Other·January 19, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00871414. Representing the Department, Health Facility Evaluator Nurse # 43261 State B citation was written. REGULATORY VIOLATIONS: Title 22 CCR § 72541. Unusual Occurrence 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. Title 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 11/28/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a compliant regarding quality of care and treatment of residents at the facility. The facility failed to provide services in compliance with the applicable Federal, State, and local laws, regulations, and codes and with accepted professional standards and principles for one of one sampled resident (Resident 17) by failing to ensure facility reported a disease outbreak on COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) to the state or federal agencies per facility policy. Resident 17 tested positive for COVID-19 on 11/16/2023. As a result, the State Agency (CDPH) was not aware of the outbreak, leading to a delay in the investigation of the facility's outbreak and had the potential for further transmission of COVID-19 infection to other residents, staff, and visitors at the facility. A review of Resident 17's Admission Record indicated Resident 17 was admitted to the facility on 10/10/2023, with diagnoses including encephalopathy, difficulty in walking and reduced mobility. A review of Resident 17's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 10/14/2023, indicated Resident 17 had an intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and needing moderate assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). A review of Resident 17's medical record, titled, "Change in Condition Evaluation," dated, 11/16/2023, medical record indicated Resident 17 tested positive for COVID-19. During an interview with the Infection Preventionist Nurse (IPN) on 11/29/2023 at 10:51 a.m., IPN stated that they were currently in an outbreak due to COVID-19 infection of Resident 17 on 11/16/2023. IPN stated and verified that she (IPN) had notified the Los Angeles County Department of Public Health (LAC DPH) and not the state agency (SA). During an interview with the Interim Director of Nursing (IDON) on 11/29/2023 at 11:33 a.m., IDON stated that facility should report any outbreak to the SA once made aware. A review of facility's policy and procedure (P&P), titled, "Unusual Occurrence Reporting," reviewed on 10/19/2023, P&P indicated that facility will ensure timely reports are made to designated agencies as required by state and federal law. P&P also indicated that the facility reports the following events by phone, and confirmed writing for safety-related events, disease outbreak and financial occurrences. The facility failed to provide services in compliance with the applicable Federal, State, and local laws, regulations, and codes and with accepted professional standards and principles for Resident 17, by failing to ensure facility reported a disease outbreak on COVID-19 to the state or federal agencies per facility policy. Resident 17 tested positive for COVID-19 on 11/16/2023. As a result, the State Agency (CDPH) was not aware of the outbreak, leading to a delay in the investigation of the facility's outbreak and had the potential for further transmission of COVID-19 infection to other residents, staff, and visitors at the facility. The above violation had a direct relationship to the health, safety, and security of Resident 1.