Health inspection·September 12, 2024

F656 §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. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).

F657 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be— (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. … (E) To the extent practicable, the participation of the patient and the resident's representative(s). An explanation must be included in a resident’s medical record if the participation of the patient and their patient representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

F689 §483.25(d) Accidents. The facility must ensure that – (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents.

F926 §483.90(i) Other environmental conditions. The facility must provide a safe, functional, sanitary, and comfortable environment for the residents, staff and the public. The facility must— (5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents. On 8/1/2024, at 10:15 AM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident and a complaint regarding Patient Safety. As a result, CDPH determined that the facility failed to ensure Patient 1 was free from accidents and smoking hazards by failing to: 1. Supervise and monitor Patient 1, who was non-compliant with the facility’s smoking policy, titled “Resident Smoking,” when the patient went to the facility's outdoor patio to smoke a cigarette while on oxygen on 7/20/2024, and 7/31/2024. 2. Implement Patient 1’s care plan interventions of being non-compliant with the facility’s smoking schedule and policy on “Resident Smoking” that indicated facility staff would supervise Patient 1 while smoking. 3. Ensure the facility nursing staff maintained Patient 1’s smoking materials, in accordance with the facility’s policy and procedures titled, “Resident Smoking.” 4. Revise and update Patient 1’s care plan of being non-compliant with the facility’s smoking schedule and smoking policies dated 6/17/2024, when Patient 1 attempted to go outside and smoke while on oxygen [a colorless, odorless, reactive gas] on 7/20/2024. 5. Designate a facility staff responsible in supervising patients while patients smoke, in accordance with the facility’s policy and procedure, titled “Resident Smoking.” 6. Ensure that Patient 1’s signed “Acknowledgement and Smoking Waiver” indicating “The facility does not allow smoking unsupervised,” is in alignment with the facility’s policy and procedure titled “Resident Smoking” which indicated any resident who was “deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas. As a result, on 7/31/2024, at around 3pm, Patient 1 went to the facility’s outdoor patio and lit his cigarette while on oxygen via nasal cannula (NC- a thin, flexible tube that wraps around the head for oxygen administration). Patient 1 sustained second-degree burns (partial thickness burn that affects the first and second layer of the skin causing blistering [painful swellings that contain liquid], skin discoloration, and pain) to both cheeks, lips, singed (burned surface) facial hairs, and both hands when a flash fire ignited the oxygen flow from the patient’s NC. Patient 1 was immediately transferred to the General Acute Care Hospital (GACH) 1 via 911 emergency services. Subsequently, Patient 1 was transferred to GACH 2 Burn Center (a hospital specializing in the treatment of burns) for additional treatment of Santyl (ointment that removes dead infected skin) and Vashe (skin and wound cleansing solution) to hands and Bactroban (antibiotic [stops growth of bacteria] ointment) topically (applied to the skin) to Patient 1’s face, including medication management for pain, Gabapentin (medication for nerve pain) and oxycodone (a strong narcotic medicine used to treat severe pain). A review of Patient 1’s Admission Record indicated the facility initially admitted the 76 year old male on 8/27/2019, and readmitted on 6/24/2024, with diagnoses that included chronic obstructive pulmonary disease (COPD; long term inflammation of lungs that causes blockages or interference with airflow in the lungs) exacerbation (worsening of a disease), acute and chronic respiratory failure (the body’s tissues does not have enough oxygen), epilepsy (seizures), and muscle weakness. A review of a facility provided document titled “Smoking Schedule” updated 7/21/2023, indicated the facility’s smoking scheduled times for patients who smoke as 9 AM, 11 AM, 1 PM, 3:30 PM, and 6:30 PM. The Smoking Schedule indicated, “Smoking assessment is done upon admission for resident safety. Smoking aprons (made from a flame-retardant material use for protection of smokers) are provided to residents for safety. Smoking supplies are kept by staff for safety.” A review of Patient 1’s care plan titled, “[Patient 1] is non-compliant with oxygen,” dated 10/10/2023, indicated Patient 1 was using oxygen 5 liters per minute for COPD. The care plan interventions included a discussion regarding the consequences of non-compliant behavior and accepting/supporting Patient 1’s decision. A review of Patient 1’s Order Summary Report indicated the following physician’s orders for Patient 1’s oxygen: 1. Physician’s order dated 5/9/2023, indicated to administer oxygen via NC at 2 liters per minute, may titrate (the process of adjusting the oxygen flow) oxygen to maintain oxygen saturation (the amount of oxygen in the blood) greater or equal to 94% (normal levels are between 95% to 100%). 2. Physician’s order dated 6/22/2023, indicated to maintain oxygen via NC at 2 liters per minute, may titrate oxygen to maintain oxygen saturation greater or equal to 92%. 3. Physician’s order dated 7/1/2023, indicated to maintain oxygen via NC at 5 liters per minute, may titrate oxygen to maintain oxygen saturation greater or equal to 94%. 4. Physician’s order dated 9/29/2023, to administer oxygen via NC at 5 liters per minute, may titrate oxygen to maintain oxygen saturation greater or equal to 94% 5. Physician’s order dated 3/13/2024, indicated to administer oxygen via NC at 5 liters per minute, may titrate oxygen to maintain oxygen saturation greater or equal to 94 %. A review of Patient 1’s History and Physical Examination (HPE, a comprehensive physician’s note regarding the assessment of the patient’s health status) signed by the attending physician (Physician 1) dated 6/6/2024, indicated Patient 1 had the capacity to understand and make decisions. A review of a facility records titled, “Acknowledgement and Smoking Waiver” signed by Patient 1 on 6/6/2024, indicated Patient 1 wished to exercise the right to smoke cigarettes while residing at the facility. The facility record indicated that in order to try to protect the lives and safety of all patients and staff, the facility requires that any patient smoking be conducted with the supervision of staff because the facility does not allow smoking unsupervised. The facility record indicated that the facility had explained to Patient 1 that the facility’s designated smoking area was the “Patio.” A review of Patient 1’s Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) dated 6/12/2024, indicated Patient 1 was moderately impaired (difficulty remembering things, thinking clearly) of cognition (thought process). The MDS indicated Patient 1 required moderate/partial assistance (helper does less than half the effort) with upper body dressing, oral hygiene, sit to stand, chair transfers, and personal hygiene while Patient 1 required substantial/maximal assistance (helper does more than half the effort) for lower body dressing, toileting hygiene, putting on/taking off footwear, and sit to lying position. A review of Patient 1’s care plan titled, “[Patient 1] is non-compliant with smoking protocols/schedule” dated 12/20/2023, and revised on 6/17/2024, indicated goals that included Patient 1 not having injuries from smoking and for Patient 1 to inform nursing staff to remove oxygen tank prior to smoking. On 7/22/2024, an intervention was added for the patient to seek assistance and supervision from facility staff for when he wants to smoke. The care plan interventions included encouraging Patient 1 to seek assistance/supervision and removing oxygen tank prior to smoking, encouraging the use of smoking apron, and respecting the patient’s rights. A review of Patient 1’s care plan titled, “[Patient 1] is non-compliant with smoking schedule, smoking policies, and keeping his own cigarette” dated 3/6/2024, and revised on 6/17/2024, indicated goals that included for Patient 1 to not smoke without supervision, that Patient 1 would participate in decisions relating to smoking schedules and policies, and that Patient 1 would not suffer injuries from unsafe smoking practices. The care plan interventions included instructing Patient 1 about smoking risks and hazards, notifying charge nurse immediately if it is suspected the patient had violated the facility’s smoking policy, observing clothing and skin for signs of cigarette burns, and instructing Patient 1 about facility policy on smoking, and locations. A review of Patient 1’s care plan titled, “[Patient 1] is a smoker” revised on 6/18/2024, indicated goals that Patient 1 would not smoke without supervision and would not suffer injury from unsafe smoking practices. The care plan interventions included information that Patient 1 required supervision while smoking, instructing Patient 1 about facility policy on smoking, locations, times, safety concerns, notifying charge nurse immediately if it was suspected that Patient 1 has violated the facility smoking policy. A review of facility records titled, “Smoking Safety – initial assessment, dated 5/9/2023, 6/5/2024, and 6/22/2024, indicated Patient 1’s risk factors included impaired gait (walking) and balance. The facility records indicated the same recommendations for 5/9/2023, 6/5/2024, and 6/22/2024 Smoking Safety (V2 initial assessments, that indicated discussion of smoking cessation plan and patient smoking with staff supervision). A review of Patient 1’s care plan titled, “Resident [1] is at risk for injury due to non-compliance with smoking policy creating/making his own cigarette,” dated 7/22/2024, indicated goals that included that Patient 1will not cause injury to himself or to others and Patient 1 will ask staff when he needs to smoke. The care plan interventions included to continue teaching/reminding Patient 1 with his risk factors, frequent monitoring of his behavior, encourage verbalization of feelings and concerns, and for the IDT to review Patient 1’s behavior regarding smoking needs, and informing him of the consequences for non-compliant behavior. A review of Patient 1’s Progress Notes dated 7/23/2024, timed at 4:02 PM, indicated an incident that occurred on 7/20/2024, during the night shift (11 PM to 7 AM), when Licensed Vocational Nurse (LVN) 3 would not allow Patient 1 to go outside the outdoor patio to smoke. A review of LVN 3’s written statement dated 7/25/2024, timed at 10:41 AM, indicated the incident that occurred on 7/20/2024, during the start of the night shift (11PM-7AM) when Patient 1 requested to smoke. LVN 3 informed Patient 1 that he could not go outside because it was past the facility’s smoking scheduled times and Patient 1 got upset. The written statement indicated Patient 1 still went out the outdoor patio smoking area while his oxygen tank was on and attached to his wheelchair while he attempted to light a cigarette. The written statement further indicated LVN 3 was able to remove the oxygen tank before Patient 1 was able to light the cigarette. A review of Patient 1’s record titled, “Change of Condition [COC]” dated 7/31/2024, timed at 3 PM, indicated another incident that occurred on 7/31/2024, when Patient 1 was heard calling for help from the facility’s outdoor patio. The patient was discovered to have sustained second degree burns on his nose, mouth, and hands. The COC indicated Patient 1 reported having severe pain, rating it at a 10 out of 10 level of pain (numerical pain rating scale with 10 being the highest level of pain and 0 for no pain). The COC indicated that emergency services (911) where contacted, and the patient was transferred to the acute hospital (GACH 1). A review of Patient 1’s GACH 1 record titled “Trauma Surgery History & Physical” dated 7/31/2024, timed at 4:55 PM, indicated Patient 1 had a primary medical history of status post (medical or clinical shorthand tha