Health inspection·October 6, 2022

T22 § 72637. General Maintenance (a) The facility, including the grounds, shall be maintained in a clean and sanitary condition and in good repair at all times to ensure safety and well-being of patients, staff, and visitors. (d) Personnel shall be employed to provide preventive maintenance and to carry out the required maintenance program. § 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient’s needs with input, as necessary, from health professionals involved in the care of the patient. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. § 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. F689 §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. On 8/2/2022 at 10:50 A.M., an unannounced visit was made to the facility to investigate a facility report regarding patient safety and death. Specifically, involving a sampled patient (Patient 1) who was assessed as having severely impaired cognition (thought process), required constant re-directing and cueing, high risk for falls, highly impaired vision, and exhibited wandering behavior with an increased need for supervision. As a result of the investigation, the Department determined that the facility failed to: 1. Remove a known environmental hazard, a nylon-like curtain cord (string) that was hanging freely forming a loop (twist) on a traverse rod mounting (a metal rod or track with a pulley mechanism for drawing curtains) attached to the ceiling by the window in Patient 1’s room that was left unsecured since June 2022. 2. Follow the facility’s policy and procedure, IIPP (Injury and Illness Prevention Program)/Safety Management Program- Hazard Communication, Identification and Control,” revised on 1/1/20, when the facility failed to prevent the accidental hanging of Patient 1 through early identification of the hazard and taking action to prevent and control this adverse outcome. 3. Conduct an assessment for a change in behavioral condition to identify Patient 1’s need for constant (occurring continuously over a period of time) monitoring and supervision. Certified Nurse Assistants (CNAs) 1 and 2 did not notify Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 of Patient 1’s constant need for supervision on the night shift of 7/31/22, when CNAs 1 and 2 observed Patient 1 exhibiting behaviors of restlessness, getting out of bed four times and walking without assistance, refusal to stay in bed and stay seated. 4. Follow the facility’s policy and procedure, “Change of condition protocol” dated 9/4/2014 revised on 11/2021 when CNAs 1 and 2 failed to observe, assess, record, and report Patient 1‘s change in condition during the night shift of 7/31/22. As a result, Patient 1, was found dead by accidental hanging with a curtain cord attached from the ceiling around her neck, inside her room on 7/31/22 at 5:58 A.M., , after CNA 1 left Patient 1 sitting on the chair between the hours of 5:50 to 5:58 A.M. The facility called Emergency 9-1-1 services on 7/31/22 at 6:25 A.M. and Patient 1 was pronounced dead at the facility at 6:40 A.M. A review of Patient 1’s Face sheet (Admission Record) indicated the facility initially admitted Patient 1, 81 years old, on 1/5/2021 with diagnoses that included transient cerebral ischemic attack (a condition that occurs when there isn’t enough blood flow to the brain to meet metabolic demand), asthma (a condition in which your airways narrow and swell and may produce extra mucus), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and senile (showing the weaknesses or diseases of old age) degeneration of the brain. A review of Patient 1’s care plan dated 1/7/2021, indicated Patient 1 was at risk for limited physical mobility related to gait (manner of walking) instability (unstable) and impaired cognition (thought process). The care plan interventions included weight bearing (any activity that one performs on one or both feet) as tolerated and to supervise the patient during ambulation (walking) with set up assistance. A review of Patient 1’s care plan dated 1/7/2021, indicated Patient 1 had impaired cognition related to impaired decision making and short-term memory loss. The care plan indicated Patient 1 had difficulty focusing, was easily distracted, or having difficulty keeping track of what was said. A review of Patient 1’s care plan dated 1/29/21, indicated Patient 1 had behavior problems of refusing care and wandering. The care plan interventions included staff doing visual monitoring of the patient’s whereabouts, encouraging to attend group activities, listening, and addressing Patient 1’s complaint and concern, re-directing, and re-orienting when confused. A review of Patient 1’s care plan dated 10/22/2021, indicated Patient 1 was at risk for falls and had a recent fall with no injury (no date). The care plan interventions included “Encouraging Patient 1 not to change positions suddenly and monitor Patient 1 frequently.” A review of Patient 1’s Multi-Interdisciplinary Care Conference record dated 7/12/2022, indicated Patient 1 remained confused and disoriented, required constant re-directing and cueing. The care conference record indicated Patient 1 was capable of ambulation (walking) with slow gait (pace; step) but constantly forgets to use her four-wheeled walker. The care conference record indicated the patient was able to walk around her room and feed herself. A review of Patient 1's Minimum Data Set (MDS, a standardized patient assessment and care-planning tool) dated 7/16/22, indicated Patient 1 had severely impaired cognition. The MDS indicated Patient 1 was assessed having minimal difficulty hearing and highly impaired vision. The MDS indicated the patient was assessed having clear speech and responds to simple, direct communication only. The MDS indicated Patient 1 exhibited wandering behavior that occurred one to three days in the week. The MDS indicated Patient 1 required one-person extensive (patient is involved in activity, staff provide weight bearing support) physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated Patient 1 required supervision (oversight, encouragement, or cueing) to walk in room, walk in corridor, and locomotion on unit. The MDS indicated Patient 1 required a walker as a mobility device. A review of Patient 1’s Progress Notes dated 7/31/2022 indicated the following events: 1. At 2:30 A.M., Certified Nurse assistant (CNA) 1 was notified by the coworker covering her assignment (CNA 2) of Patient 1’s behavior of attempting to get out of bed two times. The Progress Notes indicated that CNA 2 nicely and safely reoriented the patient “back to rest.” Offered patient other methods of comfort, in which she (Patient 1) had no reply (sic). 2. At 3:20 A.M., CNA 1 noted Patient 1’s third attempt to get up. Patient 1 re-offered comfort measures. Patient 1 noted trying to self-ambulate, aided to ambulation. Patient 1 reoriented back to bed, questioned for any needs, patient remained non-verbal to respond, patient aided back to bed. Patient 1’s brief checked and changed by CNA 1, Patient 1 is clean and free from soils. All patient’s needs met, call light left within reach, bed at lowest position for safety (sic). 3. At 5:50 A.M., LVN 1 saw CNA 1 inside Patient 1’s room, Patient 1 observed restless with new attempts to get out of bed and self-ambulate (walk). CNA 1 reoriented patient back and explained it’s best to stay seated for safety, Patient 1 physically refused to stay and non-verbal. Patient 1 offered to stay seated in chair, Patient 1 refused verbal and physical prompts to stay seated. The Progress Note indicated that after re-orientation, Patient 1 refused to stay seated… After 5 minutes of observation, CNA 1 continued her rounds… 4. At 5:58 A.M., CNA 1 and CNA 2 walked inside Patient 1’s room… CNA 1 observed Patient 1 seated on the floor with “her back towards the wall and the blind (curtain) cord in front of Patient 1’s neck.” LVN 1 was immediately notified... Patient 1 was “aided back to bed,” thoroughly assessed for respirations, vital signs unappreciated (not found; not heard). Skin observed around the neck with skin discoloration and abrasion coming from the cord, all other body parts intact, no other visible signs of bruising (sic). 5. At 6:00 A.M., 9-1-1 was called and notified. Doctor notified at 6:05 A.M. Paramedics on site pronounced time of death at 6:40 A.M. Family and police notified. Coroner arrived at the facility; body picked up at 8:45 A.M. DON called by receptionist to notify of event (sic). A review of Patient 1’s LAFD (Los Angeles Fire Department) report, dated 7/31/2022, indicated AOS (arrived on scene) to find Patient 1 lying in bed covered in sheet. The report indicated Patient 1 was last seen by facility staff at 5:45 A.M. (sic). The record indicated Patient 1 was found in her room with the cord from blinds wrapped around the patient’s neck. The record indicated Patient 1 was cold to touch, lividity (usually begins 30 minutes to 4 hours after death; it is the reddish- to bluish-purple discoloration of the skin due to the settling and pooling of blood following death) in the Patient’s lower back and flanks (the side of a person's body between the ribs and the hip), and discolored neck. A review of the Autopsy Report signed by the Department of Medical Examiner-Coroner dated 8/2/2022. The autopsy report indicated “Hanging” as the immediate cause of death. The autopsy report indicated “accident” as the manner of death. The Autopsy report indicated “Partial suspension by curtain cord around neck” as the description of how the injury occurred. The Autopsy Report indicated “Rigor mortis (stiffening of the joints and muscles of a body a few hours after death) present. Livor mortis (settling of the blood in the lower, or dependent, portion of the body after death) is fixed in a posterior dependent distribution” as a description of postmortem (after death) changes. Under the Case Report - Synopsis, the Autopsy Report indicated “On 7/31/2022 at 0550 hours, the decedent was trying to get out of her bed and needed assistance. A nurse came in and moved the decedent from the bed to the chair. At 0558 hours, the nurse checked on her again and found the decedent with a string around the front and sides of her neck with her kneed (sic) bent and feet touching the ground.” Under the Investigator’s Narrative, the Autopsy Report indicated “The decedent was an 81-yaer old Hispanic female found with a string around her neck at the nursing home. Death was pronounced at 0640 hours. She had a do not resuscitate on her file if anything were to happen. She had a history of of depression and psychosis. There were no suicide ideations or previous suicide attempts. On 7/31/2022 at 0802 hours, this call was assigned to me. I arrived on scene at 0810 hours. The decedent was moved prior to my arrival. There was a ligature mark on the front of her neck and sides. I later changed the mode from apparent suicide to accidental versus suicide. The decedent had a plethora of medical history including dementia and recurrent falls. There was no note found at scene. The decedent’s roommate was unable to communicate.” “A review of the Death Certificate signed by the Registrar-Recorder/County Clerk dated 9/14/2022, indicated Resident 1’s date of death on 7/31/2022. The Death Certificate indicated “Hanging” as the immediate cause of death and “accident” as the manner of death. The Death Certificate indicated “Partial suspension by curtain cord around neck” as the description of how the injury occurred. During an observation and concurrent interview in Patient 1’s room in the presence of the Director of Nursing (DON), on 8/2/2022 at 11:10 A.M., Patient 1’s room was observed with a metal traverse rod mounting, attached to the ceiling next to the window. Halfway between the bed and the window, a white nylon-like white curtain cord was observed hanging freely, measuring about 6 feet from the ceiling to the bottom where the cord formed a loop [twist] on the right side of the traverse rod mounting. The DON stated the white curtain cord was used to move the drapery curtains that hung along the window frame and removed from the patient’s room in June 2022. The DON stated it did not look like the white curtain cord in Patient 1’s room was ever secured or anchored to the wall. The DON stated the curtain cord should had been secured/anchored to the wall or removed since it served no purpose. During a telephone interview on 8/2/2022 at 12:21 P.M. with LVN 1, LVN 1 stated that CNA 1 called her to Patient 1’s room during the night shift of 7/31/22 around 5:55 A.M. LVN 1 stated when she entered Patient 1’s room she saw Patient 1 on the floor, in a sitting position, with the patient’s back leaning against the wall. LVN 1 stated she observed that the curtain cord hanging freely from Patient 1’s window was around the patient’s neck and underneath Patient 1’s chin. LVN 1 stated prior to the incident she did not hear any noise from inside the patient’s room. LVN 1 stated she walked inside the room with CNA 1. LVN 1 stated she removed the curtain cord from Patient 1’s neck and with the help of CNA 1, they carried Patient 1 in bed. LVN 1 stated she checked Patient 1’s respirations and pulse but did not feel or hear anything. During a telephone interview on 8/2/2022 at 1:40 P.M., CNA 1 stated Patient 1 was very confused. CNA 1 stated that on 7/31/2022 around 5:50 A.M. Patient 1 was trying to get up from the bed. CNA 1 stated she tried to get Patient 1 back to bed but Patient 1 refused. CNA 1 stated she assisted Patient 1 to sit in the chair on the left side of the bed and place Patient 1’s walker in front of her before she left the room. CNA 1 stated she returned to Patient 1’s room with CNA 2 around 5:58 A.M. and saw Patient 1 sitting on the floor by the right side of the bed with her back against the wall. CNA 1 stated she observed the curtain cord over Patient 1’s head in front of the patient’s neck under her chin. CNA 1 stated CNA 2 went to call LVN 1. CNA 1 stated when LVN 1 came to Patient 1’s room both CNA 1 and LVN 1 checked on Patient 1’s respiration (breathing). CNA 1 stated that prior to the incident, she informed LVN 1 that Patient 1 was restless and keep getting out of bed, but LVN 1 just stated “okay.” During the interview, on 8/2/2022 at 1:40 P.M., CNA 1 was asked i