Other·January 26, 2024

California Code of Regulations, Title 22, Section 72541 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. On 12/11/2023 at 8 am., the California Department of Public Health (CDPH, the Department) conducted an unannounced recertification survey. As a result of the investigation, the Department determined the facility failed to report an unusual occurrence in the facility within 24 hours that could threaten the welfare, safety, and health of Resident 21. Resident 21, who was on psychoactive medications and a smoker, tested positive on her pregnancy test on 11/2/2023 and consented to terminate her pregnancy on 11/7/2023. As a result of these failures, Resident 21's right was violated, and the failure had the potential to cause a decline in the Resident 21's physical and psychosocial well-being related to possible complications and unforeseen adverse events. A review of Resident 21’s Admission Record (AR) indicated Resident 21 was a 36-year-old female and the facility initially admitted Resident 21 on 11/17/2022 with multiple diagnoses including paranoid schizophrenia, psychoactive substance dependence, and nicotine dependence. The AR indicated Resident 21 was diagnosed with cervicalgia on 3/28/2023. A review of Resident 21's Clinic 2 (outpatient community health center) notes, dated 8/17/2023, indicated Resident 21's reason for visit was to test for pregnancy using a urine dipstick test. Clinic 2 note indicated Resident 21 had a negative urine dipstick test (not pregnant). A review of Resident 21's Social Service Note 1 (SS Note 1), dated 10/26/2023 at 9:51 a.m., indicated the Social Services Director (SSD) spoke with Resident 21's responsible party regarding an appointment with Resident 21's primary care provider (PCP) on 11/9/2023 at 3 p.m. related to Resident 21's increased nausea and vomiting. A review of Resident 21's Nursing Note 1 (NN 1), dated 11/1/2023 (late entry), indicated the Director of Nursing (DON) discussed with Resident 21 the need to obtain her human chorionic gonadotropin (hCG, hormone found in the urine and blood when a female is pregnant) level to confirm the pregnancy result. The NN 1 indicated "Resident appeared anxious as she was seeking to confirm pregnancy result." A review of Resident 21's Nursing Note 2 (NN 2), dated 11/3/2023, indicated Resident 21's "pregnancy lab test" results were faxed to PCP 1 and Licensed Psychiatric Technician 1 (LPT 1) was awaiting medical doctor's orders. During a review of Resident 21's eINTERACT SBAR Summary for Providers (SBAR), dated 11/4/2023, indicated Resident 21 and her responsible party were notified regarding the positive hCG levels and a repeat hCG levels was drawn on 11/4/2023 at 7:50 a.m. A review of Resident 21's History and Physical Examination (H&P), dated 11/6/2023, the H&P indicated Resident 21 had a diagnosis of "intrauterine pregnancy." A review of Resident 21's Social Service Note 3 (SS Note 3), dated 11/7/2023, indicated the following: 1. Resident 21 made an appointment at Clinic 1, health care facility that offers reproductive health services, including birth control, sexually transmitted disease (STD) tests, pelvic exams, cancer screenings, and pregnancy-related services, on 11/7/2023 at 12:30 p.m. for the termination of her pregnancy. 2. During the conference call with the treatment team and Resident 21's responsible party, Resident 21 expressed her choice to terminate her pregnancy that was a result of consensual intercourse with a male peer at the facility. A review of Resident 21's eINTERACT SBAR Summary for Providers (SBAR), dated 11/7/2023 timed at 8:21 p.m., the SBAR indicated the following: 1. Resident 21 came back from her appointment for the termination of pregnancy. 2. Resident 21 was administered Mifepristone (medication to end an early pregnancy by blocking the hormone progesterone needed for the continuation of pregnancy) 200 milligrams at 3:47 p.m. at Clinic 1. 3. New orders included administering to Resident 21 Misoprostol 200 micrograms 4 tablets (medication used in conjunction with Mifepristone to end pregnancy by causing strong contractions of the uterus, resulting in tissue expulsion) on 11/8/2023 at 4 p.m., Dramamine (medication used to treat nausea and vomiting) 50 milligrams every 4-6 hours as needed starting 11/8/2023 at 4 p.m., Ibuprofen 800 milligrams orally every 6-8 hours as needed starting 11/8/2023 at 4 p.m. 4. Resident 21's follow-up appointment at Clinic 1 was scheduled on 11/21/2023. A review of Resident 21's Change in Condition (COC) Follow up Note, dated 11/8/2023 timed at 9:04 p.m., indicated LVN 2 administered Misoprostol 200 micrograms 4 tablets at 4:30 p.m. The COC Follow up Note indicated Resident 21 was educated to inform the nurse in case Resident 21 was bleeding more than 2 pads in an hour. A review of Resident 21's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 11/20/2023, indicated Resident 21 did not have an impairment in cognitive patterns. The MDS indicated Resident 21 experienced hallucinations and delusions. The MDS indicated Resident 21 displayed behavioral symptoms not directed toward others for 1-3 days in a 7-day period. The MDS indicated Resident 21 was independently performing her activities of daily living (ADLs). During an interview on 12/13/2023 at 2:19 p.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 21 started being nauseous and was confirmed to be pregnant about a month ago. CNA 1 stated Resident 21 talked to her responsible party and decided to terminate the pregnancy. CNA 1 stated it was not common for female residents in the facility to get pregnant. During an interview on 12/13/2023 at 3:13 p.m., LPT 1 stated Resident 21 got pregnant at the facility and decided to terminate the pregnancy. LVN 1 stated it was not common for female residents to get pregnant while being treated in the facility. During an interview on 12/13/2023 at 3:55 p.m., the DON stated Resident 21 got pregnant in the facility and met with the interdisciplinary team (IDT, group of individuals from different disciplines who work together, involving the resident and/or responsible party, to determine the plan of care for the residents) to express her wish to terminate the pregnancy. The DON stated Resident 21 decided to terminate the pregnancy with Resident 21's responsible party signing the consent. The DON stated the incident was "out of the norm." Resident 21 opted to go to Clinic 1 and underwent a "successful outpatient procedure, was given pads and monitored for bleeding for a few days" at the facility. During an interview on 12/14/2023 at 9:58 a.m., Resident 21 stated she consented to have sexual intercourse with a male peer partner, who used a condom that broke. Resident 21 stated she, her responsible party, and male peer partner consented to have the 9-week pregnancy terminated. Resident 21 stated she had to take 4 pills to "get everything out of me" and went back to the doctor for follow-up. During an interview on 12/14/2023 at 1:19 p.m., the Administrator 2 (Admin 2) stated unusual occurrences must be reported to the Department within 24 hours to ensure the safety of the residents affected and ensure that all facility's policies and procedures and national regulations were followed. Admin 2 stated it was unusual for the facility to have an incidence of resident pregnancy while being treated in the facility. Admin 2 stated since she started working at this facility, this was the first incident of resident pregnancy she encountered. Admin 2 stated she did not report the incident to the Department because it was more of Resident 21's "medical condition" and there were no suspicions of "sexual abuse." During a review of the facility's policy and procedures (P&P), dated 8/27/2021, the P&P indicated the following: 1. The facility must follow all applicable state and federal laws and regulations regarding the reporting of unusual occurrences. 2. Unusual occurrences must be reported to the appropriate agency within 24 hours by telephone and then confirmed in writing. 3. The facility must conduct and document timely and thorough investigations into all unusual occurrences and take corrective action as appropriate. The investigation and documentation must include, but is not limited to: a. Interviews of residents and staff b. Review of facility records c. Audits of a service/system As a result of the investigation, the Department determined the facility failed to report an unusual occurrence in the facility within 24 hours that could threaten the welfare, safety, and health of Resident 21. Resident 21, who was on psychoactive medications and a smoker, tested positive on her pregnancy test on 11/2/2023 and consented to terminate her pregnancy on 11/7/2023. As a result of these failures, Resident 21's right was violated, and the failure had the potential to cause a decline in the Resident 21's physical and psychosocial well-being related to possible complications and unforeseen adverse events. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 21.