Health inspection·February 28, 2025

F883, Code of Federal Regulations, Title 42, Section §483.80(d) Influenza and pneumococcal immunizations §483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that- (i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and (iv)The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. 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. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (3) Infection control policies and procedures. § 72321. Nursing Service -Patients with Infectious Diseases. (a) The facility shall adopt, observe and implement written infection control policies and procedures. These policies and procedures shall be reviewed at least annually and revised as necessary. On 1/14/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding infection control and quality of care/treatment. As a result of the investigation, the facility failed to: 1. Ensure Infection Preventionists (IPs 1 and 2) provided information/education regarding the benefits, risks, and the potential side effects of the flu vaccine to Residents 1, 2, 3 and 4. IPs 1 and 2 also failed to provide an opportunity for Residents 1, 2, 3 and 4 and/or their responsible parties (RPs) to decline or accept the flu vaccine for the flu season that began on 10/1/2024. 2. Ensure IPN 1 offered to the flu vaccine to Resident 6’s RP instead of Resident 6 who did not have the capacity to understand and make decisions due to a diagnosis of dementia. 3. Ensure IP 1 and IP 2 administered the flu vaccine to Resident 7 after Resident 7 consented to receive the flu vaccine on 12/18/2024. 4. Ensure facility policy & procedure “Influenza Prevention and Control” implemented. This includes but is not limited to properly documenting/tracking flu vaccination status. These violations resulted in Residents 1, 2, 3, 4, and 6 not being offered the flu vaccine, and Resident 7 giving consent to receive the flu vaccine (on 12/18/2024) but not receiving the vaccine. Residents 1, 2, 3, 4, 6, and 7 were diagnosed with the flu (serious flu/influenza can lead to pneumonia. Pneumonia can lead to sepsis and/or death) and the residents had respiratory symptoms (symptoms that affect the lungs and or the airways). Residents 1, 2, 3, 4, 6, and 7 were hospitalized due to sepsis (a serious condition in which the body responds improperly to an infection) and/or pneumonia (PNA, an infection that inflames the air sacs in one or both lungs and may cause a buildup of fluid or pus that can be life-threatening). a. A review of Resident 1's Admission Record (AR) indicated the facility admitted Resident 1, an 82- year-old male, on 5/25/2022 with diagnoses that included immunodeficiency, and personal history of COVID -19. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/9/2024, indicated Resident 1's cognition was severely impaired. A review of Resident 1's eINTERACT/Change in Condition Evaluation (CIC) form, dated 12/27/2024, timed at 3:25 pm, indicated Resident 1 was noted with increased fatigue and slept more than usual. A review of Resident 1's Order Summary Report (OSR), dated 12/28/2024, indicated for Resident 1 to be transferred to General Acute Care Hospital (GACH) 1 for evaluation and treatment. A review of Resident 1's CIC form, dated 12/28/2024, timed at 2:54 pm, indicated Resident 1 had episodes of vomiting and oxygen (O2) desaturation. The CIC indicated Resident 1 was sent to GACH 1. A review of Resident 1's GACH 1 History and Physical (H&P), dated 12/28/2024, timed at 6:20 am indicated Resident 1 was brought to GACH 1's Emergency Department (ED) for fever and hypoxia. The H&P indicated Resident 1 was febrile tachycardic and sepsis. Resident 1 received intravenous (IV) fluids and antibiotic per sepsis protocol. The H&P indicated, Resident 1's laboratory result indicated, Influenza A was detected. b. A review of Resident 2's AR indicated the facility admitted Resident 2, a 93-year-old female, on 4/16/2024 with diagnoses that included unspecified immunodeficiency, and type 2 diabetes mellitus (DM2) A review of Resident 2's H&P, dated 12/20/2024, indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2's CIC, dated 12/26/2024, timed at 6:34 pm, indicated Resident 2 had a O2 saturation of 79 % (normal lever is between 95% to 100%) and a fever of 102.1 degrees Fahrenheit (°F). The CIC indicated Resident 2's primary care provider recommended for Resident 2 to be transferred to GACH 2 via emergency services by calling 911. A review of Resident 2's GACH 2 H&P, dated 12/27/2024, timed at 3:06 pm, indicated Resident 2 tested positive for Influenza A, and had a fever secondary to the flu and PNA. A review of Resident 2's MDS, dated 1/6/2025, indicated Resident 2 had moderate impaired cognition. c. A review of Resident 3's AR indicated the facility admitted Resident 3, an 88-year-old female, on 3/27/2018 with diagnoses that included DM2, immunodeficiency, and personal history of COVID - 19. A review of Resident 3's MDS, dated 12/3/2024, indicated Resident 3 had moderate impaired cognition. A review of Resident 3's CIC, dated 12/30/2024, timed at 9:03 am, indicated Resident 3 was noted with increased weakness and poor oral intake. A review of Resident 3's OSR, dated 12/30/2024, indicated to transfer Resident 3 to GACH 3 for further evaluation. A review of Resident 3's GACH 3 H&P, dated 12/31/2024, timed at 12 pm, indicated Resident 3 presented to GACH 3's ED with failure to thrive. The H&P indicated Resident 1 was currently on Levofloxacin (medication used to treat infections) 250 milligrams, (mg) IV, every 24 (Q 24) hours. A review of Resident 3's GACH 3 Discharge Summary (DS), dated 1/5/2025, timed at 10:17 am, indicated Resident 3 was admitted with multiple diagnoses including Influenza A and PNA. The DS indicated the hospital problem list included hypoxia likely due to PNA. The DS indicated to continue droplet isolation and starting Tamiflu (medication used to treat the flu). A review of Resident 3's Progress Note (PN), dated 1/5/2025, timed at 4:55 pm, indicated Resident 3 was readmitted from GACH 3 with Influenza A and was currently on droplet precautions. d. A review of Resident 4's AR indicated the facility admitted Resident 4, a 69-year-old male on 9/21/2018 with diagnoses that included atherosclerotic heart disease of native coronary artery, and immunodeficiency. A review of Resident 4's MDS, dated 11/22/2024, indicated Resident 4 had moderately impaired cognition. A review of Resident 4's CIC, dated 12/25/2024, at 9:21 pm, indicated Resident 4 had a fever of 102.3 °F, O2 saturation of 83 % on room air (no supplemental oxygen), and was tachycardic at 117 beats per minute (BPM). The CIC indicated Resident 4's attending physician recommended to transfer Resident 4 to GACH 1 via emergency services by calling 911 for further evaluation. A review of Resident 4's GACH 1 Emergency Department Physician Note (EDPN), dated 12/26/2024, timed at 12:18 am, indicated Resident 4 presented to the ED with shortness of breath, productive (wet- full of mucus or phlegm) cough, and fevers of 103 °F for two days. The EDPN indicated Resident 4 needed to be admitted to GACH 1 for treatment of Influenza A, PNA, and sepsis. e. A review of Resident 6’s AR indicated the facility admitted Resident 6, an 88-year-old female, on 9/22/2023 with diagnoses that included unspecified respiratory failure, unspecified dementia, and DM 2. A review of Resident 6's H&P, dated 9/27/2024, indicated Resident 6 did not have the capacity to understand and make decisions due to a diagnosis of dementia. A review of Resident 6's MDS, dated 12/17/2024, indicated Resident 6 had severe impaired cognition. A review of Resident 6's CIC dated 1/5/2025, timed at 11:09 am, indicated Resident 6 could not swallow, had a productive cough, and Resident 6's O2 saturation was at 87 % when on room air. The CIC indicated Resident 6 was transferred to the ED for further evaluation. A review of Resident 6's GACH 1 H&P, dated 1/5/2025, indicated Resident 6 was exposed to Influenza at the facility, and presented with upper respiratory symptoms, short of breath, acute (sudden) respiratory failure, and tested positive for Influenza A. The H&P indicated a chest X-ray showed pulmonary infiltrate PNA. A review of Resident 6's PN, dated 1/14/2025, timed at 10:51 pm, indicated IP 1, "spoke with resident regarding influenza vaccine. Resident is self-responsible and verbally declined ..." The PN indicated IP 1 was the author of the note. During a concurrent interview and record review on 1/15/2025 at 11:39 am, with IP 1, Resident 6's MDS, dated 12/17/2024 was reviewed, the MDS indicated Resident 6 had severe impaired cognition. IP 1 stated Resident 6 declined the flu vaccine. IP 1 stated, "It was not safe" to offer Resident 6 the flu vaccine because Resident 6 could not understand the risks and benefits of the flu vaccine. f. A review of Resident 7's AR indicated, the facility admitted Resident 7, a 72-year-old male, to the facility on 12/16/2024 with multiple diagnoses including DM2 without complications, immunodeficiency, and heart failure. A review of Resident 7's H&P, dated 12/17/2024, indicated, Resident 7 could make needs known but could not make medical decisions. A review of Resident 7's MDS, dated 12/23/2024, indicated Resident 7's cognition was moderately impaired. A review of Resident 7's CIC, dated 1/11/2025, timed at 7:11 am, indicated a CNA (unidentified) reported Resident 7 complained Resident 7 could not breath. The CIC indicated Resident 7's O2 saturation was at 78 % while Resident 7 was on two liters (L) of O2 via nasal cannular (NC, a device that gives additional oxygen through the nose). The CIC indicated Resident 7's oxygen delivery rate was increased to 4 L. A review of Resident 7's OSR, dated 1/11/2025, indicated to send Resident 7 to GACH 1 due to altered level of consciousness and O2 desaturations (a drop in blood oxygen levels). A review of Resident 7's GACH 1 H&P, dated 1/11/2025, timed at 6:57 pm, and signed on 1/12/2025 at 12:57 am, indicated Resident 7 presented to ED with reports of acute onset shortness of breath, hypoxia, and cough. The H&P indicated, Resident 7 was afebrile, hypoxic, and tachypneic. The H&P indicated, Resident 7's workup revealed pneumonia and Resident 7 was positive for influenza. The H&P's assessment/plan indicated, Resident 7 was in septic shock (severe drop in blood pressure caused by an infection) and the plan was to admit Resident 7 to the ICU (Intensive Care Unit - a department of a hospital in which patients who are dangerously ill are kept under constant observation) and continue administration of IV antibiotics and bronchodilators (medication used to widen the airways to make breathing easier). A review of Resident 7's GACH 1 Critical Care/Pulmonologist (doctor who specializes in lung conditions) Consultation Notes (CN), dated 1/11/2025, signed at 12:58 pm, indicated, Resident 7 was in severe sepsis and acute hypoxic with respiratory failure 2/2 (secondary to) pneumonia. The CN indicated Resident 7 was ill-appearing, frail, moderate distress, awake but not alert on HFNC (HiFlow Nasal Cannula - a type of non-invasive device for providing supplemental oxygen) and to monitor closely for intubation (a procedure involving a tube placed inside your trachea, also called the windpipe, through the mouth or nose and attached to a machine that helps you breathe). The CN indicated, to continue empiric (medical treatment initiated without definitive knowledge of the underlying cause or pathogen) antibiotics and start Tamiflu. A review of Resident 7's GACH 1 Infectious Disease (doctor who specializes in the diagnosis and treatment of illnesses and infections) CN, dated 1/12/2025, timed at 1:41 pm, indicated, Resident 7 was in septic shock likely secondary to Influenza A. The Infectious Disease CN indicated Resident 6’s pneumonia likely secondary to Influenza A. During a concurrent interview and record review of Resident 7's Consent/Declination Influenza Immunizations (CDII) form on 1/14/2025 at 5:08 pm, with IP 1, IP 1 stated Resident 7's RP consented for Resident 7 to receive the flu vaccine on 12/18/2024. IP 1 stated the flu vaccine was not administered to Resident 7. IP 1 stated Resident 7 should have been offered the flu vaccine upon admission on 12/16/2024. During a review of Resident 7’s GACH 1 Discharge Summary (DS), dated 1/17/2025, timed at 9:49 am, the DS indicated on 1/16/2025, Resident 7 remained on pressor support, received comfort care (end of life care) and Resident 7 subsequently expired on 1/16/2025. During a concurrent interview and a review of facility's line list (a table that summarizes key information about each case during an outbreak) for the influenza, on 1/14/2025 at 5:08 pm with IP 1, the line listing was incomplete with missing information for Residents 1, 2, 3, 4, 6, and 7. IP 1 stated the flu season started on 10/1/2024 until 3/31/2025. IP 1 stated staff (licensed nurses) began offering the flu vaccine as early as late September and began administering the flu vaccine to residents as early as 10/1/2024. IP 1 stated (in general) the flu vaccine should be administered within three days, after a resident or the resident’s RP consented to receive the flu vaccine. IP 1 stated it was important to offer the flu vaccine at the beginning of each flu season to prevent residents from getting sick from the flu, or for the flu symptoms to be minimized. IP 1 stated the IPs (IPs 1 and 2) were not following the process and were not appropriately tracking residents' flu vaccine status because "the facility was not organized." During an interview on 1/15/2025 at 4:21 pm with the DON, the DON stated the process for obtaining flu vaccine consents was for admitting nurses to offer and obtain the consent or declination form from either the residents or their RPs. The DON stated all licensed nurses were responsible for conducting flu vaccine status screening upon a residents' admission. The DON stated, "It was important to screen residents" to protect them from the flu and prevent the development of an infection. The DON stated the IPs were supposed to follow up on any newly admitted residents and screen all residents in August to offer and obtain consents for the flu season that started on 10/1/2024. The DON stated a flu vaccine tracking system was important because it allowed for the facility to keep track of all residents' flu vaccination status. The DON stated when there was no tracking system or log in place, residents who were medically eligible to receive the flu vaccine would not be offered the vaccine because of the facility's disorganization [lack of tracking]. A review of the facility's undated Centers for Disease Control and Prevention Vaccine Information Statements (CDC VIS), the CDC VIS indicated people 65 years and older, and people with certain health conditions such as heart disease, cancer, diabetes, or a weakened immune system were at greater risk of flu complications. The CDC VIS indicated flu could cause fever and chills, sore throat, muscle aches, fatigue, cough, headache, and runny or st