Health inspection·November 23, 2022

Reporting of Alleged Violations §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. §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. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. On 9/8/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about Resident 1’s quality of care. The facility failed to implement the unusual occurrence reporting policy and procedure for Resident 1 and failed to report to the State Survey Agency the unusual occurrence of Resident 1's fall, including his death the following day within 24 hours. As a result, there was a delay of an onsite inspection by the Department of Public Health and there was a potential for other injury and falls to go unrecognized in the facility. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the 89-year-old male, resident on 7/13/2022, with diagnoses including fall, unsteadiness on feet, and dementia (loss of memory, thinking and reasoning). A review of the Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 7/19/2022 indicated Resident 1 had mildly impaired cognition (trouble remembering, learning new things, or making decisions) and required extensive assistance with one person assist for transfer, bed mobility, dressing, walk in room, walk in corridor and toilet use. A review of the post Fall Risk assessment dated 7/26/2022 indicated, Resident 1 was chair bound and had a balance problem while standing and walking. The form indicated that Resident 1 had decreased muscular coordination, required use of assistive devices, and had a total score of 14. A score of 10 or greater indicated resident should be considered a high risk for potential falls. According to a review of the Orders-Administration Notes dated 8/18/2022 at 1:13 AM by LVN 1, Certified Nurse Assistant 2 (CNA2) reported that Resident 1 was in his room, laying on pillows and blankets on the floor, as if he slid off the bed. CNA2 assisted Resident 1 back to his bed prior to a physical assessment. A review of Nursing Progress Note dated 8/19/2022 indicated at 5:15 PM, CNA4 was preparing dinner for Resident 1 and observed Resident 1 in his wheelchair, pale and sleeping. The note indicated Resident 1 was unresponsive and unable to be stimulated by tactile (activation of sensory receptor by a touch stimulus) and verbal commands. The progress notes indicated a code blue was announced, Cardiopulmonary Resuscitation (CPR) was initiated and 911 was called. Further review of the progress notes indicated at 5:40 PM, 911 paramedics declared Resident 1 had expired. During an interview on 9/8/2022 at 1:46 PM, the Director of Nursing (DON) stated, LVN 1 was assigned to Resident 1 on 8/18/2022 when the alleged incident occurred and LVN 1 failed to comply with post fall procedures. During an interview on 9/22/2022 at 10:18 AM, the Quality Assurance Nurse (QA) stated, "We were not aware of Resident 1’s unwitnessed fall on 8/18/2022. The facility's DON and I did not find out about it until the surveyor brought it to our attention." The QA stated LVN 1 did not communicate this incident sufficiently with the management. The QA stated, "I am not sure if any licensed staff informed Resident 1 ' s physician about this incident. During an interview on 9/22/2022 at 11:06 AM, CNA1 stated, "On 8/19/2022, I was assigned to Resident 1 during the morning shift. Resident 1 slept all morning and woke up around 12 PM. He did not want to eat. Resident 1 was sleepy all the time and did not eat breakfast or lunch". CNA1 stated, "I did not report Resident 1 ' s poor appetite to any of the charge nurses that day." On 10/14/2022 at 10:36 AM, during a telephone interview, Resident 1's physician stated he was not aware of Resident 1's fall that occurred on 8/18/2022, as staff did not notify him about the fall. The physician stated he visited Resident 1 couple of days prior to 8/18/2022, then he received a call from the facility's staff on 8/19/2022 reporting Resident 1's death. The physician stated, "I was surprised since I just saw Resident 1 a few days before his death". The physician stated, "I have told the facility's staff they can call me anytime, even at 2 AM." The physician stated depending on the resident's condition after a fall, I would normally order neuro check and 72 hours monitoring. The physician stated in the event a resident hit his head during a fall, he must be transferred to hospital for further evaluation. The physician stated staff did not notify me that Resident 1 refused to eat his breakfast and lunch and was sleepy on 8/19/2022. During an interview on 10/14/2022 at 11:35 AM, the DON stated the facility's Administrator was on vacation and not available for an interview. During an interview on 10/14/2022 at 12:48 PM, the DON stated in the case of an unusual occurrence, the facility was required to initiate an investigation and report to California Department of Public Health (CDPH), Ombudsman and the police. The DON stated the investigation for Resident 1's fall on 8/18/2022 was not initiated until the surveyor brought it to our attention. A review of the facility's policy and procedure titled, "Unusual Occurrence Reporting," revised December 2017, indicated as required by federal and state agencies, the facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees, or visitors. The facility will report the following events to appropriate agencies: death of a resident, employee, or visitor because of unnatural causes (e.g., suicide, homicide, accidents, etc.) and other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employee, and visitors. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state agencies. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations. The administrator will keep a copy of written reports on file. A review of facility's policy and procedure titled, "Accidents and Incidents-Investigating and Reporting," revised July 2017, indicated all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the report of incident/accident form: the date and time the accident or incident happened, the nature of injury/illness (e.g., bruise, fall, nausea, etc.), the time the injured person`s Attending physician was notified, as well as the time the physician responded and his or her instructions, any corrective actions taken, follow up information, other pertinent data as necessary. The Nurse Supervisor/ Charge Nurse and/or department director or supervisor shall complete a report of incident/Accident form and submit the original to the Director of Nursing Services with 24 hours of the incident or accident. Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. The facility failed to implement the unusual occurrence reporting policy and procedure for Resident 1 and failed to report to the State Survey Agency the unusual occurrence of Resident 1's fall, including his death the following day within 24 hours. As a result, there was a delay of an onsite inspection by the Department of Public Health and there was a potential for other injury and falls to go unrecognized in the facility. The above violation had a direct or immediate relationship to the health, safety, and security of Resident 1.