SSD stated the facility's procedure for OOP included getting a doctor's order for each OOP. The SSD stated there had been times when Patient 1 would call the SSD while out on pass and Patient 1 sounded as if the Patient was "under the influence (drunk)." The SSD stated Patient 1's doctor's office's staff (unidentified) would call the SSD to report Patient 1 being intoxicated (drunk or under the influence). The SSD stated on 4/13/2023, PO 1 returned Patient 1 to the facility because the police department received a call from a City Hall staff reporting a "homeless drunk" disturbing the City Hall. The SSD stated facility's staff (in general) would not check Patient 1 for contraband (items that are illegal to trade, carry, produce, or otherwise have in one's possession) when Patient 1 would return to the facility because "she won't allow us. It's scary, I'm afraid." The SSD reported another incident on 4/10/2023 in which Patient 1 left the facility for an 8 am medical appointment and at 1 pm the SSD noticed Patient 1 had not returned to the facility. The SSD called the doctor's office and was informed the Patient left the appointment around 11:10 am. The SSD stated she called the transport company who informed the SSD the Patient had been dropped off at the facility at 11:50 am. The SSD stated at that point she (the SSD) called Patient 1's listed emergency contacts and local hospitals until the Patient was located at a neighboring city's ER. The SSD stated Patient 1 called the SSD at 3:00 pm to inform the SSD she (Patient) had been in a car accident. A review of Patient 1's Nurses Progress Notes dated 4/24/2023 at 2:50 pm, indicated at 12:40 pm, Patient 1 was behind the local Mental Health Wellness Center building. The note indicated PO 2 spoke with Patient 1 and Patient 1 agreed to go back to the facility. During a concurrent interview and a review of the facility's OOP form on 4/24/2023 at 3:13 pm, Licensed Vocational Nurse 1 (LVN 1) stated every time a Patient (in general) left the facility, the Patient needed to sign out in a logbook and sign back in upon returning to the facility. LVN 1 reviewed the facility's OOP form and stated Patient 1 left the facility almost daily and stated not all dates on which Patient 1 left had the facility staff's signature or a sign-out or return time listed. LVN 1 stated there had been times in which Patient 1 would return to the facility appearing to be intoxicated with slurred speech (when a person has trouble speaking, the words are slow or garbled, or run together) and more aggressive than normal. A review of Patient 1's Nurses Progress Note dated 4/24/2023 at 5:45 pm, indicated Patient 1 returned to the facility and was verbally aggressive with staff using vulgar (rule or offensive) language. A review of Patient 1's Nurses Progress Note dated 4/25/2023 at 2:28 am, indicated Patient 1 entered the Nurse's Station "attempting to open another Patient's chart." The note indicated Patient 1 "noted to have multiple attempts to open locked medication cart and was also opening drawers at the receptionist's desk." The note indicated "Staff reported seeing Patient in staff breakroom and supply closet and touching items." The note indicated "Staff escorted Patient out of the unauthorized area. The Patient returned to the SNF station and began swearing at CN (charge nurse), backing CN against the wall before pushing CN. CN politely asked the Patient to back away and return to the Patient's room. The Patient refused and began laughing, invading CN'S personal space by putting her (Patient 1's) face in front of CN's face. CN walked away from the situation and the Patient continued to follow CN for the remainder of the med pass." During an observation on 4/25/2023, at 7:28 am, Patient 1 was awake and walked inside the facility's conference room. Patient 1 said loudly "You all are [derogatory word] crazy." Patient 1 had a cell phone in her hand and was recording the surveyors. During an interview on 4/25/2023, at 7:44 am, the facility's Cook 1 (Cook 1) stated Patient 1 would go inside the kitchen daily in the morning and would cross the "yellow line," toward the clean area, and would yell derogatory words to staff and would record using Patient 1's cell phone. Cook 1 reported witnessing Patient 1 attacking Activities Assistant 1 (AA 1) and Cook 1 stood in front of AA 1 to prevent Patient 1 from hitting AA 1. Cook 1 stated she (Cook 1) then escorted Patient 1 back to Patient 1's room. During a follow-up interview and review of Patient 1's Physician orders for OOP, on 4/25/2023 at 9:24 am, the DON stated per facility policy an order needed to be obtained for each OOP day. The DON reviewed Patient 1's physician orders and stated on 4/13/2023, 4/17/2023, and 4/24/2023 Patient 1 left the facility without OOP orders. The DON stated orders were necessary to ensure Patient 1 was safe to leave the facility. The DON stated she was aware Patient 1 would go into the kitchen and stated the interventions in place to prevent Patient 1 from going into unauthorized areas were not working and the facility's staff were not able to manage Patient 1's behaviors. The DON stated the last psychiatrist visit for Patient 1 was in February 2023 and was not sure why Patient 1 had not been assessed by a psychiatrist since then. The DON stated Patient 1 could potentially consume drugs or alcohol while out on pass unsupervised and could harm herself due to overdose on drugs or alcohol. During a telephone interview on 4/25/2023 at 11:31 am, Psychiatrist 1 (Psych 1) stated the last time he saw Patient 1 was in February 2023. Psych 1 denied being aware of the behaviors Patient 1 had been displaying such as entering restricted areas in the facility, other Patients' rooms, going out on pass unsupervised, being involved in a car acc