Health inspection·April 26, 2024

F 580 Code of Federal Regulations, Title 42, Section 483.10 (i)(A)(B) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention. (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). California Code of Regulations, Title 22, Section 72311 Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. California Code of Regulations, Title 22, 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 3/11/2024 at 8 AM., the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding quality of care. As a result of the investigation, CDPH determined Licensed Vocational Nurse 4 (LVN 4) failed to notify the primary care provider (MD 1) regarding Resident 3’s change in condition that occurred on 3/1/2024. Certified Nursing Assistant 5 (CNA 5) reported to LVN 4 Resident 3's seizure-like (sudden, uncontrolled body movements and changes in behavior due to abnormal electrical activity in the brain) episode and unresponsiveness on 3/1/2024 at around 8 AM and seizure precautions (additional safety measures taken to prevent injury during a seizure) were not implemented for Resident 3. On 3/1/2024, in the Activity Room and at around 2 PM. Resident 3 was observed having seizure-like activity and fell from Resident 3's wheelchair. This failure resulted in Resident 3 sustaining a on the forehead that measured 36 millimeters (mm,) by 14 mm and a nasal laceration (deep cut) that measured 3 centimeters (cm,). Resident 3 was transferred to General Acute Care Hospital 1 (GACH 1) on 3/1/2024 at 2:22 PM and required wound repair to the right external nostril and inner septal mucosa. Resident 3 required use of 5 sutures and 2 sutures, respectively. A review of Resident 3's Admission Record (AR), indicated the facility admitted Resident 3, a 62-year-old female to the facility on 1/3/2023 with multiple diagnoses including history of falling, dementia, type 2 diabetes mellitus, encephalopathy and convulsions. A review of Resident 3's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated 1/9/2024, indicated Resident 3 had severe impairment in cognition. The MDS indicated Resident 3 required substantial/maximal assistance with toileting hygiene, showers, lower body dressing, and personal hygiene. The MDS indicated Resident 3 required partial/moderate assistance with upper body dressing, walked 10 feet, sit-to-stand, and chair/bed-to-chair transfers. A review of Resident 3's History and Physical Examination (H&P), dated 3/7/2024, indicated Resident 3 did not have the capacity to understand and make decisions. During an interview on 3/11/2024 at 11:05 AM, Physical Therapy Assistant 1 (PTA 1) stated PTA 1 was assisting another resident when PTA 1 heard a "thump" on the floor, in the activities room. PTA 1 stated PTA 1 turned and saw Resident 3 on the floor after Resident 3 fell from Resident 3's wheelchair. PTA 1 stated PTA 1 immediately went to Resident 3 and observed Resident 3 face down on the floor, nonverbal with eyes closed and blood dripping from Resident 3's nose. PTA 1 stated PTA 1 turned Resident 3 on her left side. PTA 1 stated Resident 3 did not seem to have "used her hands to break the fall." During an interview on 3/11/2024 at 11:28 AM, Activity Staff 2 (AS 2) stated on 3/1/2024 at around 1:30 PM to 2 PM, PTA 1 and AS 2 were assisting other residents when they [PTA 1 and AS 2] heard a "big thump" on the floor. AS 2 stated they [PTA 1 and AS 2] saw Resident 3 on the floor with the whole body "twitching" or "shaking." AS 2 stated it was AS 2's first time seeing Resident 3 "twitch." AS 2 stated PTA 1 turned Resident 3 on Resident 3's left side, and AS 2 heard Resident 3 "snoring shortly after." During a concurrent observation and interview on 3/11/2024 at 12:04 PM with CNA 3, Resident 3 was alert and confused, unable to answer questions coherently, and unable to recall the fall incident on 3/1/2024. Resident 3 was able to propel wheelchair with her feet. Resident 3 had dried scabs on the right nostril and slight discoloration on the forehead. During an interview on 3/11/2024 at 12:11 PM, Registered Nurse 1 (RN 1) stated Resident 3 had no prior episodes of shaking or twitching. RN 1 stated Resident 3 fell from Resident 3's wheelchair and was observed with moderate bleeding from the nose. RN 1 stated Resident 3 was transferred to GACH 1 on 3/1/2024 and came back to the facility on 3/4/2024. During an interview on 3/12/2024 at 10:19 AM, CNA 4 stated Resident 3 "was not feeling well" on 3/1/2024 in the morning. CNA 4 stated Resident 3 did not want to eat breakfast. During an interview on 3/12/2024 at 10:31 AM, CNA 5 stated, on 3/1/2024, Resident 3 was "not feeling well" and "was not listening" to CNA 5 while CNA 5 talked to Resident 3. CNA 5 stated Resident 3 was "shaking." CNA 5 stated CNA 5 informed LVN 4 and LVN 3 regarding Resident 3's "shaking." CNA 5 stated after approximately 30 minutes, Resident 3 was "not shaking" and was "listening and speaking" to CNA 5 again. CNA 5 stated CNA 5 brought Resident 3 to the dining/activities room on 3/1/2024 at around 9:20 AM. During an interview on 3/12/2024 at 11:01 AM, LVN 3 stated CNA 5 informed LVN 3 Resident 3 "did not look good," appeared sleepier than usual, and was "very lethargic." LVN 3 stated the CNA (unidentified) informed LVN 3 that Resident 3 was having a "seizure." LVN 3 stated LVN 3 immediately went to Resident 3's room and saw Resident 3's eyes were closed. LVN 3 stated LVN 3 did not think it was a "seizure," because Resident 3 was "not moving." LVN 3 stated Resident 3 returned to Resident 3's baseline condition within 20 minutes. LVN 3 stated LVN 3 did not notify Resident 3's primary care provider. During an interview on 3/12/2024 at 12:18 PM, LVN 4 stated a CNA informed LVN 4 that Resident 3 was "shaking." LVN 4 stated LVN 4 immediately went to Resident 3's room and saw Resident 3 with eyes closed, appeared "very sleepy," and was "loudly snoring." LVN 4 stated Resident 3 was not responding verbally, but Resident 3 was not observed "shaking" at the time of the assessment. LVN 4 stated this was the first time Resident 3 "acted or behaved this way." LVN 4 stated LVN 4 did not administer Resident 3's morning medications at the usual time of administration for safety due to Resident 3 not being alert and at risk for aspiration. LVN 4 stated LVN 4 returned to Resident 3's room within 30 minutes with LVN 5. LVN 4 stated Resident 4 had returned to Resident 4's baseline condition. LVN 4 stated LVN 4 did not notify Resident 3's primary care provider regarding the observed change in Resident 3's condition. LVN 4 stated LVN 4 did not place Resident 3 on seizure precautions. During an interview on 3/12/2024 at 1:46 PM, LVN 5 stated LVN 4 asked LVN 5 to check Resident 3 on 3/1/2024 at around 8 AM to 9 AM. because the CNA reported Resident 3 was "shaking." LVN 5 stated they (LVN 4 and LVN 5) went to Resident 3's room and observed Resident 3's eyes were open, but LVN 5 did not have a conversation with Resident 3. LVN 5 stated LVN 5 did not observe Resident 3 "shaking." LVN 5 stated LVN 5 was more concerned that LVN 4 held Resident 3's morning routine medications due to Resident 3 being "not fully awake." LVN 5 stated LVN 5 did not notify Resident 3's primary care provider. During an interview on 3/12/2024 at 11:47 AM, MD 1 stated MD 1 was not notified of Resident 3's altered level of consciousness (ALOC) and episode of "shaking" on 3/1/2024 in the morning. MD 1 stated licensed nurses must notify the physician regarding any changes in condition even if the condition was resolved. MD 1 stated MD 1 would have ordered STAT laboratory tests (tests needed immediately to manage medical emergencies) to check for high sodium levels, a urinalysis (test of the urine) to rule out any infection, and glucose levels. MD 1 stated MD 1 would have recommended closer monitoring of Resident 3. During an interview on 3/12/2024 at 1:14 PM with the Director of Nursing (DON), the DON stated the DON was not aware Resident 3 had a change in condition and an episode of "shaking" on 3/1/2024 in the morning. The DON stated the licensed nurse must report all changes in Resident 3's condition, even if resolved, to the physician to obtain any orders. The DON stated MD 1 could have ordered labs for Resident 3. The DON stated MD 1 could have ordered closer or 1:1 (constant) monitoring for Resident 3. The DON stated to ensure Resident 3's safety, the licensed nurse should have informed CNA 5 or the activity staff of Resident 3's seizure precautions, kept Resident 3 in bed for safety, and/or placed Resident 3 in front of the nurses' station for closer monitoring by the licensed nurse. During a review of the facility's policy and procedure (P&P 1), titled "Change of Condition Notification," dated 4/1/2015, P&P 1 indicated the following: 1. The licensed nurse must promptly notify the attending physician when any sudden and marked adverse change in the resident's physical, mental, or psychosocial condition-which is manifested by signs and symptoms different than usual-denotes a problem, complication, or permanent change in status and requires a medical assessment, coordination, and consultation with the Attending Physician and a change in the treatment plan. 2. The licensed nurse must assess the change in condition and determine what nursing interventions are appropriate. 3. The licensed nurse must document the following: a. Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes. b. The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether orders were received or not. c. The time the responsible party was contacted. d. Updated care plan to reflect the resident's current status. 4. The licensed nurse must communicate any changes in the required interventions to the CNAs involved in the resident's care. 5. The licensed nurse must document each shift for at least 72 hours. During a review of the facility's P&P 2, titled "Seizure," dated 4/1/2015, P&P 2 indicated the facility must provide preventative measures prior to and during seizure activity to prevent resident injury to the extent possible. P&P 2 indicated seizure precautions may include: 1) Medications as ordered by the physician, 2) Labs as ordered by the physician, 3) Adjusting the resident's bed to the lowest setting, and/or 4) padding the side rails, as applicable. P&P 2 indicated the licensed nurse must document all seizure precautions in the resident's medical record. P&P 2 indicated the licensed nurse must record each episode of seizure activity describing the times when seizure began and ended, observed resident reactions such as cyanosis, vomiting, muscle movements, aspiration and/or injury, and physician and responsible party notification. As a result of the investigation, CDPH determined LVN 4 failed to notify MD 1 regarding Resident 3’s change in condition that occurred on 3/1/2024. CNA 5 reported to LVN 4 Resident 3's seizure-like episode and unresponsiveness on 3/1/2024 at around 8 AM and seizure precautions were not implemented for Resident 3. On 3/1/2024, in the Activity Room and at around 2 PM. Resident 3 was observed having seizure-like activity and fell from Resident 3's wheelchair. This failure resulted in Resident 3 sustaining a hematoma on the forehead that measured 36 mm by 14 mm and a nasal laceration that measured 3 cm. Resident 3 was transferred to GACH 1 on 3/1/2024 at 2:22 PM and required wound repair to the right external nostril and inner septal mucosa. Resident 3 required use of 5 sutures and 2 sutures, respectively. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 3.