Health inspection·August 9, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00904906. Representing the Department, HFEN # 43454. A Class A Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 42 C.F.R. § 483.40 Behavioral Health Services Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. Title 22 California Code of Regulations: 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. 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 6/28/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident abuse and neglect. The facility failed to: 1. Implement Resident 1's plan of care by properly repositioning Resident 1 with at least two to three persons assist on 6/10/2024 during perineal care according to Resident 1's plan of care dated 7/16/2023. 2. Implement the facility's policy and procedures (P&P) titled, "Refusal of Treatment" by refraining from forcibly treating a resident who resists intervention, and instead documenting detailed information relating to the refusal and notifying the supervisors if the resident refuses care, as evidenced by Certified Nurse Assistant (CNA) 1 changing Resident 1's incontinence diaper over her resistance. 3. Implement the behavioral provisions of the care plan (CP) dated 7/16/23, to allow Resident 1 to achieve her highest level of physical, mental, and psychosocial wellbeing, including a provision stating "Do not force resident to comply against their wishes" as evidenced by Resident 1 "telling staff to not change me (Resident 1), I'm okay" during perineal care. On 6/10/2024 at around 6 a.m., Resident 1 needed to be changed (incontinent brief) because she was wet. CNA1 stated, Resident 1 was combative and resistance with care, however, CNA 1 proceeded to change Resident 1. 4. Review, evaluate, and update the patient CP as necessary for a change in the patient's change of condition (COC, a decline or improvement in a resident's status that requires review or revision to the CP) as indicated in the facility's P&P titled, "Change in a Resident's Condition or Status", revised in 2024 when Resident 1 sustained a humerus (upper arm bone) fracture (break in bone) on 6/11/2024 according to the radiology report (a clinical summary or analysis of series of tests that take pictures or images of parts of the body). As a result of these failures, on 6/10/24 at approximately 6:00 A.M., Resident 1, who has a risk of fracture secondary to osteoporosis, who cannot safely bear weight on her left side due to hemiplegia, and who requires at least two people during repositioning and perineal hygiene, sustained a left distal humerus fracture when CNA 1 forcibly transferred Resident 1 to bear full weight on her left side during a resisted diaper change. A review of Resident 1's Admission Record indicated that Resident 1 was initially admitted to the facility on 7/5/2019 with diagnoses including osteoporosis (a bone disease characterized by loss of bone density and bone strength resulting in higher likelihood of fracture), hemiplegia (loss of the ability to move in one side of the body) secondary to cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side, and unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning). A review of Resident 1's CP for activities of daily living (ADLs) (ADL-bed mobility, dressing, toilet use, eating and personal hygiene), dated 7/16/2023 indicated Resident 1 needs total assistance with bed mobility and toileting with two to three (2-3) staff. The CP included an approach plan (intervention) that included assisting the resident with transfers and requesting extra help (staff) as needed. A review of Resident 1's CP dated 7/16/2023 and titled "Behavior Problem" (as evidenced by Resident 1 telling staff to "not change me, I'm okay, I'm dry" despite requiring a change) included the goal, "Resident will not harm herself." The CP interventions included instructions for staff to anticipate the resident's care needs and to provide care before the resident becomes overly stressed. The CP interventions also instructed staff to be calm and self-assured in the event the resident would become agitated, and to re-approach the resident later when the resident was no longer agitated. A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 6/12/2024, indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) was severely impaired. She required total dependence/ maximal assistance from staff, including two person-assists for ADLs. Resident 1 also required partial to substantial assistance with mobility including sit to lying, chair/bed-to-chair transfer and toilet transfer. A review of Resident 1's Licensed Personnel Progress Notes indicated the following: On 6/11/2024 timed 3 p.m., a licensed nurse documented that at approximately 2:30 p.m., nurse informed the staff in the nurse's station that Resident 1 was complaining of pain. The nurse recorded her own observation that "skin discoloration was noted to the left arm" and the surrounding area was swollen. When the resident was asked what had happened, she (Resident 1) stated in Spanish, "tengo dolor, por favor ayudame (I have pain, please help me)." ...and she endorsed pain 7/10 (7/10 - numeric pain rating scale; [7 means severe pain]) to the left arm using numeric pain scale. The progress note further indicated that pain medication was administered, and the left arm was stabilized with pillows. On 6/11/2024 at 9 P.M., a laboratory (lab test - a medical procedure that involves testing a sample of blood, urine, or other substance from the body) order was reviewed, Medical Doctor (MD)1 was notified and issued an order for Motrin (used to relieve pain, fever, and inflammation [A normal part of the body's response to injury or infection]) consisting of 600 milligram (mg - unit of measurement) every six hours as needed for pain. The MD also ordered transfer of Resident 1 to a hospital for evaluation and treatment of the humerus fracture. A review of Resident 1's Physician Order dated 6/11/2024 at 3pm, included an X-Ray (an electromagnetic radiation of an extremely short wavelength that can penetrate various thicknesses of solids and to act on photographic film as light does) of left arm. A review of Resident 1's Radiology Report, dated 6/11/2024 at 6:33 p.m., indicated, "elbow and humerus with acute distal humeral fracture" (a break in the lower end of the humerus). On 6/12/2024, Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) for a humerus fracture. A review of Resident 1's Licensed Personnel Progress Notes indicated, "On 6/12/2024 at 11:59 a.m., Resident 1 was transported to GACH 1 by ambulance." Resident 1 experienced pain in her left arm with a pain scale score of seven out of 10 (7/10 - numeric pain rating scale; [7 means severe pain]) on 6/11/2024 and verbalizing in resident's primary language (Spanish), "tengo dolor, por favor ayudame." A review of GACH 1's Consultation Report by MD 2, dated 6/14/2024 indicated a chief complaint of left humerus fracture. The MD 2's notes recommended against surgery in favor of conservative management. A well-padded long arm posterior splint (immobilization aid used for injuries of the elbow and forearm) was applied on the resident's arm for comfort, support, and protection. During an observation on 6/28/2024 at 10:39 a.m., Resident 1 was observed with a long arm splint on the left arm. During an interview, on 6/28/2024 at 10:41 a.m., CNA 2 stated, Resident 1 refused to be moved and turned because of pain. CNA 2 stated that prior to hospitalization on 6/12/2024, Resident 1 had allowed staff to turn her with assistance. CNA 2 further stated, at least two persons had always assisted when turning Resident 1. During an interview, on 6/28/2024 12:41 p.m., Licensed Vocational Nurse (LVN) 1 stated on 6/11/2024 that it was reported to her (did not state by whom) that Resident 1 complained of pain and refused her incontinent brief (is a type of reusable undergarment designed to absorb urine) to be changed. LVN1 further stated that upon assessment of Resident 1, LVN1 observed bruises and swelling on the resident's arm and the resident complained of pain. LVN 1 further stated on 6/10/2024 (day prior), Resident 1 had not complained of pain on the left arm. LVN 1 stated during the interview she was unaware of how Resident 1 had sustained a bruise or swelling to the left arm. During an interview on 6/28/2024 at 12:52 p.m., LVN 2 stated, on 6/10/2024 at evening shift (time unknown), Resident 1 complained of pain on her left arm when she was touched and during perineal hygiene. LVN 2 stated that he was not notified if Resident 1 experienced an accident of fall or injury on 6/10/2024. During a concurrent medical record review and interview with the Director of Nursing (DON), on 6/28/2024 at 1:10 p.m., Resident 1's Medical Record was reviewed. There was no COC documented after Resident 1 sustained a humerus fracture on 6/11/2024. The DON stated there was no COC completed on 6/11/2024 but agreed they should have completed one. The DON stated, staff needed to complete a COC assessment for Resident 1. The DON further stated Resident 1 has hemiplegia requiring total care with two persons to assist during bed mobility. Resident 1 is unable turn side to side while in bed on her own without assistance from staff. The DON stated, he observed Resident 1 had discoloration on her left arm and complained of pain level of 7/10 on the left arm on 6/11/2024. The DON stated, after investigation, he found out that on the morning of 6/10/2024, CNA 1 had repositioned and changed Resident 1's incontinent brief. The DON stated, upon interview, CNA 1 failed to reposition Resident 1 properly while doing incontinent care. The DON stated, CNA 1 did not follow the facility's protocol on turning and repositioning. Because Resident 1 is hemiplegic (paralysis that affects only one side of your body) on her left side, she shouldn't be turned to her left for a long period of time and there should not be a lot of pressure put on her (Resident 1) left side. The DON stated that Resident 1 was resistant to care on the morning of 6/10/2024 while being changed, but CNA 1 proceeded to turn and change Resident 1. Furthermore, CNA1 did not utilize at least two persons to assist during ADL care. The DON further stated that CNA 1 did not report the incident (of Resident 1 refusing care) to the charge nurse (LVN2). During an interview with CNA 1 on 6/28/2024 at 1:37 p.m., CNA 1 stated, on 6/10/2024 at around 6 a.m., Resident 1's incontinence diaper needed to be changed because it was soiled. CNA 1 stated, Resident 1 was combative and resistance with care, however, he proceeded to change her (Resident 1). CNA 1 stated that he turned the resident to face the window (left side) because she was resisting, it took him longer to change Resident 1. CNA 1 further stated that he didn't ask for any assistance and didn't report the incident to the charge nurses. During a follow-up interview with the DON, on 6/28/2024 at 3:21 p.m., DON stated, Resident 1's fracture was avoidable, and it could have been prevented if CNA1 followed their protocol on proper repositioning during perineal care and he should have reported the incident to the charge nurse and management. During a review of the facility's P&P titled, "Turning a Resident on His/her Side Away from You", revised in 2024, the P & P indicated, the purpose of this procedure is to provide comfort to the resident, to prevent irritation and breakdown, and to promote good body alignment. Steps in the Procedure: ... a). Slide both your arms under the resident's back to his/her far shoulder. b). Slide the resident's shoulders toward you on your arms. c). Slide both your arms under the resident's buttocks. d). Slide the resident's buttocks toward you. e). Slide both arms under the resident's feet and ankles. f). Slide the resident's feet toward you. g). Cross the resident's arms over his/her chest. h). Cross the resident's leg nearest you over the leg farthest from you... i). Place one hand on the resident's shoulder nearest you. j). Place your second hand under the resident's buttocks. k). Gently turn the resident away from you l). Should the resident become weak or faint during the procedure, cease the procedure and summon the staff/charge nurse... m). Position the resident's arms and legs in a comfortable position and free from pressure. The following should be recorded in the resident's medical record: if and how the resident participated in the procedure or any changes in the residents' ability to participate in the procedure and any problems or complaints made by the resident related to the procedure." The same P&P also indicated, notify the supervisor if the resident refuses the care. During a review of the facility's P&P titled, "Perineal Care", revised on 2024, the P&P indicated, "the following information should be recorded in the resident's medical record: how the resident tolerated the procedure or any changes in the residents' ability to participate in the procedure, if the resident refused the procedure, the reason(s) why and the intervention taken, notify the supervisor if the resident refused the perineal care." During a review of the facility's P&P titled, "Refusal of Treatment", revised on 4/2024, the P&P indicated under "Policy Interpretation and Implementation," The resident is not forced to accept any medical treatment and may refuse specific treatment even though it is prescribed by a physician...If a resident refuses treatment, the Unit Manage