Health inspection·January 2, 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. The facility failed to report a Coronavirus 2019 (COVID-19; an infectious disease) outbreak in the facility, for Patient 2 within 24 hours of occurrence of the incident, to the California Department of Public Health Licensing and Certification District Office (CDPH L&C DO). This failure had the potential to threaten the welfare, safety, or heath of the patients, personnel, or visitors due to the spread of the infectious disease. As a result, the CDPH L&C DO was not aware of the incident and could not conduct a timely on-site investigation to ensure the facility was taking proper precautions to protect the welfare of the patients and staff during this outbreak , resulting in an increase of positive COVID-19 residents in the facility. On 11/21/23 at 9:20 AM, an unannounced complaint investigation was conducted regarding an outbreak at the facility that started on 11/08/23. During a concurrent initial observation of the facility and interview with the assisting Infection Preventionist (IP2), on 11/21/2023 at 9:42 AM, the IP2 stated the facility currently had a total of 92 patients residing in-house with 13 total positive patients for COVID-19. The IP stated the first patient residing in the facility that was confirmed COVID 19 positive was Patient 2 on 11/8/2023. During a review of Patient 2’s Admission Record indicated that Patient 2 was initially admitted the facility on 05/01/2023 and readmitted on 11/13/2023, with diagnoses of primary generalized osteoporosis (an age-related disorder characterized by decreased bone mass and increase susceptibility to fractures). During a review of Patient 2’s History and Physical (H&P) dated 05/02/2023, the H&P indicated Patient 2 had the capacity to understand and make decisions. During a review of Patient 2’s Minimum Data Set (MDS; a standardized assessment and care planning screening tool) dated 08/08/2023, the MDS indicated Patient 2’s brief interview of mental status (BIMS; brief screener that aids in detecting cognitive impairment) score was 14 (a score of 13-15 indicated cognitive skills for daily decision making was intact). A review of Patient 2’s November Order Summary Report indicated an order for contact/ droplet isolation for COVID-19, with a start date of 11/13/23. A review of Patient 3’s Admission Record indicated that Patient 2 was admitted to the facility on 2/15/23 with diagnoses of Parkinson’s Disease (a movement disorder), diabetes (high blood sugar), and hypertension (high blood pressure). During a review of Patient 3’s H&P dated 02/15/2023 indicated Patient 3 did not have the capacity to understand and make decisions. During a review of Patient 3’s MDS, dated 08/21/2023 indicated Patient 3’s BIMS score was 7 (a score of 13-15 indicated cognitive skills for daily decision making was intact) indicating moderate impaired cognition. Patient 3 required extensive assistance with one-person physical assist with bed mobility, transfers, dressing, toilet use and hygiene. A review of Patient 3’s November Order Summary Report indicated an order for contact/ droplet isolation for COVID-19, with a start date of 11/14/23. A review of Patient 4’s Admission Record indicated that Patient 4 was admitted to the facility on 8/4/23 with diagnoses chronic obstructive pulmonary disorder (COPD, group of diseases that cause airflow blockage and breathing-related problems) and hypertension (high blood pressure). During a review of Patient 4’s H&P dated 08/5/2023 indicated Patient 4 had the capacity to understand and make decisions. During a review of Patient 4’s MDS, dated 08/21/2023 indicated Patient 4’s BIMS score was 10 (a score of 13-15 indicated cognitive skills for daily decision making was intact) indicating moderate impaired cognition. Patient 4 required assistance with bed mobility, transfers, dressing, toilet use and hygiene. During an interview on 11/21/2023 at 10:08 AM with Director of Nursing (DON), DON stated that their facility policy for reporting COVID-19 is for them to report to National Healthcare Safety Network (NHSN; a healthcare-associated infection tracking system) and the Research Electronic Data Capture (REDCap; an application that provides facilities a platform to report COVID-19 data and other information to the Department of Public Health). The DON stated the Assisting Infection Preventionist (IP2) was the one responsible for reporting. During an interview on 11/21/2023 at 3:18 PM with Public Health Nurse (PHN), PHN stated she was first notified on 11/13/2023 of the first COVID-19 positive patient, and that PHN was not aware of Patient 2 testing positive on 11/08/2023. During an interview on 11/21/2023 at 4:34 PM with the Director of Nursing (DON), and in the presence of the assisting infection preventionist (IP2), the DON stated Patient 2 was tested for COVID-19 based on transfer protocols on 11/8/23 and was confirmed positive. The DON stated it was not until Patient 3 and Patient 4 tested positive on 11/13/23 did the IP2 inform public health via REDCap. During an interview on 11/21/23 at 5:06 PM with the DON and IP2, the DON stated reporting to CDPH L&C was not done when Patient 2 was confirmed COVID positive or after identifying 13 (thirteen) cumulative COVID positive residents from 11/8/23 to 11/20/23. During an interview on 11/21/2023 at 5:49PM with the DON, the DON stated the facility considered one patient testing positive as an outbreak. The DON stated as soon as there was an outbreak, reporting to the California Department of Health Licensing and Certification District Office (CDPH L&C DO) was required. The DON stated she had not reported the Covid-19 case of Patient 2, and that IP 2 should have reported to CDPH L&C DO. During an interview on 11/21/2023 at 5:534 PM with IP 2, IP2 stated not reporting the Patient 2 positive COVI- 19 status to CDPH L&C DO. IP 2 stated that she was responsible for reporting positive COVID cases and was unaware IP2 had to report to CDPH L&C DO. During a concurrent interview and record review on 11/21/2023 at 5:54 PM with the DON, the facility’s policy and procedure (P&P) titled, Unusual Occurrences, dated 12/19/2022 was reviewed. The P&P indicated DON indicated outbreaks must be reported to CDPH L&C DO. The DON stated informing IP 2 to report the first positive COVID-19 case on 11/08/2023 and assumed IP 2 reported the outbreak to CDPH L&C DO. The DON also confirmed that per facility policy and procedure of, “Unusual Occurrences,” the outbreak should have been reported to CDPH L&C DO. During a review of the facility’s policy and procedure (P&P) titled, “Unusual Occurrences,” revised 12/19/2022, the P&P indicated that, “It is the policy of the facility that an unusual occurrence is reported to the Department of Public Health within 24 hours of occurrence,” for the facility to, “Contact the local L&C DO,” and that an unusual occurrence includes, “an epidemic outbreak of any disease.” During a review of the facility’s policy and procedure (P&P) titled, “Coronavirus Surveillance,” revised 12/19/2022, the P&P indicated, “the local health department will be notified of resident or staff with suspected or confirmed COVID-19.” During a review of, “Heritage Manor COVID 19 Mitigation Plan” (undated), the mitigation plan indicated that the “Facility will report any positive tests in accordance with current Local Health Department (LHD) and the California Department of Public Health (CDPH) guidance, but at a minimum the facility will contact the LHD and CDPH District Office, as well a document any positive cases on CDPH daily survey.” The facility failed to report a Coronavirus 2019 (COVID-19; an infectious disease) outbreak in the facility, for one of 11 sampled patients (Patient 2) within 24 hours of occurrence of the incident, to California Department of Public Health Licensing and Certification District Office. This failure had the potential to threaten the welfare, safety, or heath of the patients, personnel, or visitors due to the spread of the infectious disease. As a result, the California Department of Public Health Licensing and Certification District Office was not aware of the incident and could not conduct a timely on-site investigation to ensure the facility was taking proper precautions to ensure the welfare of the residents and staff during this outbreak. This violation had a direct relationship to the health, safety, and security of all residents.