Health inspection·September 6, 2024

F740 §483.40 Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident’s whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. 22 CCR § 72301. Required Services. (d) Written arrangements shall be made for obtaining all necessary diagnostic and therapeutic services prescribed by the attending physician, podiatrist, dentist, or clinical psychologist subject to the scope of licensure and the policies of the facility. If the service cannot be brought into the facility, the facility shall assist the patient in arranging for transportation to and from the service location. 22 CCR § 72311. Nursing Service-General (Care Plan) (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. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time- limited. 22 CCR §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. An unannounced visit was conducted by California Department of Public Health on 7/23/2024 at 7 AM to investigate a facility reported incident regarding Patient 1 alleging Certified Nurse Assistant (CNA) 1 touched the patient’s private area. The facility failed to identify and provide treatment and services to attain the highest practicable mental and psychosocial wellbeing for Patient 1 who was diagnosed with major depressive disorder (a constant feeling of sadness and loss of interest, which stops you doing your normal activities) and anxiety disorder (persistent and excessive worry that interferes with daily activities) by facility staff failing to: 1. Identify, determine possible causal factors, monitor, and document Patient 1’s behavior of falsely accusing staff members. 2. Contact the attending physician regarding Patient 1’s new behavior of falsely accusing staff members. 3. Create a comprehensive patient centered care plan and implement interventions to address Patient 1’s behavior of falsely accusing staff members. These deficient practices may result to delay in treatment and care to Patient 1. In addition, it placed Patient 1 at risk for not being treated in a manner that promotes mental, behavioral, and psychosocial well- being. A review of Patient 1’s Admission Record (Face Sheet) indicated Patient 1 is a 48- year- old- female patient who was admitted to the facility, on 9/30/21, with diagnoses including aphasia (disorder that results from damage to portions of the brain that are responsible for language), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), major depressive disorder and anxiety disorder. A review of Patient 1’s History and Physical exam from the facility dated 7/22/24, indicated Patient 1 did not have the capacity to understand and make decisions. A review of Patient 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/3/24, indicated Patient 1 had severe impairment of cognitive (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) skills for daily decision making and required maximal assistance (the greatest amount of help) from staff with oral hygiene, toileting, showering, dressing and personal hygiene. The MDS indicated under Behavior Assessment indicated Patient 1 did not reject evaluation or care. A review of Patient 1’s Care Plan (CP) titled “Patient 1 has communication problem related to confusion, aphasia,” dated 10/6/21 and revised on 4/2/24, indicated Patient 1 has an increased risk for needs not being met. The CP interventions included Patient 1 would have her reasoning ability monitored and documented. A review of Patient 1’s CP titled “Patient allegedly claimed CNA touched her private area,” dated 7/20/24, indicated Patient 1 will have no further complication. A review of Patient 1’s SBAR (Situation, Background, Appearance, Review and Notify) dated 7/20/24 at 6:50 PM, indicated a male CNA (CNA 1) touched the patient’s private area when the male CNA was changing the patient’s diaper. A review of Progress Notes dated 7/20/24 at 8:38 PM, Progress Notes indicated, “Patient is noted to be visibly upset and claimed assigned male CNA (CNA 1) touched her private area while CNA was assisting her during incontinent brief change. Patient 1 motions to brief and repeats "Mira, sangre, sangre." (Spanish for: look, blood, blood) scant serosanguineous (yellowish with small amounts of blood) fluid noted on brief.” During a concurrent observation and interview on 7/23/24 at 8:18 AM with Patient 1 in her room, Patient 1 was observed to have difficulty communicating and used a lot of gestures to communicate. Patient 1 stated, “a tall man, pulled down his pants and inserted his penis into my vagina. I went out of the room in my wheelchair and reported it to someone.” During an interview on 7/23/24 at 10:57 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, “I know Patient 1 and can honestly say she is confused many times. She (Patient 1) accuses CNAs of stealing her property. She makes accusations and her stories never match up (LVN 1 was unable to give a date of the said accusation).” During an interview on 7/23/24 at 12:11 PM with CNA 2, CNA 2 stated, “she (Patient 1) tends to make up stories when she wants attention. If she does not like a CNA she will refuse care.” During an interview on 7/23/24 at 12:53 PM with the Activities Director (AD), AD stated, Patient 1 will make up drama or false story about the CNA if she does not like a CNA and wants a different CNA. During a concurrent interview and record review on 7/23/24 at 1:38 PM with LVN 1, Patient 1’s Care Plan History (all care plans created for Patient 1 from admission) was reviewed. The Care Plan History did not have documented evidence that there was a care plan initiated to address Patient 1’s behavior of making up false stories about facility staff. LVN 1 stated, “there are no care plans for the patient making up stories about staff members if she (Patient 1) does not like them and prefers a different CNA.” LVN 1 stated there should be a care plan to address Patient 1’s behavior to prevent issues with care in the future. LVN 1 also stated, it is considered a change in condition (CoC) if a patient started a new behavior such as making false stories or accusations. LVN 1 stated “I do not know why it was not done.” During an interview on 7/23/24 at 3:03 PM with CNA 3, CNA 3 stated, “Patient 1 will accuse a CNA of not providing care if she does not like them. She (Patient 1) requests to have her genitals scrubbed very hard and if staff does not do it, Patient 1 will complain. She has said CNAs are rude to her (Patient 1) but it was not true.” During a concurrent interview and record review on 7/24/24 at 9:56 AM with Registered Nurse (RN) 1, Patient 1’s Care Plan History, CoC and Progress Notes dated 7/23/24 to 5/25/24 were reviewed. The Care Plan History did not indicate a care plan to address Patient 1’s behavior of making up false stories. The Progress Notes and CoC (dated 7/23/24 to 5/25/24) did not indicate that Patient 1’s behavior of false accusations was identified, and that the facility tried to determine possible causal factors and monitored the patient’s behavior. In addition, there was no documented evidence that the attending physician was called regarding Patient 1’s behavior of making false accusation. RN 1 stated, if a patient has been making up stories about staff, she (Patient 1) does not like it would be considered a CoC and it should have been documented. RN 1 also stated the licensed nurses would need to evaluate the reason for the complaints and monitor the behavior and needed to inform the doctor/ attending physician. RN 1 added, a care plan would also be necessary and there was no CoC, CP or monitoring found for Patient 1. RN 1 stated, the consequences of not monitoring this behavior are the patient would receive inappropriate care and could be deprived of care. During a concurrent interview and record review on 7/24/24 at 10:17 AM with the Director of Nursing (DON), Patient 1’s Care Plan History, CoC and Progress Notes dated 7/23/24 to 5/25/24 were reviewed. The Care Plan History did not indicate that there was a care plan initiated to address Patient 1’s behavior of making up stories to falsely accuse staff and there was no CoC done to assess and monitor Patient 1’s behavior of making false accusation. The DON stated the behavior of making up stories or complaining about staff should be care planed and a CoC should have been done. The DON also stated, behavior should have been identified, the facility should have tried to determine the causal factor, monitored, doctor should be notified, and psychology consult should be done. The DON also stated if it is not monitored, it will not be known how to manage Resident 1’s behavior or how often the patient does this, the patient will not be able to be referred to specialist like the psychologist, and lastly it will delay proper treatment if not monitored. During a concurrent interview and record review on 7/24/24 at 2:50 PM with the Director of Nursing (DON), the facility’s policy and procedure (P&P) titled Change of Condition Notification, dated 6/1/17 was reviewed. The P&P indicated, members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent a CoC. The DON stated, Patient 1 should have had an IDT meeting done to address accusing behavior and false accusations of the facility staff and there was no IDT for this behavior. The DON stated, there should have been a change in condition done for this kind of behavior and IDT should be done for CoC, but it was not done for Patient 1. The DON stated the consequences of not doing this is the patient will have delayed care because problems will not be addressed in a timely manner and referrals will be delayed. During a review of the facility’s P&P titled, “Change of Condition Notification” dated 6/1/17, indicated, “The facility will promptly inform the patient, consult with the patient’s attending physician and notify the patient’s legal representative when the patient endures a significant change in their condition caused by, but not limited to cognitive and behavioral status.” During a review of the facility’s P&P titled, “Behavior Management” dated 11/1/17, indicated, “When a patient displays adverse behavioral symptoms, Licensed Nursing Staff will assess the symptoms to determine possible causal factors, contact the attending physician, and implement nondrug interventions to alleviate the behavioral symptoms.” The facility failed to identify and provide treatment and services to attain the highest practicable mental and psychosocial wellbeing for Patient 1 who was diagnosed with major depressive disorder (a constant feeling of sadness and loss of interest, which stops you doing your normal activities) and anxiety disorder (persistent and excessive worry that interferes with daily activities) by facility staff failing to: 4. Identify, determine possible causal factors, monitor, and document Patient 1’s behavior of falsely accusing staff members. 5. Contact the attending physician regarding Patient 1’s new behavior of falsely accusing staff members. 6. Create a comprehensive patient centered care plan and implement interventions to address Patient 1’s behavior of falsely accusing staff members. These deficient practices may result to delay in treatment and care to Patient 1. In addition, it placed Patient 1 at risk for not being treated in a manner that promotes mental, behavioral, and psychosocial well- being. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.