Other·May 21, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00893123. Representing the Department, HFEN # 43452. A Class B Citation was written. REGULATORY VIOLATIONS: 22 CCR § 72549. Patient Death Reports. (a). All patients' deaths shall be reported by the licensee when requested by the Department or its designee. The report shall be made accurately at a time and in such a manner as may be requested by the Department or its designee. 22 CCR § 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. 22 CCR § 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. On 4/5/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about a resident's death. The facility failed to ensure resident received treatment and care in accordance with professional standards of practice for Resident 1 by failing to: 1. Implement facility's policy and procedure (P&P) titled, "Death of a Resident, Documenting" when Resident 1 expired on 6/2/2023. 2. Report the unusual occurrence as required by federal or state regulations which affect the health, safety, or welfare of residents, employees, or visitors. As a result, there was incomplete assessment and documentation as required per facility's P&P upon death and a delay of onsite inspection by CDPH to investigate the circumstances surrounding Resident 1's death. A review of Resident 1's Admission Record indicated resident was originally admitted to the facility on 1/8/2021 and readmitted on 11/30/2022, with diagnoses including unspecified atrial fibrillation (afib. - an irregular and very rapid heart rhythm that and can lead blood clots in the heart), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), and muscle weakness. The Admission Record also indicated; Resident 1 expired (death) on 6/2/2023 at 9:03 p.m. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 3/30/2024, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were severely impaired. A review of Resident 1's Progress Notes dated 6/2/2023 at 10:37 p.m. indicated, on 8:30 p.m., Certified Nursing Assistant called Registered Nurse 1 (RN 1) as resident was found non-responsive to stimuli, chest was with no rise and fall for a full minute, absence of respirations and a cardiopulmonary resuscitation (CPR - medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest) was initiated. A review of Resident 1's Responsible Party (RP)'s record submitted to the State Agency on 4/3/2024, RP took a Forensics Toxicology Laboratory Test Autopsy (the analysis of biological samples for the presence of toxins, including drugs) on 6/16/2023, which the report indicated, Resident 1's blood was found to have a lethal dose of diphenhydramine (Benadryl - an antihistamine used to relieve symptoms of allergy, hay fever, and the common cold, these symptoms include rash, itching, watery eyes, itchy eyes/nose/throat, cough, runny nose, and sneezing, it is known to cause drowsiness, or sedating, antihistamine as it makes you sleepy). RP indicated on his letter that according to Resident 1's medical record, she was not on Benadryl medication during her stay in the facility and was baffled how she ended up with a lethal dose of Benadryl in her blood. RP further indicated; he reported this result to the facility. A review of Resident 1's medical record on 4/5/2024 at 4:15 p.m., indicated there was no physician's progress notes that was completed within 24 hours of resident's death and no record of death was filed. During an interview with Registered Nurse 1 (RN 1) on 4/5/2024 at 4:35 p.m., RN 1 stated, on 6/2/2024 at about 3 p.m., she started her shift that day and she observed Resident 1 eating burgers and she said "hi" to her. RN 1 stated, there was nothing unusual with Resident throughout her whole shift until the CNA called for help when she was found unresponsive at around 8:30 p.m. RN 1 stated, she was surprised when Resident 1 was found unresponsive as there was no signs and symptoms of her impending death, and she was in stable condition. RN 1 further stated, Resident 1 was not in hospice care (medical care for people with an anticipated life expectancy of 6 months or less, when cure isn't an option, and the focus shifts to symptom management and quality of life) and her Physician Orders for Life Sustaining Treatment form (POLST-a medical order from a physician that aids people with serious illnesses more control over their own care by stating the type of treatment they want to receive) indicated, full code (if a person's heart stopped beating or breathing, the person will allow all medical measures to be taken to maintain and resuscitate life). During a concurrent interview and record review of Resident 1's medical record with Director of Nursing (DON) on 4/5/2024 at 5:33 p.m., DON stated and confirmed, there was no physician's progress notes regarding Resident 1's cause of death and if facility filed a death certificate with the appropriate agency within 24 hours. DON further stated, Resident 1 was not on Benadryl medication while under the facility's care. DON stated, she found out about RP's complained about the Benadryl dose found in Resident 1's blood. DON further stated, she did not report incident to the Stage Agency, Ombudsman and Police upon knowing of the report. DON further stated, it is a usual occurrence for a resident to die under their care in their facility. During an interview with Administrator (ADM) on 4/5/2024 at 5:47 p.m., ADM stated, resident deaths are not required to be reported in the State Agency, Ombudsman and Police. ADM stated, there are people dying every day and it is not an unusual occurrence for people to die in the facility. ADM further stated, "people die all the time". A review of the facility's P&P titled, "Death of a Resident, Documenting", reviewed on 1/31/2024 indicated, "Appropriate documentation shall be made in the clinical record concerning the death of a resident... The Attending Physician must record the cause of death in the progress notes and must complete and file a death certificate with the appropriate agency within 24 hours of the resident's death or as may be prescribed by state law." A review of the facility's P&P titled, "Unusual Occurrence Reporting", reviewed on 10/26/2023 indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors... out facility will report the following events to appropriate agencies: death of a resident, employee or visitor because of unnatural cause (e.g. suicide, homicide, accidents, etc)... Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within 24 hours of such incident... A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency within 48 hours of reporting the event or as required by federal and state regulations." The facility failed to ensure resident received treatment and care in accordance with professional standards of practice for Resident 1 by failing to: 1. Implement facility's P&P titled, "Death of a Resident, Documenting" when Resident 1 expired on 6/2/2023. 2. Report the unusual occurrence as required by federal or state regulations which affect the health, safety, or welfare of residents, employees, or visitors. As a result, there was incomplete assessment and documentation as required per facility's P&P upon death and a delay of onsite inspection by CDPH to investigate the circumstances surrounding Resident 1's death. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1.