Health inspection·September 9, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00910488. A Class A Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations §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. Title 22, California Code of Regulations § 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. On 7/23/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident neglect and safety. The facility failed to ensure Resident 1, who was identified with wandering episodes, was provided supervision, and maintained a safe and hazard free environment as indicated in Resident 1's care plan dated 2/21/2024. The facility failed to ensure a full bottle of hand sanitizer was not within Resident 1's access or reach. As a result, Resident 1 ingested (drank) a toxic substance (hand sanitizer, a liquid or gel, typically one containing alcohol, that is used to clean the hands and kill bacteria, viruses, and other disease-causing agents on the skin) requiring admission to the General Acute Care Hospital (GACH) for care and treatment and was diagnosed with toxic encephalopathy (a neurologic disorder [nervous system problems] caused by consumption or exposure of harmful chemicals/toxins, that cause lead to altered mental status, memory loss, and visual problems) caused by the consumption of the hand sanitizer. A review of Resident 1's admission record, indicated the facility initially admitted Resident 1 on 2/17/2024 and was readmitted on 7/12/2024 with diagnoses that included toxic encephalopathy, dementia (loss of cognitive functioning-thinking, remembering, and reasoning), chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), and aphasia (loss of ability to understand or express speech, caused by brain damage). During a review of Resident 1's care plan (CP) titled, "Resident with wandering episode secondary to: Dementia" initiated 2/21/2024, the CP indicated for interventions: Constant monitoring of whereabouts and maintain safe and hazard free environment. A review of Resident 1's Minimum Data Set (MDS- standardized data collection tool used to assess cognitive and functional status, and care needs) dated 6/23/2024, indicated Resident 1 had severe cognitive impairments (when social and occupational functions are limited where an individual may not be able to recognize people, use language, or execute purposeful movements). The MDS indicated Resident 1 required between partial/moderate to substantial/maximal assistance for Activities of Daily Living (ADLs - eating, oral hygiene, toileting, showers/bathing, dressing, personal hygiene, and toilet transfer). During a review of Resident 1's "History and Physical (H & P)" dated 6/8/2024, the "H & P" indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's nurse progress notes dated 7/7/2024 at 4:30 pm, indicated Resident 1 had ingested 165 cc of hand sanitizer, called [the nurse] Medical Doctor (MD) with new orders to transfer out to hospital to monitor for symptoms of intoxication (the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs). A review of Resident 1's physician's order dated 7/7/2024 at 4:30 pm, indicated transfer resident to hospital for further evaluation of ingestion of hand sanitizer. A review of Resident 1's nurse progress notes dated 7/7/2024 at 6 pm, indicated Resident 1 was picked up by two Emergency Medical Technicians (EMTs- a person who is trained to give emergency medical care at the scene of an accident or in an ambulance) in an ambulance and transported to a GACH for further evaluation for ingestion of alcohol hand sanitizer. A review of Resident 1's CP initiated on 7/7/2024 for behavioral problems, indicated, "resident ingested almost 165cc of hand sanitizer, resident is more confused, Wandering." A review of Resident 1's GACH History and Physical (H&P) records dated 7/12/24 under assessment and plan indicated the following: "Toxic encephalopathy due to ingestion of hand sanitizer, cognitive impairment (Problems with a person's ability to think, learn, remember, use judgement, and make decisions) and altered mental status upon admission, consistent with toxic encephalopathy." The same H&P indicated, "monitor neurological status (consists of a physical examination to identify signs of disorders affecting your brain, spinal cord, and nerves) and mental alertness every 2 hours. Administer intravenous (a way of giving a drug or other substance through a needle or tube inserted into a vein) fluids and electrolytes (minerals in your blood and other body fluids that carry an electric charge) to manage dehydration (a condition that occurs when the body loses too much water and other fluids that it needs to work normally) due to ingestion. Provide activated charcoal (a fine, odorless, black powder often used in emergency rooms to treat overdoses) if within ingestion window to reduce systemic absorption (the movement of drug from the site of drug administration to the systemic circulation). Consult Poison Control Center for further management and antidote (a remedy to cancel the effects of poison) recommendations PRN (as needed) for complex cases." During an interview LVN 3 on 7/23/2024 at 12:21 pm, stated that on 7/7/2024 at 4:30 pm while he (LVN 3) was sitting on the inside of the nurses' station, LVN 3 observed Resident 1 who was sitting on a wheelchair grab a bottle of hand sanitizer which was full (221 cc) opened it and started drinking it. LVN 3 stated Resident 1 drank 165 cc of the hand sanitizer. LVN 3 admitted Resident 1 was known (no time stated) to place items in her mouth that she could get her hands on, but that the behavior was not care planned. During a concurrent observation of the reception desk and interview with the DSD on 7/23/24 at 1:22 pm, the DSD confirmed and stated there was no staff present at the reception desk. The DSD stated the sanitizer should be at the receptionist desk but was unable to state how the facility would prevent a confused resident with easy access from consuming the hand sanitizer. The DSD stated the hand sanitizer could be toxic if consumed especially that residents are taking medications. During a concurrent observation of a desk in the admission's office and interview with the DON 7/23/24 1:27 pm, a loose bottle of hand sanitizer was observed on the desk within easy access for residents. The DON admitted the residents had access to the office and that the residents who are confused might consume the easily accessible hand sanitizer. The DON stated the potential effect, if consuming hand sanitizer, may be toxic and require medical attention. The affected resident may result in resident getting drunk. During a concurrent observation of Resident 1, interview, and record review with the ADON and the activities staff (AS) c on 7/23/24 at 4:22 pm, Resident 1's admission records dated 7/12/24 were reviewed. Resident 1 was readmitted to the facility on 7/12/2024. Resident 1 was observed sitting on a chair against the wall in the dining room unsupervised with the door closed. Behind Resident 1 within easy access, was a wall mount containing two boxes of gloves and next to the gloves was about one liter of sanitizing wipes with one wipe hanging over the container. The ADON and the AS confirmed the observation. The ADON admitted that Resident 1 had easy access to the sanitizing wipes and could ingest them with her history of ingesting nonedible substances. During a concurrent observation and interview of the maintenance room (just across the hallway from the dining room approximately 30 feet from the dining room where Resident 1 was sitting) on 7/23/24 at 4:48 pm with the DON, the door was tied open using a string connected to the doorknob and a wire behind the door. There were no staff observed near the Maintenance Room to monitor and ensure residents were not going inside the room. Inside the Maintenance Room there was a door to a wired cage where cleaning solutions/chemicals were stored. There were several stored cleaning supplies and chemicals such as bleach and aerosols. The wired cage door was observed wide open, making cleaning supplies available to residents. The DON confirmed the observation and stated the room was easily accessible to residents. During a concurrent observation and interview with the DON of the Maintenance Room on 7/23/24 at 5:57 pm, the Maintenance Room was unattended, the doors were open, and the caged door (containing cleaning supplies) was open. The DON confirmed and stated that residents had easy access and may consume the chemicals stored in the room. During an interview Resident 1's Primary Medical Doctor/Medical Director (PMD/MD) on 7/24/24 at 10 am, stated Resident 1 required a 1:1 sitter after the incident on 7/7/24 for safety to prevent her from consuming toxic substances. The potential effects of consuming these toxic substances may result in metabolic acidosis (too much acid in the blood and can be life-threatening if not treated appropriately), esophageal strictures (narrowing of your esophagus (swallowing tube), cell injury, and death. A review of the facility's policy and procedures (P&P) title "Dementia-Clinical Protocol. Resident Behavior", release date 8/1/2023, the P & P indicated, "The physician will order appropriate interventions to address significant behavioral and psychiatric symptoms, based on pertinent clinical guidelines and consistent with regulatory requirements." During a review of the facility's P & P titled "Alcohol-Based Hand Rub Dispensers, Installation and Use," release date 1/2024, the P & P indicated, "Alcohol-based hand rub dispensers shall be installed in areas that facilitate access by healthcare personnel and maintain a safe environment for the residents and staff." The same P&P indicated processes which included: Residents with cognitive or behavioral challenges and will be observed when they are near Alcohol Based Hand Rub (ABHR) dispensers. The facility failed to ensure Resident 1, who was identified with wandering episodes, was provided supervision, and failed to maintain a safe and hazard free environment as indicated in Resident 1's care plan dated 2/21/2024. The facility failed to ensure a full bottle of hand sanitizer was not within Resident 1's access or reach. As a result, Resident 1 ingested (drank) a toxic substance requiring admission to the GACH for care and treatment and was diagnosed with toxic encephalopathy caused by consumption of the hand sanitizer. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.