Health inspection·September 8, 2022

§483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. 22 CCR § 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (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. (C) An unusual occurrence, as provided in Section 72541, involving a patient. (E) Any untoward response or reaction by a patient to a medication or treatment. (F) Any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety, or security of the patient. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). 22 CCR §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 6/15/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint investigation about Resident 1's quality of care. The facility failed to ensure two of two residents (Residents 1 and 2) were free from chemical restraint and were not administered antipsychotic medications (used to treat mental illness) imposed for purposes of discipline or convenience as evidenced by: 1. Resident 2, who was nonverbal (not involving or using words or speech) with spastic quadriplegia (partial or total loss of the ability to move of all four limbs) with intellectual disabilities (term used when there are limits to a person's ability to learn at an expected level and function in daily life) since birth, would raise his hand to his face and/or tap his face, to communicate he was constipated and or had a problem. Resident 2 had no prior history of schizophrenia diagnosis (a chronic [long lasting] and severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). Resident 2 was started on a psychotropic medication (a drug that affects behavior, mood, thoughts, or perception), Zyprexa ([Olanzapine] an antipsychotic medication used to treat mental illness) from 12/7/2020 through 6/28/2022 after being given an inappropriate diagnosis of schizophrenia upon admission to the facility. As a result, Resident 2 was admitted at a General Acute Care Hospital 1 (GACH 1) on 5/14/2022 and 5/30/2022 in GACH 2, for constipation with fecal impaction (a mass of dry, hard stool that cannot pass out of the colon or rectum) and dilation of the bowel (sign of mechanical or functional bowel obstruction), urinary tract infections (UTI- an infection in any part of the urinary system - the kidneys[organs that remove waste and extra water in the body], ureters [tubes that carry urine from the kidneys to the bladder], bladder [a pouch where urine collects in the body], and urethra [a tube through which urine leaves the body]) and low oxygen levels requiring care and treatments. 2. Resident 1, who was non-verbal, non-mobile (not capable of moving), and communicated via a communication board with no prior history of mental disorder was started on Zyprexa and given a diagnosis of schizophrenia after admission that was ruled out on 5/13/2022 after the resident's family questioned the diagnosis and use of the antipsychotic medication. As a result, Resident 1 received an unnecessary drug with an inappropriate diagnosis and increased Resident 1's potential for underlying stress and anxiety to go unrecognized or not addressed increasing the resident's feelings of isolation, sadness, and affecting the resident's ability to attain or maintain physical, mental, and psychosocial well-being. Resident 1 received Zyprexa from 9/29/2020 to 5/13/2022. A review of Resident 2's Face Sheet (Admission Record) indicated the facility admitted Resident 2 on 5/28/2020 and was readmitted on 6/7/2022 with diagnoses including intellectual disabilities (below-average intelligence or mental ability and a lack of skills necessary for day-to-day living), cerebral palsy (CP- group of disorders that affect a person's ability to move and maintain balance and posture), spastic quadriplegia (most severe form of spastic CP with partial or total paralysis of all four limbs, the trunk, and the face), and schizophrenia. A review of 12 of Resident 2's History and Physical Exam (H&Ps) from 11/18/2019 through 4/15/2021, indicated Resident 2 did not have the capacity to understand and make decisions due to profound mental retardation and intellectual disability and did not include the diagnosis of schizophrenia. A review of Resident 2's care plan titled "Exhibits Physical Behaviors," initiated on 9/28/2020 and revised on 1/5/2022, indicated the focus was on Resident 2's physical behaviors of hitting his face. Interventions included to administer Zyprexa 5 mg (milligrams - unit of measurement) via G-tube (a flexible tube inserted into the stomach for nutrition, hydration, and or medication) twice a day for "schizophrenia manifested by hitting himself in the head for no reason," staff to "evaluate the nature and circumstances (i.e., triggers) of the physical behavior with resident/patient and/or resident representative and discuss findings with resident/patient and family members/caregivers and adjust care delivery appropriately." A review of the Physician's Telephone Order for Resident 2 dated 12/7/2020, indicated Resident 2 to receive Zyprexa (medication to treat mental illnesses including schizophrenia 5 (five) milligram (mg - unit dose measurement) tablet, one tablet by mouth (PO) two times a day for schizophrenia manifested by (m/b) hitting himself for no reason. A review of Resident 2's care plan titled, "Risk for complications related to the use of psychotropic drugs on Olanzapine (Zyprexa)" initiated on 3/29/2021 and revised on 6/8/2022, indicated intervention(s) included to monitor for continued need of medication as related to behavior or mood, and to monitor for side effects. However, there was no documented evidence of nonpharmacological (any type of health intervention which is not primarily based on medication) interventions attempted, implemented, and or monitored for the effectiveness and potential triggers for discomfort prior to the use and or while on Zyprexa for Resident 2. The care plan interventions did not include to monitor and or assess Resident 2 for side effects of Zyprexa including constipation and urinary tract infection (UTI). A review of Resident 2's Initial Psychiatric Evaluation (PE - relating to mental illness or its treatment), dated 7/19/2021, indicated "This patient was requested for psychiatric evaluation per staff due to hitting himself ... resident currently taking Zyprexa 5 mg via G-tube twice a day. Per staff, he does attempt to hit himself when he appears frustrated, but the 1:1 sitter was able to prevent him from injuring himself ... Inpatient psychiatric history: unable to obtain due to communication deficit." Under behavior: involuntary (done other than in accordance with the conscious will of the individual) movement. Under speech: nonverbal. Under thought process: thought content, insight/judgement, and orientation was documented "Unable to Assess." Plan to continue Zyprexa 5 mg via G-tube twice a day. There was no documented evidence of nonpharmacological interventions attempted or monitoring parameters identified in psychiatric evaluation for Resident 2. A review of Resident 2's Psychiatric Evaluation (PE) notes dated 8/31/2021, indicated "The patient is lying down in his bed, nonverbal, and presents as anxious with mild involuntary head and arm movements ... the patient is nonverbal and unable to communicate ... continue Zyprexa 5 mg twice a day via G-tube." A review of Resident 2's PE dated 9/14/2021, indicated "The patient seen, chart reviewed, and case discussed with staff. This patient with significant intellectual and developmental delays presenting for follow-up psychiatric encounter ... Plan, continue Zyprexa 5 mg via G-tube for symptoms of schizophrenia." Resident 2's psychiatric exam documentation indicated the resident was nonverbal and was unable to assess resident for thought process, thought content, insight/judgement, orientation, recent memory, remote memory, attention/concentration, or knowledge. The psychiatric Nurse Practitioner 1 (NP 1) electronically signed the psychiatric encounter was on 10/18/2021 at 5:06 p.m. A review of Resident 2's PE dated 10/5/2021, 11/2/2021, and 12/9/2021, indicated "The patient remains nonverbal and lacks comprehension and is unable to respond to his name or verbal stimulus or unable to track movements. He remains on Zyprexa 5 mg via G-tube for psychosis (a mental disorder characterized by a disconnection from reality)." A review of Resident 2's PE dated 1/18/2022, indicated "Patient with history of schizophrenia [sic], marked intellectual and developmental delays. The patient is awake to self and is non-verbal. The patient is unable to make needs known. Plan to continue Zyprexa 5 mg via G-tube BID (twice a day)." A review of Resident 2's PE dated 2/15/2022, 3/17/2022, and 4/15/2022, indicated "the patient was unable to assess or make needs known. Plan to continue Zyprexa 5 mg via G-tube BID." A review of Resident 2's Admission Minimum Data Set (MDS - a standardized assessment and care- screening tool), dated 3/17/2022, indicated Resident 2 had severe cognitive (mental ability to make decisions of daily living) impairment and was rarely or never understood. The MDS indicated Resident 2 was totally dependent on staff and required one to two person physical assist for activities of daily living (including bathing, dressing, getting in and out of bed or a chair, eating, and toileting). A review of Resident 2's PE dated 5/4/2022, indicated "He (Resident 2) is non-verbal and displays minimal ability for communication. Plan to continue Zyprexa 5 mg via G-tube BID. Patient is stable with current medications. "Dose reduction is likely to impair functions or cause psychiatric instability." A Review of the GACH's Face Sheet for Resident 2 dated 5/14/2022, indicated Resident 2 was transferred from the Skilled Nursing Facility (SNF-the facility) to the GACH with admitting diagnosis of sepsis (is a potentially life-threatening condition that occurs when the body's response to an infection) due to urinary tract infections (UTI - an infection in any part of the urinary system - the kidneys, ureters, bladder, and urethra). Resident 2 was admitted on the Medical Surgical Unit at the GACH. A review of GACH's x-ray results for Resident 2 dated 5/14/2022, indicated Resident 2 had "Large stool ball in the rectum with severe dilation of the large bowel and dilatation of multiple small bowel loops in addition to the stomach." Resident's active hospital problem list included, "Sepsis due to UTI (5/14/2022) ... Plan: admit to hospital, continue Levaquin (levofloxacin - an antibiotic to treat infection) ... Fecal impaction in rectum (5/14/2022), Chronic constipation ... Plan: bowel regimen, soap suds enema given ..." A review of GACH 1's History and Physical (H&P) for Resident 2, dated from 5/14/2022 to 5/15/2022, indicated Resident 2, "who presented from Skilled Nursing Facility (SNF) with shortness of breath, abdominal distention, constipation, and fever for unclear amount of time. Patient started treatment with levofloxacin (an antibiotic to treat infection) and aggressive bowel regimen." A review of Resident 2's GACH 1"Discharge to SNF Summary and Transfer Orders," dated 5/16/2022, indicated the imaging showed fecal impaction with dilation of the bowel, with sepsis (blood infection) due to a urinary tract infection as well as aspiration (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed) pneumonitis (inflammation on the lungs) vs pneumonia. He will be discharged with supplemental oxygen (to provide extra oxygen to breathe in) as needed and levofloxacin" and to start taking the following medications: 1. Bisacodyl (to treat/prevent constipation) 10 milligram (mg - unit of measure of weight), insert one suppository rectally daily as needed (if no BM for 2 [two] days) 2. Lactulose (used to treat occasional constipation) 10 grams per 15 milliliter ([ml] - a unit of measure for volume), take 30 ml by mouth daily to prevent constipation 3. MiraLAX (used to treat occasional constipation) 17 grams per dose as needed for constipation. Mix powder with eight (8) ounces ([oz] - a unit of measure for volume) of water or juice daily for five days 4. Senna Laxative (to treat/prevent constipation) 8.6 mg via g-tube daily at bedtime 5. Levofloxacin (antibiotic for infection) 750 mg tablet via G-tube daily for five (5) days A review of Resident 2's care plan titled at Risk for respiratory complications, indicated on 5/30/2022, Resident 2 was transferred to GACH 2 via 911 (emergency ambulance) due to actual shortness of breath (SOB), 80% [percentage] oxygen saturation (amount of oxygen carried in the blood) on room air, distended abdomen, cough and mucus. A review of Resident 2's Face Sheet at GACH 2, indicated the resident was transferred from the SNF and admitted to the GACH 2 through the emergency department on 5/30/2022. The admitting diagnoses were hypoxic (inadequate levels of oxygen in the tissues/blood) respiratory failure and pneumonia. A review of Resident 2's H&P at GACH 2, dated 5/31/2022, indicated Resident 2 had profound intellectual disabilities and documented under P