Health inspection·February 15, 2024

§ 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. On 02/08/2024 at 10 AM, an unannounced complaint investigation was conducted by California Department of Public Health (CDPH) regarding a Coronavirus [COVID] 19 [a highly infectious disease caused by the SARS-CoV-2 virus] outbreak that started at the facility on 12/21/2023. As a result of the investigation, CDPH determined the facility failed to report a COVID 19 outbreak to CDPH within 24 hours by telephone and then confirmed in writing, in accordance with the facility policy and procedure on “Unusual Occurrence Reporting.” The facility had 4 patients (Patients 6, 7, 8, 9) who tested positive for COVID 19 on 12/21/2023. On 2/1/24, the facility had a total of 14 patients and 7 facility staff who tested positive for COVID 19, since 12/21/2023. On 2/9/2024, during a review of the facility document titled “Covid –19 Residential Line List Plus Staff, indicated the facility’s final count for Covid 19 were 14 positive patients and the final count for Covid 19 positive staff were 7. A review of Patient 6’s Admission Record indicated, an 87 – year – old male, admitted to the facility on 04/14/2023, with diagnoses of heart failure (condition in which the heart muscle can’t pump enough blood to meet the body’s need for blood and oxygen), and dementia (impaired ability to remember, think, or make decisions), and Covid 19 diagnosis dated 12/21/2023. A review of Patient 6’s History and Physical dated 04/17/2023, indicated Patient 6 had residual deficits (refers to leftover issues that occur due to a condition) and aphasia (loss of the ability to understand or express speech) because of a prior cerebrovascular accident (CVA- stroke). A review of Patient 6’s Situation, Background, Assessment and recommendation or request (SBAR) dated 12/21/2023, indicated Patient 6 was tested for Covid 19 (COVID - a highly contagious respiratory disease caused by the SARS-CoV-2 virus) with a positive result. A review of Patient 6’s results from Covid Rapid test log, indicated that on 12/21/2023 Patient 6 was confirmed positive. A review of Patient 7’s Admission Records indicated, a 94 – year old male, admitted to the facility on 12/08/2023, with diagnoses of kidney failure, dementia, and Covid – 19 dated 12/21/2023. A review of Patient 7’s History and Physical dated 11/11/2023, indicated Patient 7 did not have the capacity to understand and make decisions. A review of Patient 7’s SBAR dated 12/21/2023, indicated patient was positive for Covid 19. A review of Patient 7’s results from Covid Rapid test log, indicates on 12/21/2023, Patient 7 was confirmed positive. A Review of Patient 8’s Admission Record indicated, an 83-year – old female, admitted to the facility on 11/15/2023, with diagnoses of Type 2 diabetes, fracture of first lumbar vertebra and Covid 19 diagnosis dated 12/21/2023. A review of Patient 8’s History and physical dated 11/27/2023, indicated Patient 8 had the capacity to understand and make decisions. A review of Patient 8’s Change in Condition Evaluation (COC) dated 12/21/2023, and timed at 4:17 pm, signed by Licensed Practical Nurse (LPN) 1 indicated Patient 8 tested positive for Covid 19. A review of Patient 8’s results from Covid Rapid test log, indicated on 12/21/2023, Patient 8 was confirmed positive. A review of Patient 9’s Admission Record indicated, an 85 -year – old female, admitted to the facility on 11/30 2023, with diagnoses of atrial fibrillation (irregular and often abnormally fast heart rate), joint replacement, and Covid 19 diagnosis on 12/21/2023. A review of Patient 9’s History and physical dated 12/4/2023, indicated Patient 9 had the capacity to understand and make decisions. A review of Patient 9’s COC dated 12/21/2023 and timed at 9:15 pm, and signed by LPN 1 indicated Patient 9 was positive for Covid 19. A review of Patient 9’s result from Covid Rapid test log, indicated on 12/21/2023, Patient 9 was confirmed positive. During a concurrent interview and record review on 2/8/2024 at 2:03 pm with the Infection Preventionist (IP) 1, IP 1 stated she was unable to provide documentation for the facility’s notification to CDPH, other than the notification to “Red Cap (secure web application for building and managing online surveys and databases).” IP 1 stated that the Director of Nursing (DON) was notified of the facility’s initial outbreak and IP 1 stated she was under the impression that the DON would report the outbreak to CDPH. During an interview on 2/8/2024 at 2:30 pm with the DON, the DON stated that “Red Cap” was notified of initial Covid -19 outbreak. The DON stated only “Red Cap” was notified (secure web application for building and managing online surveys and databases) and thought that it was that same as reporting to CDPH Licensing and Enforcement. During an interview on 2/8/2024 at 2:45 pm with the Administrator (ADM), the ADM stated the facility outbreak started on 12/21/2023 and four patients tested positive for Covid 19. The ADM stated “they” reported to “RED CAP” and thought that they already notified CDPH Licensing and Enforcement. A review of the facility’s policy revised 10/1/2017, titled “Unusual Occurrence Reporting” indicated that purpose of the policy is to ensure that timely reports are made to designated agencies as required by state and federal law. The facility will follow all applicable state and federal laws and regulations regarding the reporting of unusual occurrences. The facility has a no-retaliation policy toward anyone who makes good faith reports to the Department of Public Health or for any other reporting required by law. The Facility reports the following events by phone and in writing to the appropriate State or Federal agencies: Disease outbreaks. Other occurrences that interfere with Facility operations and affect the welfare. Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing. The facility failed to report a COVID 19 outbreak to CDPH within 24 hours by telephone and then confirmed in writing, in accordance with the facility policy and procedure on “Unusual Occurrence Reporting.” The facility had 4 patients (Patients 6, 7, 8, 9) who tested positive for COVID 19 on 12/21/2023. On 2/1/24, the facility had a total of 14 patients and 7 facility staff who tested positive for COVID 19, since 12/21/2023. The above violation had a direct or immediate relationship to the health, safety, or security of Patients 6, 7, 8, and 9 and other patients residing in the facility. .