Other·November 3, 2023

§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. 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. 22 CCR § 72311 (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. On 10/2/23, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility for an annual recertification survey. The evaluator observed a candle maker being utilized by Resident 92 stored in her room. The facility failed to: 1. Ensure Resident 92 had a safe room environment free from potential fire hazard and burns when using a candle maker. The candle maker had the ability to reach high temperatures ranging from 196 - 315 degrees Fahrenheit (a scale of temperature). 2. Ensure Resident 92 did not have an excessive number of cluttered items (hoarding), stored in her room. As a result, these deficient practices of having cluttered items in the room including storage carts on wheels with empty containers (to hold the wax after the candles are created), refrigerator, coffee maker, heater, two fax machines, drills, arts and craft machines, large containers of food, large containers of unknown objects and sodas, and an improperly stored and usage of a candle maker reaching a temperature of 315 degrees Fahrenheit placed Resident 92 and her roommate, staff, and other residents at risk for serious harm and injury and for a possible fire in the facility. A review of Resident 92’s Admission Record (Face Sheet) indicated Resident 92 was a 67-year-old female admitted to the facility on 12/19/2018 and readmitted to the facility on 10/01/2019. Resident 92's diagnoses included dementia (the loss of thinking, remembering, and reasoning), anxiety (persistent worry and fear about everyday situations), schizophrenia (a serious mental condition involving inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy), and encephalopathy (damage or disease that causes brain dysfunction). A review of Resident 92's History and Physical (H&P), dated 7/30/2023, indicated Resident 92 has the capacity to understand a make decision. A review of Resident 92's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 8/18/2023, indicated Resident 92's had the cognition (ability to learn, reason, remember, understand, and make decisions) to recall information and when asked, to repeat information. The MDS indicated Resident 92 had potential indicators of psychosis (a mental disorder characterized by a disconnection from reality) such as hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated Resident 92 had two falls with no injury. During a concurrent observation and interview on 9/26/2023 at 10:24 a.m. with Resident 92, in the resident's room, Resident 92 was observed to have a cluttered and disorganized room including a candle maker in the corner of the room surrounded with items resting on top and against the candle maker, shelving blocking a window, multiple empty containers, dry food items on the floor, refrigerator with food items (cheese, olives, and green bell pepper), empty carbonated beverages cans on floor and throughout the room. Resident 92 stated, she uses the candle maker to make soap and candles and when the wax was melted, she would place the wax in the containers. Resident 92 stated the candle maker is a 10-quart container that hold up to 20 pounds of wax. Resident 92 stated, when she used the candle maker the wax gets hot enough to form the wax into candles. During an interview on 9/28/2023 at 12:55 p.m., Resident 92 stated, the candle maker melts up to 20 pounds of wax. Resident 92 stated, she plugged the device into an outlet to make the candles. Resident 92 stated she purchased the candle maker a year ago and had used it twice. Resident 92 stated, the staff had not done an inventory of her candle maker and did not have an interdisciplinary team meeting about the candle maker in the room. Resident 92 stated, she could not recall who monitored her while using the candle maker. During an interview on 9/28/2023 at 2:09 p.m., Certified Nursing Assistant (CNA) 1, stated she was not aware of a candle maker in Resident 92's room, and it was not discussed during huddles (daily communication meeting between staff members). CNA 1 stated Resident 92 room was very cluttered and there was no plan in place to prevent accidents for Resident 92 in the room. CNA 1 stated, if there was an emergency in the room there would be no space to help Resident 92. During an interview on 9/28/2023 at 3:01p.m., Registered Nurse (RN) 1, stated she was not aware of the candle maker in Resident 92's room. RN 1 stated, Resident 92 had a cluttered room, and it was a safety hazard. RN 1 stated, Resident 92's room had been cluttered for a long time. RN 1 stated, if there was an emergency in Resident 92's room there would be a delay in care because the staff would have to move the items out of the way, to reach Resident 92. During a concurrent interview and record review on 9/28/2023 at 3:30 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 92's "Care Plan (CP)," dated 8/17/2021 was reviewed. The CP indicated, Resident 92 preferred to have multiple appliances, hoard things at her bedside and was at risk for injury. The CP interventions were as follows: 1. Explain risk and benefits of multiple appliances at bedside and hoarding things. 2. Refer to psychiatry and psychology as needed. 3. Help resident to organized and sort items. 4. Offer storage. 5.Respect residents rights. 6. Do not force to clean up. 7. Notify Medical Doctor (MD) as needed. LVN 2 stated, she would tell Resident 92 the clutter in the room was not safe and would remind Resident 92 to be careful. LVN 2 stated, she was not aware of the candle maker in the room. LVN 2 stated, if the candle maker was used it could be a fire hazard and Resident 92 can get hurt. LVN 2 stated if there was an emergency in the room, there would be no space to help Resident 92 and the staff will be spending time moving the clutter out of their (facility's staff) way. LVN 2 stated, the plan in place was to continue to remind Resident 92 to move the clutter. During a concurrent interview and record review on 9/29/2023 at 11:04 a.m., with the Social Service Director (SSD) 1, Resident 92's "Intradisciplinary Team (IDT) Meeting," dated 8/29/2023 was reviewed. The IDT note indicated, on 8/29/2023 there was no reference of the hoarding conditions and no reference of the candle maker in Resident 92's room. SSD 1 stated there were multiple meetings regarding the hoarding and failed to mention the hoarding conditions at the last IDT meeting. SSD 1 stated, when Resident 92 uses the candle maker there should be a one-to-one supervision (the resident and one staff member to supervise the resident) and could be a risk for injury. SSD 1 stated, keeping the candle maker in the room was a potential fire hazard and if there was an emergency, the staff would not be able to provide services to Resident 92 due to the clutter in the room. During an interview on 9/29/23 at 12:11p.m., the DON stated, Resident 92 continuously orders items, and was not aware of the candle maker in Resident 92's room. The DON stated it is not safe to have the candle maker in the room. The DON stated, she was not aware Resident 92 had used the candle maker. The DON stated, having the candle maker in the room was a fire hazard. The DON stated, there was no system in place to keep track of the items in Resident 92's room. The DON stated, if there was an emergency in Resident 92's room there would be a delay in care due to the clutter in the room. The DON stated, the facility's staff failed to keep track of the inventory of Resident 92's items and keep the room free from fire and safety hazards. During a concurrent observation and interview on 9/30/2023 at 10:54 a.m. with the maintenance staff (MS) 1, in the basement, the candle maker was observed to have used wax on the inside, a ladle (a large, long-handled spoon with a cup-shaped bowl) inside of the container filled with wax, and a warning sign on the outside of the container indicating high temperature, do not touch. MS 1 plugged in the candle maker and in ten minutes the candle maker reached a temperature of 196.5 degrees Fahrenheit on the outside of the container and on the inside of the melted wax, the temperature reached 315 degrees Fahrenheit in the container. MS 1 stated, he was not aware of the candle maker in the room and Resident 92 room was cluttered. MS 1 stated, this was a fire hazard and using the candle maker would cause a burn if it encountered your skin. A review of the facility's policy and procedure (P&P) titled, "Fire Safety Precautions," dated 12/2009, indicated, "Personnel will follow facility established fire safety precautions in order to provide safety to all concerned ...Do not allow accumulation of papers, boxes, clothes in resident rooms ...Report all hazardous conditions and safety violations ...Report all violations immediately." A review of the facility's policy and procedure (P&P) titled, "Safety and Supervision of Residents," dated 12/2017, indicated, Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The facility failed to: 1. Ensure Resident 92 had a safe room environment free from potential fire hazard and burns when using a candle maker. The candle maker had the ability to reach high temperatures ranging from 196 - 315 degrees Fahrenheit (a scale of temperature). 2. Ensure Resident 92 did not have an excessive number of cluttered items (hoarding), stored in her room As a result, these deficient practices of having cluttered items in the room including storage carts on wheels with empty containers (to hold the wax after the candles are created), refrigerator, coffee maker, heater, two fax machines, drills, arts and craft machines, large containers of food, large containers of unknown objects and sodas, and an improperly stored and usage of a candle maker reaching a temperature of 315 degrees Fahrenheit placed Resident 92 and her roommate, staff, and other residents at risk for serious harm and injury and for a possible fire in the facility. This violation had a direct or immediate relationship to the health, safety, or security of residents.