Other·February 8, 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 01/25/2024 at 10 AM, an unannounced complaint investigation was conducted by CDPH regarding a COVID 19 outbreak that started at the facility on 1/10/2024. As a result of the investigation, CDPH determined the facility failed to report a Coronavirus (COVID - a highly contagious respiratory disease caused by the SARS-CoV-2 virus) 19 outbreak to the California Department of Public Health [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 5 patients who tested positive for COVID 19 on 1/10/2024. On 2/7/2024, the facility had a total of 23 patients and 10 facility staff who tested positive for COVID 19, since 1/10/2024. A review of Patient 2’s Admission Record indicated, a 62-year-old male, admitted to the facility on 1/01/2024, with diagnoses of Parkinson’s Disease (a disorder of the central nervous system that affects movement, often including tremors), protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and COVID 19 diagnosis dated 1/10/2024. A review of Patient 2’s History and Physical dated 1/02/2024, indicated Patient 2 had the capacity to understand and make decisions. A review of Patient 2’s Change in Condition Evaluation (COC) dated 1/10/2024, and timed at 4:17 PM signed by the Director of Nursing (DON) indicated “Patient has been checked for Covid 19 due to facility outbreak. Patient has had positive reading for Covid at this time.” A review of Patient 2 Laboratory Report dated 1/11/2024 indicated SARS-CoV-2 RT-PCTA Positive. A review of Patient 3’s Admission Record indicated, 64-year-old male, admitted to the facility on 11/13/2023, with diagnoses of epilepsy (a neurological condition involving the brain that makes people more susceptible to having recurrent unprovoked seizures, uncontrolled movement of body), sepsis (a serious condition in which the body responds improperly to an infection), and COVID 19 diagnosis dated 1/10/2024. A review of Patient 3’s History and Physical dated 11/22/2023, indicated Patient 3 had the capacity to understand and make decisions. A review of Patient 3’s Change in Condition Evaluation (COC) dated 1/10/2024 and timed at 3:52 PM signed by the DON, indicated “Patient has been checked for Covid 19 due to roommate being positive. Patient has had a positive reading for Covid at this time.” A review of Patient 3’s Laboratory Report dated 1/11/2024 indicated SARS-CoV-2 RT-PCTA Positive. A review of Patient 4’s Admission Record indicated, 74 year old female, admitted to the facility on 12/28/2023, with diagnoses of respiratory failure (the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient.), sepsis (a serious condition in which the body responds improperly to an infection), and COVID 19 diagnosis dated 1/10/2024. A review of Patient 4’s History and Physical dated 12/29/2023, indicated Patient4 has the capacity to understand and make decisions. A review of Patient 4’s Change in Condition Evaluation (COC) dated 1/10/2024 and timed at 6:38 PM signed by Registered Nurse (RN)1 indicated “Covid 19 +.” A review of Patient 4 Laboratory Report dated 1/11/2024 indicated SARS-CoV-2 RT-PCTA Positive. A review of Patient 5’s Admission Record indicated an 84 year old male, admitted to the facility on 12/25/2023, with diagnoses of Broncho pneumonia (inflammation of the lungs), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and COVID 19 diagnosis dated 1/10/2024. A review of Patient 5’s History and Physical dated 1/2/2024, indicated Patient 5 did not have the capacity to understand and make decisions. A review of Patient 5’s Change in Condition Evaluation (COC) dated 1/10/2024 and timed 3:20 PM signed by LVN 3 indicated “Patient has been checked for Covid 19 due to roommate being positive. Patient has had a positive reading for Covid at this time”. A review of Patient 5’s Laboratory Report dated 1/11/2024 indicated SARS-CoV-2 RT-PCTA Positive. A review of Patient 6’s Admission Record indicated a 70 year old male, admitted to the facility on 11/07/2014, with diagnoses of respiratory failure (a serious condition that makes it difficult to breathe and lungs can't get enough oxygen into the blood), Type 2 Diabetes (High blood sugar), and COVID 19 diagnosis dated 1/10/2024. A review of Patient 6’s History and Physical dated 9/20/2023, indicated Patient 6 had the capacity to understand and make decisions. A review of Patient 6’s Change in Condition Evaluation (COC) dated 1/10/2024, and timed at 2:11 PM signed by LVN 3 indicated “Patient present this AM shift with sore throat and dry cough.” A review of Patient 6 Laboratory Report dated 1/11/2024 indicated SARS-CoV-2 RT-PCTA Positive. A review of a facility document titled “Covid-19 Outbreak Line List for Congregate Residential Settings” updated on 2/7/2024 indicated the facility’s final count for COVID 19 positive patients were 23 patients. The Line List further indicated the final count for COVID 19 positive staff were 10 facility staff. During an interview on 1/25/2024, at 10 :05 AM, with the Infection Preventionist (IP) nurse stated that on 1/10/2024 Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6 all tested positive for the rapid COVID 19 test. During a concurrent interview and record review of a form provided by the IP nurse titled “Facility name Positive Cases,” on 1/25/2024, at 10:15 AM, the IP nurse stated, since 1/10/2024, the facility had 12 residents that tested positive for COVID 19. The IP nurse stated, per regulation, the COVID 19 outbreak should be reported to CDPH. The IP nurse stated she reported the outbreak to the Public Health Nurse (PHN), however, she was not able to provide evidence that it was reported to CDPH Licensing and Enforcement. The IP nurse stated she was under the impression that the Administrator (ADM) had reported the outbreak to CDPH. During an interview on 1/25/2024, at 11:25 AM, the ADM stated the facility’s outbreak started on 1/10/2024 and five residents tested positive for COVID 19. The ADM stated that the COVID 19 outbreak should be reported to CDPH within 24 hours. The ADM stated he reported the outbreak to “REDCap” (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. A review of the facility’s policy revised August 2012, 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. I. 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 Coronavirus (COVID - a highly contagious respiratory disease caused by the SARS-CoV-2 virus) 19 outbreak to the California Department of Public Health [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 5 patients who tested positive for COVID 19 on 1/10/2024. On 2/7/2024, the facility had a total of 23 patients and 10 facility staff who tested positive for COVID 19, since 1/10/2024. The above violation had a direct or immediate relationship to the health, safety, or security of Patients 2, 3, 4, 5 and 6 and other patients residing in the facility.