Other·December 21, 2023

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00869726. Representing the Department, Health Facility Evaluator Nurse # 43454 State B citation was written. Title 22 § 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. Title 22 § 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. On 11/14/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding infection control, coronavirus 2019 disease (COVID-19, an infectious disease that can cause respiratory illness in humans) outbreak. The facility failed to implement its policy and procedure (P&P) of incident reporting for unusual occurrence for Resident 1, by failing to report an unusual occurrence to the State Survey Agency (SA) and send a written report within 24 hours of Resident 1's death. As a result, there was a delay of an onsite investigation by CDPH and had the potential to place other residents, staff, and visitors at risk during an COVID-19 outbreak. A review of Resident 1's Admission Record indicated Resident 1 was originally admitted to the facility on 1/30/2023 and readmitted on 8/10/2023 with diagnoses including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), peripheral vascular disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 11/1/2023, indicated Resident 5's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were moderately impaired. The MDS indicated Resident 1 required moderate to maximal assistance from staffs for activities of daily living (ADL - oral hygiene, toileting, shower/bathe, upper and lower body dressing). A review of facility's COVID-19 Outbreak Notification Letter and Health Officer Order (HOO) sent by the Los Angeles County Department of Public Health (LACDPH), dated 11/3/2023, indicated to "A COVID-19 outbreak is a reportable situation that requires investigation and follow-up as specified by the Acute Communicable Disease Control Program. A review of Resident 1's COVID-19 rapid test indicated, tested positive for COVID-19 on 11/5/2023. A further polymerase chain reaction (PCR test for COVID-19 - a test used to diagnose people infected with SARS-CoV-2, the virus that causes COVID-19) confirmed, Resident 1 was detected with COVID-19 infection. A review of Resident 1's Care plan for positive COVID-19, revised on 11/5/2023 indicated an intervention that included follow current policy and procedure for management of Coronavirus (COVID-19). A review of Resident 1's Situation Background Assessment Recommendation (SBAR - a written or verbal communication tool used to provide essential and concise information, usually during crucial situations), dated 11/5/2023 at 4:20 p.m., indicated, change of condition of fever with positive (test) COVID-19, noted sore throat with cough, recommendations of contact/droplet isolation (separation of an infected individual from the healthy until that individual is no longer able to transmit the disease) and monitor COVID-19 symptoms every 4 hours. A review of Resident 1's SBAR dated 11/6/2023 at 11:25 a.m., indicated, change of condition of tachycardia (fast heart rate [HR]) of 130 - 150 heart rate (HR) beats per minute (bpm - normal HR is between 60 - 100 bpm) with recommendations by the medical doctor to transfer to hospital emergency room (ER). A review of Resident 1's medical chart indicated, Resident 1 passed away with date of death: 11/13/2023 and time of death: 12:00 p.m. During an interview with Registered Nurse 1 (RN 1) on 11/14/2023 at 3:07 p.m., RN 1 stated, Resident 1 tested positive of COVID-19 on 11/5/2023 and symptomatic with fever, sore throat and cough. RN 1 stated, Resident 1 was transferred to ER on 11/6/2023 due to tachycardia and returned to the facility on the same day (11/6/2023). RN 1 stated, Resident 1 would have on and off tachycardia after returning to the facility with some shortness of breath and labored breathing. RN 1 stated, on 11/13/2023, the staff nurse reported to her that Resident 1 was found unresponsive. RN 1 stated, Resident 1 passed away on 11/13/2023. During an interview with Infection Preventionist Nurse (IPN) on 11/14/2023 at 11/14/2023 at 4:01 p.m., IPN stated, Resident 1 tested positive of COVID-19 and was symptomatic with fever, sore throat and cough. IPN further stated, Resident 1 passed away 11/13/2023 while she had COVID-19. IPN stated, this incident was not reported to the State Agency, and she did not know that this was reportable incident. A review of the facility's P&P titled, "Coronavirus Prevention and Response", revised on 3/14/2023 indicated, "This facility will respond promptly upon suspicion of illness associated with a SARS-CoV-2 infection in efforts to identify, treat and prevent the spread of the virus." A review of the facility's P&P titled, "Unusual Occurrence", revised on 12/19/2022 indicated, "It is the policy of the facility that an unusual occurrence is reported to the Department of Public Health within 24 hours of occurrence... The State of California, Department of Public Health distributed in January 1996 the following list of unusual occurrences. This list was not all inclusive...: an epidemic outbreak of any disease, prevalence of communicable disease... death of a patient/resident, personnel or visitor because of unnatural causes... other occurrences which constitute an interference with facility operations which affect the welfare, safety, or health of patients/residents, personnel or visitors." The facility failed to implement its P&P of incident reporting for unusual occurrence for Resident 1, by failing to report an unusual occurrence to the SA and send a written report within 24 hours of Resident 1's death. As a result, there was a delay of an onsite investigation by CDPH and had potential to place other residents at risk during an COVID-19 outbreak. The above violation had a direct relationship to the health, safety, and security of Resident 1.