Health inspection·December 26, 2023

§ 72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. § 72641. Emergency Lighting and Power System. (c) If the Department determines that an evaluation of the emergency electrical system of a facility or portion thereof, is necessary, the Department may require the licensee to submit a report by a registered electrical engineer which shall establish a basis for alteration of the system to provide reasonable compliance with Subarticle E702-B, Part 3, Title 24, California Administrative Code (Emergency Electrical Systems for Existing Nursing Homes). Essential engineering data, including load calculations, assumptions and tests, and where necessary, plans and specifications, acceptable to the Department, shall be submitted in substantiation of the report. When corrective action is determined to be necessary, the work shall be initiated and completed within an acceptable time limit. On, 12/8/23, at 5:40 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Life Safety Code. The facility failed to report that the permanent emergency generator was non-operational within 24 hours of the failure, and failed to ensure that the temporary emergency power generator was permitted or the in the process of being permitted, since the failure of the permanent generator on 11/30/23 and the installation of the temporary emergency generator on 12/1/23. This failure directly affected 57 patients residing in the facility. This deficient practice has the potential for this department to be unaware of any hardships experienced by the facility and the unregulated/unmonitored installation of the generator, which may affect the facility’s ability to operate in an emergency power outage, affecting the facility’s ability to provide care to patients and rendering all electrical equipment, that are not battery powered, non-functional (such as refrigerators for food and medication, air mattresses, and oxygen therapy machines). On 12/8/23, at 5:41 p.m., during an interview with the Administrator, and Director of Nursing (DON), the administrator stated that the permanent emergency power generator broke down and is not functioning. Due to the inoperability of the permanent emergency generator, the facility obtained a rental generator for the emergency power supply. The Administrator stated that after the recent Life Safety Code (LSC) survey (an annual survey required for health facilities, who are participants with the Medicare program [the USA’s health insurance program for individuals 65 years or older], to continue participation and receive funding/re-imbursement through Medicare) conducted on 11/15/23, the facility was decided to conduct routine generator testing. About a week after the LSC survey, the facility was informed by the generator service technician, that there were issues with the functionality of the generator and would require further evaluation, but the generator was still able to operate. The Administrator stated that on 11/30/23, the technician was working on the generator and the generator broke down, no longer able to function. The facility obtained a temporary emergency generator on 12/1/23. The administrator stated that the Department of Public Health (DPH) was not notified and that at the time, he did not think to notify DPH. On 12/8/23, at 6:41 p.m., during a concurrent observation and interview with the Administrator and Maintenance Supervisor, the temporary generator was observed on the north-east side of the building, behind a gate. The temporary generator was connected to the building and ready for use. The administrator stated that they do not have an estimation on when the permanent generator will be repaired and back in operation. The administrator stated that he did not apply for any work permits from the Department of Health Care Access and Information (HCAI – the department responsible for regulating construction and upgrades for healthcare facilities throughout California) nor did the facility have any policies for notifying HCAI for any facility upgrades/modifications. Record review of the facility’s lease agreement for the temporary generator (dated 11/30/23), indicated that the contract the facility obtained the contract on 11/30/23 with a lease start date on 12/1/23. Record review of the facility’s policy titled “Unusual Occurrence” (dated 12/19/22) indicated that “It is the policy of the facility that an unusual occurrence is reported to the Department of Public Health within 24 hours of occurrence.” On 12/8/23, at 6:41 p.m., during a concurrent interview and record review of the generator maintenance log (not dated), the record indicated that a generator was tested on 12/1/23 and 12/7/23. The administrator stated this record is for the testing of the temporary generator. The facility failed to report that the permanent emergency generator was non-operational within 24 hours of the failure, and failed to ensure that the temporary emergency power generator was permitted or the in the process of being permitted, since the failure of the permanent generator on 11/30/23 and the installation of the temporary emergency generator on 12/1/23. This failure directly affected 57 patients residing in the facility. The above violations had a direct or immediate relationship to the health, safety, or security of all patients.