Table: ltc_citation_narratives_2012_2017_data_file , facility_name like I*

A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z  *

facid	facility_name	penalty_number	class_assessed_initial	penalty_issue_date	eventid	narrative_length	narrative
060001076	INDEPENDENT OPTIONS, INC. CHRISTOPHER HOUSE	060010835	B	24-Jun-14	KU9K11	3909	T22 - 76907(a) Licensee - General Duties (a) The licensee shall comply with licensing, statutory and regulatory requirements and be responsible for the organization a, management, operation and control of the licensed facility. The delegation of any authority by a licensee shall not relieve the licensee of his/her responsibility. The above regulation was NOT MET as evidenced by: Based on observations and interview, the facility failed to provide a safe means of escape from the facility by locking the front screen door of the facility with a lock that required a key to unlock. The facility houses six individuals with intellectual disabilities who require supervision from staff. Two of the six clients require assistance from staff with activities of daily living.On 5/15/14 at approximately 1600 hours, an unannounced visit was made to the facility. The front door of the facility was open; however, the screen door was closed. The surveyor knocked at the door and a DCS (direct care staff) came to the door but was unable to let the surveyor in as the screen door had been locked from the inside with a key. The DCS had to call the house leader to bring the key to let the surveyor in. The surveyor asked why the door was locked and the DCS stated Client 1 elopes from the facility.Review of Client 1's clinical record showed the client was admitted to the facility on 2/10/14. The DCS stated Client 1 would try to leave the facility whenever he saw a van or bus. Client 1 had a behavior plan in place for "leaving the facility or going off on his own without permission when he is out in the community. He will make 3 to 4 attempts /day because he wants to go for a van ride." Documented in the client's 30 day review was the following: "______ (client name), will open and leave through front door of facility if he has opportunity. He will attempt to elope when sees bus, truck or van. Staff is to make sure front door is closed at all times or monitor when open." The surveyor informed the DCS the door cannot be locked by any means that takes more than one action to open the door when clients are present. Two clients and two DCS were present in the facility during this visit. The QIDP (qualified intellectual disabilities professional) was interviewed by telephone. She was made aware of the key locked screen door and was told that could not be done per NFPA (National Fire Prevention Authority) 101, Life Safety Code 2000 edition 7.2.1.5.4 K43, which requires "no door in any means of escape shall be locked against egress when the building is occupied." The QIDP stated she was aware and the door should not be locked. She also stated the door alarm would be used. On 5/16/14 at approximately 1545 hours, an unannounced visit was made to the facility. Again, the screen door was found to be locked from the inside with a key. At this time, there were three clients in the facility and one DCS. The QIDP was called and made aware of the above for a second time in as many days. On 6/2/14, another unannounced visit was made to the facility. The screen door was not locked this time. The QIDP was interviewed. A policy and procedure was asked regarding elopement and locking of the facility doors. Neither was able to be found by the QIDP. The facility's human rights committee meeting minutes were reviewed. The last documented meeting minutes was dated 2/26/14. Per a review of the minutes and interview with the QIDP, Client 1 was not reviewed at this meeting. The QIDP did state a HRC meeting was held in May 2014, but the minutes had not yet been typed up. The locking of the door by this means could cause a delay in exiting the facility in case of an emergency. Therefore, the facility failed to provide a means of escape by locking the screen door while clients were present in the facility. The above violation has a direct relationship to the health, safety or security of clients.
060002257	INDEPENDENT OPTIONS, INC. HARBOR VILLAGE VI	060011116	B	10-Nov-14	J1L811	10093	Welfare and Institutions Code, Section 4502(h). 4502 - Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) ? A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect.Client 5 was a 67 year old female, who was admitted to the facility on 7/26/05. She had diagnoses that included profound intellectual disability (a developmental disability with IQ scores under 20-25 and need a high level of structure and supervision) and stereotypic movement disorder (a condition in which a person makes repetitive, purposeless movements [such as hand waving, body rocking, or head banging]. The movements interfere with normal activity or have the potential to cause bodily harm). Client 5 had behaviors of physical aggression and self-injurious behavior. Client 1 was a 55 year old nonverbal female, who was admitted to the facility on 10/26/04. She had diagnoses that included profound intellectual disability and Down syndrome (a genetic disorder caused by the presence of all or part of a third copy of chromosome 21. It is typically associated with physical growth delays and characteristic facial features). On 9/9/14 at 0750 hours, during a recertification survey visit, Client 1 was observed sitting on a chair in the living room. Suddenly, Client 1 started crying. The direct care staff (DCS 1) and the surveyor went to the living room where Client 5 was observed pulling Client 1's hair on both sides of her head. DCS 1 told Client 5 to stop. DCS 1 was observed prying Client 5's fingers off of Client 1's hair. Client 5 stopped pulling Client 1's hair; however, Client 5 started pulling her own hair on both sides. DCS 1 told Client 5 to stop. Client 5 stopped pulling her hair and went to her room. On 9/9/14 at 0755 hours, an interview with DCS 1 was conducted. When asked what she had done when Client 5 had behaviors, DCS 1 stated she calmed Client 5 by talking to her and offering her water. DCS 1 stated she also sat and talked with Client 5 and took her for a walk. DCS 1 stated Client 5?s behavior could change, one minute Client 5 was good and the next minute she was not. DCS 1 stated Client 5 would be good for a while and then she would snap. She also stated Client 5 had a lot of behaviors lately, and had behaviors every morning. DCS 1 stated this morning Client 5 flipped over a table in the living room. When DCS 1 was asked if she was trained to deal with Client 5's behaviors, DCS 1 stated she did what the other staff did. Also, she took a class in management of assaultive behavior when she started working at the facility. DCS 1 stated Client 1 was afraid of Client 5 and urinated on herself this morning when Client 5 pulled her hair. DCS 1 stated she had never seen a behavior plan for Client 5, and no one has trained her on how to deal with Client 5's behaviors. On 9/9/14 at 0755 hours, Client 5 went to her bedroom she shared with Client 4. Client 5 was observed to throw everything off the top of the dresser, then pushed her dresser into the middle of her room and flipped it over. She then pulled her night stand into the middle of the room and flipped it over. Client 5 then pulled the vertical blinds off the bedroom window. While Client 5 was doing all these, she was also yelling unintelligible.Then, Client 5 sat on her bed and started pulling her hair. DCS 1 was observed saying, "No! No! No! Stop! Stop pulling your hair! Let's go for a walk." Client 5 stopped and DCS 1 took Client 5 for a walk.On 9/9/14 at 0800 hours, DCS 1 and Client 5 returned from their walk.On 9/9/14 at 0807 hours, DCS 1 stated Client 5 attacked her when they went for a walk,DCS 1 stated Client 5 tried to hit her and pulled her hair so she brought her back from their walk. On 9/9/14 at 0810 hours, an interview with DCS 1 was conducted. DCS 1 stated Client 5 had thrown over the coffee table, thrown furniture and pulled hair. DCS 1 stated Clients 1 and 5 went to the day program together and they sat in the back seat of the job coach's car while traveling to various activities in the community during the day, five days a week. DCS 1 stated Client 1 was the target of Client 5's aggression. DCS 1 verified she had not received training to specifically deal with Client 5's behaviors. DCS 1 stated Client 1 was nonverbal and was afraid of Client 5.On 9/9/14 at 0830 hours, an interview with DCS 3 was conducted. DCS 3 stated Client 5 pulled her own hair, banged her head and threw furniture. The DCS stated she monitored Client 5 when she had behaviors, and yesterday (9/8/14) Client 5 did not go to her day program because she had a behavior when the job coach came to pick her up. DCS 3 stated she had not received training on how to deal with Client 5's behaviors. DCS 3 stated Client 5 never attacked her, but she had attacked the House Leader.On 9/9/14 at 0835 hours, an interview with Client 5's job coach was conducted. The job coach stated when she came to pick up Clients 1 and 5 for day program yesterday (9/8/14), they were all walking from the facility towards the car when Client 5 grabbed Client 1, pulled her by her hair, pushed her to the ground, and kicked her. The job coach stated when she tried to help separate Clients 1 and 5, the client (Client 5) pinched the job coach leaving a bruise on her arm. The job coach stated she called out for facility staff's assistance and DCS 2 and 4 came to help. The job coach stated Client 5 had attacked Client 1 in the back seat of the car used daily for the day program. The job coach stated she had notified the facility staff of Client 5's behaviors when she brought Client 5 home from day program.On 9/9/14 at 0840 hours, an interview with the Qualified Intellectual Disabilities Professional (QIDP) was conducted. The QIDP stated she came to the facility every day to check on Client 5. She said she was aware of the incident that happened yesterday (9/8/14) between Client 5, Client 1 and the job coach. The QIDP stated she did an internal incident/investigation report but did not send an incident report to California Department of Public Health (CDPH). She further stated Client 1 was the only person Client 5 picked on. The QIDP stated she provided staff training on how to manage Client 5's behaviors. When asked where she documented the training, the QIDP verified she had not documented the training. The QIDP stated the psychiatrist (a medical doctor who specializes in the diagnosis and treatment of mental disorders) increased Client 5's medication in late June 2014, and a psychiatrist visited the facility monthly to evaluate the clients but no other psychiatry appointment was made for Client 5 as of now.On 9/9/14 at 1600 hours, during an interview, the House Leader stated she knew there was a problem with Client 5. The House Leader stated she had seen Client 5 pulled Client 1's hair but usually had let go and had apologized after. The House Leader stated she had seen Client 5 threw things but would not verify if Client 5 had ever hurt her. Review of the DCS notes showed the following documentation of behaviors manifested by Client 5 towards Client 1:In May 2014: - Three incidents of pulling Client 1's hair. - One incident of biting Client 1's hand. - One incident of slapping Client 1. In June 2014: - One incident of pulling Client 1's hair. In July 2014: - None. In August 2014: - None. In September 2014: - Three incidents of pulling Client 1's hair. - One incident of scratching Client 1 and pushing her to the ground. - One incident of throwing Client 1 to the ground and kicking her. Review of the facility?s policy (no date) for Prevention of Abuse, Neglect and Mistreatment showed the following: - The system to prevent abuse/neglect/mistreatment, identifies events and occurrences as well as regulatory definitions that constitute abuse/neglect/mistreatment and the related reporting procedures. - The facility Administrator or other management personnel will immediately initiate an investigation of any alleged incident of abuse. - A thorough report will be completed by the management staff which will include the action taken to protect, respond, prevent, and report.- All incidents of unusual occurrence which occurs in a Department of Public Health licensed facility will be reported to the local Licensing and Certification office by telephone within 24 hours. - Any incident of substantiated abuse will be reported to the local Department of Public Health Licensing and Certification immediately. - Client to client abuse is the willful physical motion or action, (hitting, slapping, punching, kicking, pinching, etc.) from one individual receiving services to another individual receiving services, by which bodily harm or trauma occurs not requiring emergency medical treatment and by which a pattern has been established and no interventions to protect the individual subjected to the abuse have been established by the facility. Even though facility staff knew Client 5 was physically and psychologically abusing Client 1, no plan was developed to stop the abuse and prevent Client 5 from repeating the abusive attacks to Client 1, an individual who cannot protect herself from the attack. The facility?s failure to ensure Client 1 was not subjected to physical and psychological abuse from Client 5 resulted to Client 1 being subjected to repeated hair pulling, pushing, hitting, slapping, and kicking as a result of Client 5's aggressive behavior. This violation had a direct relationship to the health, safety, or security of the client.
060000934	INDEPENDENT OPTIONS, INC. HARBOR VILLAGE II	060012968	B	14-Feb-17	Z7KT11	16955	W331 - The facility must provide clients with nursing services in accordance with their needs. On 1/17/17, the facility reported an incident to the California Department of Public Health (CDPH) alleging Client 1 had fallen on his right knee and sustained a fracture to the right hip on "12/16/17". On 1/19/17 at 1500 hours, an unannounced visit was conducted at the facility to investigate the above Entity Reported Incident (ERI). On 1/19/17 at 1545 hours, Direct Care Staff (DCS) 1 was interviewed. When asked if she was at the facility the day Client 1 came home from the day program on 12/16/16, DCS 1 stated yes. When asked if Client 1 was walking when he came back from the day program on 12/16/16, DCS 1 stated Client 1 did not want to walk; he was put in a wheelchair and had a small reddened area on his right knee. When asked if the Registered Nurse (RN) assessed Client 1 on 12/16/16, DCS 1 stated the RN was on vacation or had already left for the day and the Qualified Intellectual Disability Professional (QIDP) assessed Client 1. When asked if the QIDP found anything wrong, DCS 1 stated no. When asked if Client 1 was taken to the hospital or urgent care to be evaluated on 12/16/16, DCS 1 stated no. DCS 1 stated Client 1 had stated he was afraid of walking, but she stated Client 1 always said that. DCS 1 stated Client 1's right leg was shorter than his left leg. When asked if she was at the facility when the RN came to assess Client 1, DCS 1 stated no. When asked if the DCS documented the information regarding Client 1's pain or how Client 1 was doing, DCS 1 stated no. The DCS stated she only wrote what kind of care she provided for the clients, like changing diapers and giving showers. When asked what instructions were given to her regarding the care of Client 1, DCS 1 stated she tried to make sure the client was comfortable. DCS 1 stated Client 1 did not want to move his leg. DCS 1 stated, "I think the nurse was thinking there maybe something wrong with him that is when he was taken to get x-rayed again. The first time they only x-rayed the bottom part (used her hand to indicate knee down), they did not x-ray up here (used her hand and ran her hand from hip area down to thigh area)." On 1/19/17 at 1555 hours, DCS 2 was interviewed. DCS 2 stated she was a floater and worked wherever she was needed. DCS 2 stated when she came back to work at the facility, Client 1 had his fall incident a week or so before. DCS 2 stated when they needed to take Client 1 to the restroom, it took several prompts to get him to be up. Client 1 would say no or "help." DCS 2 stated Client 1 always said that. When asked if Client 1 was on bed rest, DCS 2 stated Client 1 was already in the wheelchair when she came to work, so he would not have to move too much. DCS 2 stated in the morning, the DCS had gotten Client 1 up and placed him in the wheelchair. On 1/19/17 at 1620 hours, both DCS 1 and 2 stated when Client 1 stood up, he placed all his weight on his left leg and not on his right leg. Both DCS stated Client 1 did not say he was in pain. DCS 1 stated Client 1 was able to make his needs known and very smart. On 1/19/17, review of Client 1's clinical record was initiated. Client 1 is a 70 year old male, residing at the facility with diagnoses including moderate intellectual disability (a person with an Intelligence Quotient score of 36 to 49) and cerebral palsy (a condition marked by impaired muscle coordination) with spastic hemiplegia (increased tendon reflexes and uncontrolled contraction) on his right side. On 1/19/17 at 1625 hours, the Regional Director and RN arrived at the facility. When asked for the documentation to show the RN assessed Client 1 when he fell on 12/16/16, the RN stated the day program staff stated they were going to do a report. The RN found some electronic documentation dated 12/30/16, and stated it was her Annual Health Care Report. The RN was asked for a copy of the report. On 1/23/17, the documents were provided by the RN. Review of the documents provided by the RN showed the following: - A General Event Reports was completed by the RN on 12/20/16 at 0830 hours, four days after the fall incident. Documentation showed the RN assessed the client on 12/19/16 at 0800 hours. The RN documented while Client 1 was walking with his job coach outside of day program to come home on 12/16/16, the client lost his balance and fell landing on his right knee; no obvious or outward injury was noticed by staff; three days later, Client 1 complained of pain in his right knee, lower leg, right ankle, and right foot; Client 1 had difficulty bearing weight; no swelling was noted, only pain upon palpitation; x-rays were ordered of all of the above areas which showed no fractures; the Primary Care Physician (PCP) was notified and ice, leg rest, Tylenol (pain medication), and Advil (pain medication) were ordered and implemented; Client 1 was to stay home from day program until he was able to bear weight on his leg comfortably; and the RN would reassess on a frequent basis. Further review of the General Event Reports showed the RN had instructed the DCS to apply ice, provide leg rest, give pain medications as needed, and use the wheelchair for all activities. The DCS was also instructed to only allow weight bearing when pivoting from the wheelchair to toilet. Documentation showed the PCP was notified on 12/19/16 (three days after the fall incident), and the client's family was notified on 12/20/16 (four days after the fall incident). - The Physical Therapy Update dated 12/28/16, showed Client 1 was seen by the Physical Therapist (PT) and RN today to address concerns regarding standing and walking. The PT documented Client 1 was not standing or walking and using a loaner wheelchair; Client 1 refused to try to stand or walk and pointed to his knee and verbally indicated that it hurt; Client 1 required a two person lift assistance to transfer from the wheelchair to and from the bed, couch or toilet; and even with two person assistance, Client 1 was observed to partially bear weight on his left leg using a severe crouched trunk and hip/knee flexion position and did not bear weight on his right leg, which made pivot during transfers exceptionally difficult. The PT documented slight bruising was noted on Client 1's right knee with no heat palpated and no edema noted; the importance to encourage Client 1 to bear weight to help maintain knee strength and mobility as immobility can increase knee adhesion and decrease future mobility; stand-pivot transfers required maximum assist of two person and it was still awkward as the client was a tall weighty individual and cannot be totally lifted by two staff. The PT also documented if Client 1 did not start standing for transfers and bearing weight on his right leg, future options would need to be considered, such as a mechanical lift. - On 12/30/16, two weeks after Client 1's fall incident, the RN completed an Annual Health Care Report. The RN documented since Client 1's fall, he had refused to stand or ambulate and became a total assist with toileting, hygiene, meal preparation and all transfers. The PT was consulted and found similar results as the RN; for example, no physical reason for his inability to stand or ambulate. The RN documented DCS were doing diaper changes in bed, provided bed baths, and encouraged Client 1 to do all of this on his own as before his fall. The RN also documented they would give it two to three more weeks, then would reassess the client's abilities. Further review of the Annual Health Care Report showed Client 1 denied pain but appeared to be fearful of being upright; a wheelchair and walker have been provided; Client 1 refused to use the walker but preferred to be sitting in the wheelchair at all times; the PT determined Client 1 was either too fearful to walk or had significant pain or both; the DCS were given leg exercises to perform daily with Client 1 as frequently as possible; the staff encouraged Client 1 to stand and ambulate; and the accommodations were made for a shower chair, special diapers, lifting sheets, gait belt, and knee brace. - A General Event Reports was completed by the RN on 1/13/17 at 1243 hours. The RN documented Client 1 continued to refuse to bear weight on his right leg and x-rays of the non-painful areas of his leg were taken, which included the right hip and femur. The x-rays showed a fracture of the femoral neck. Documentation showed the PCP was notified and Client 1 was taken to the Emergency Room (ER) for evaluation. Further review of the documents provided by the RN on 1/23/17, showed no documented evidence the RN had assessed Client 1 immediately after the fall incident on 12/16/16. Documentation showed the RN assessed Client 1 on 12/19/16, three days after the fall incident. After the PT documented Client 1 was seen by the PT with the RN on 12/28/16, the RN completed an Annual Health Care Report on 12/30/16. However, there was no documented evidence the RN had reassessed Client 1 after 12/30/16, even though the client continued to refuse to stand and ambulate and had become dependent on staff with his activities of daily living skills. On 1/13/17, an x-ray of Client 1's right hip was ordered and showed a fractured right femoral neck. Client 1 was sent to an acute hospital's ER. On 1/14/17, Client 1 had a surgery to repair the fracture right hip. On 1/23/17 at 1445 hours, DCS 1 was interviewed. When asked if the RN was at the facility the day Client 1 fell at the day program to assess him, DCS 1 stated no, and the QIDP was the one who checked Client 1. When asked if she was given an in-service on how to care for Client 1, DCS 1 stated the PT came and showed the DCS how to do the range of motion exercises to help Client 1 get his strength back. The DCS stated the RN and PT checked if Client 1 was in pain. Client 1 was afraid to walk. Before he got hurt, he walked around the house with no problem. When asked if Client 1 was given pain medications for his right leg, DCS 1 stated yes, but it was because he was in the wheelchair. DCS 1 stated when they asked Client 1 if he wanted to get up and stand to stretch his legs he would say, "no, I am afraid." When asked if Client 1 was on bedrest most of the time, DCS 1 stated Client 1 got up in the morning and was in the wheelchair when DCS 1 got to work at 1400 hours, but sometimes he was in bed. When asked if they kept a record of when Client 1 was up in his wheelchair and when he was on bedrest, DCS 1 stated, no they did not document. On 1/23/17 at 1505 hours, DCS 3 was interviewed. DCS 3 stated she was a new employee at the facility. DCS 3 stated she worked that Sunday (12/18/16) after Client 1 fell. When asked if she provided care to Client 1, DCS 3 stated she assisted with taking Client 1 to the restroom and when putting him to bed. When asked if Client 1 bear weight on his right leg when she assisted the client to the restroom, DCS 3 stated, "no, he tried not to put weight on his right leg and we tried to help him to not put weight on his right leg." When asked if Client 1 seemed to be in any pain, DCS 3 stated no just out of breath. On 1/23/17 at 1520 hours, the RN, QIDP, and Regional Director were interviewed. When asked if the RN was at the facility the day Client 1 fell at the day program, the RN stated she thought she might have been at the facility or maybe the next day. The RN then stated it was the next day after Client 1 fell. When asked what hours she worked, the RN stated Monday through Friday from 0700 hours to 1530 hours. The RN stated the day program did not report the incident so she called the day program. The day program staff stated Client 1 fell and complained of pain to his knee. The RN stated when she saw Client 1 he complained of pain to his right knee, ankle, tibia, and fibula. The RN stated she got an order for Client 1's x-rays the same day. The RN stated she got the results of the x-rays back the same day and they were negative. The RN stated she placed the client on bedrest; she contacted the PCP and the PCP agreed also to put him on bedrest. The RN continued by stating Client 1 was still not bearing weight on his right leg after three weeks. The RN stated she did an assessment and there were no signs of shortening of the leg or rotation of the leg, but the RN decided to get an x-ray of the hip. Client 1 went by ambulance. The results came back with a fractured right femoral neck. When asked why Client 1 was not taken to the ER to get checked out after the incident, the RN stated the facility had a contracted company that would go to the home to do the x-rays, a PT, and a nurse all going to the home. The RN was informed of the concern regarding the RN's untimely assessments of Client 1 since the client had fallen on 12/16/16, and the RN's assessment was done on 12/19/16, three days later. The RN stated she did not remember when it happened. The RN was also informed of the concern regarding the lack of assessment notes until 12/20/16, an annual note dated 12/30/16, and the last RN note done 1/13/17, after the x-ray results showed Client 1 had sustained a fracture. When asked if Client 1 had a history of falls, the RN stated no, but Client 1 had spastic paralysis on his right side due to cerebral palsy. The Regional Director added Client 1 had no history of unsteady gait. When asked if the RN developed a care plan for Client 1's injury, the RN stated no. On 1/23/17 at 1525 hours, the QIDP was asked if he had gotten an incident report from the day program. The QIDP stated he did get an incident report from the day program. When asked if he did an assessment on Client 1's right leg, the QIDP stated the next morning after the fall incident he looked at Client 1's leg and did not see anything. The RN, QIDP, and Regional Director were informed of the concern regarding the QIDP doing an assessment on Client 1. The QIDP stated he only did it to make sure Client 1 was okay. On 1/23/17 at 1550 hours, the QIDP and RN's job descriptions were requested from the QIDP and Regional Director. Review of the facility's job description for the RN (no date) showed the following: - The RN's major responsibility is the development, implementation, and coordination of health care services. - Develop, implement, and monitor a written plan for each client to provide for nursing services as part of the Individual Service Plan (ISP), consistent with diagnostic therapeutic, and medication regimens. - Notify the physician immediately of any sudden and or marked adverse change in signs and symptoms or behavior exhibited by a client. - Monitor the health care needs of the clients through visits to the clients, review of progress notes and telephone reports from the staff. Establish temporary objectives and plans for transient illness and injuries. - Monitor staff performance as it relates to health care issues and instruct the staff about changes in the ISP or their duties if a temporary problem is established. - Participate in ongoing staff training as it relates to the nursing/medical problems or needs of the clients. On 1/24/16 at 1325 hours, the electronic Medication Administration Record (MAR) for Client 1 was requested from the RN. Review of the MAR showed Client 1 was given Tylenol 325 milligrams (mg) per tablet, two tablets for a total of 650 mg, for pain on the following days: - 12/27/16 at 2005 hours, - 12/28/16 at 1100 hours, - 12/28/16 at 1800 hours, and - 1/2/17 at 1830 hours. On 1/26/17 at 1310 hours, the Regional Director, QIDP, and RN were informed of the concern regarding the RN not assessing Client 1 immediately after the client had a fall incident on 12/16/16, and failure of the RN to monitor Client 1 when he continued to refuse to ambulate and became dependent on staff to provide activities that the client was able to perform independently prior to the fall incident. The facility failed to ensure Client 1 was assessed by the RN in a timely manner after the client sustained a fall at the day program. The RN failed to provide an ongoing assessment and monitoring of Client 1's injured right leg. In addition, the RN failed to develop a care plan to address Client 1's injury and provide instruction to the staff on how to care for the client's injury. These failures resulted in Client 1 not being allowed to remain on bedrest, was subjected to having to get out of bed daily, and transferred in and out of his wheelchair with his injured right leg for almost one month until he was diagnosed with a fractured right hip femoral neck. Consequently, Client 1 did not receive the appropriate medical intervention for almost one month after the fall incident. The above violations, either jointly, separately, or any combination had a direct or immediate relation to Client 1's health, safety, or security.
060000971	INDEPENDENT OPTIONS, INC. HARBOR VILLAGE III	060013374	B	26-Jul-17	EOME11	8697	W331 - The facility must provide clients with nursing services in accordance with their needs. A complaint was received by the California Department of Public Health, Licensing & Certification Program on 4/28/17, related to a client who was left in an acute care hospital's Emergency Department (ED) alone, screaming in pain, and diagnosed with a fracture to the right leg. A telephone interview was conducted with Client 1's family member on 5/5/17 at 0930 hours. Client 1's family member stated Client 1 had a seizure two weeks ago, and since then, Client 1 was unable to ambulate. Client 1's family member stated Client 1 was transferred to the acute care hospital on XXXXXXX17, and diagnosed with a right leg fracture which according the physician was about two weeks old. Client 1's family member further stated Client 1 had passed away in the hospital on XXXXXXX17. On 5/5/17 at 1355 hours, an unannounced visit was conducted at the facility to investigate the above complaint. Clinical record review for Client 1 was initiated on 5/5/17. Client 1 was admitted to the facility on XXXXXXX03, with diagnoses including severe intellectual disability (a person with an Intelligence Quotient score of 20 to 35) and Down syndrome (a congenital disorder causing intellectual impairment and physical abnormalities including short stature and a broad facial profile.) Client 1 was ambulatory but nonverbal. The General Event Report dated 4/12/17, showed on 4/11/17 at 0700 hours, Client 1 just had a blood draw when he lost consciousness, started shaking, and became unresponsive. The documentation showed a Direct Care Staff (DCS) called the Registered Nurse (RN) who instructed the DCS to call 911. Review of the RN's note dated 4/13/17 at 1214 hours, showed while Client 1 was having a blood draw at the facility; Client 1 had a seizure and was transferred to an acute care hospital. The nurse's note also showed Client 1 was discharged to the facility after six hours. The RN also documented Client 1 refused to walk the day after (XXXXXXX17) the client returned from the acute care hospital. Review of the Cardiologist's progress note dated 4/14/17, showed Client 1 was at the office for follow-up for a complete atrioventricular septal defect (a congenital heart disease.) The documentation showed the DCS informed the Cardiologist, since returning from the hospital, Client 1 had not been getting up and walking around as he usually did. The physician's note also showed when they put Client 1 in a chair; he had difficulty maintaining a seating position without support. The documentation showed when the staff changed Client 1's incontinence brief, the client would grunt a lot, and the staff was not sure what this signified. Review of the RN's note dated 4/17/17 at 1614 hours, showed the Cardiologist called the RN on 4/14/17 to report Client 1's heart appears to be stable. The Cardiologist ordered to let Client 1 rest for several days, then reassess him. Review of the RN's note dated 4/19/17 at 1536 hours, showed whenever Client 1 had a change in position from a lying to sitting position; Client 1 moved his legs vigorously. The RN note also showed when the staff attempted to assist Client 1 to ambulate, Client 1 refused. Review of the RN's note dated 4/20/17 at 1324 hours, showed Client 1 was unable to walk and was very somnolent (drowsy). Review of the RN's notes dated 4/21/17 at 1123 hours, showed Client 1's vital signs were normal; however, Client 1 was still unable to or refused to walk. Review of the RN's notes dated 4/26/17 at 1402 hours, showed Client 1's condition remained stable and had no peripheral edema. However, the RN note dated 4/26/17 at 1411 hours (nine minutes after) showed Client 1 had "swelling and tightness to his right lower extremity" and the RN was unable to feel a pedal pulse. The documentation showed Client 1 was transferred to an acute care hospital's ED via facility van. On 5/5/17 at 1355 hours, an interview with the House Leader was conducted. The House Leader stated she was at the facility on 4/26/17, caring for Client 1 when she noticed his leg was swollen. The House Leader further stated she called RN 2. The House Leader stated when RN 2 arrived at the facility; RN 2 looked at Client 1's swollen leg and instructed the staff to take Client 1 to an acute care hospital. Client 1 was transferred by the House Leader, DCS 1, and Client 2. The House Leader further stated the ED nurse asked the House Leader if she knew Client 1 had a broken hip, and she responded no. On 5/8/17 at 1209 hours, an interview was conducted with DCS 1. DCS 1 stated on 4/11/17, DCS 1 observed Client 1 sitting and then, laying on the floor with his eyes staring up and moaning a little bit, however, breathing. DCS 1 and the House Leader decided to call 911. On 5/9/17 at 1730 hours, an interview with DCS 3 was conducted. DCS 3 stated after Client 1 came back from the hospital on 4/11/17, Client 1 had not walked since that day. DCS 3 further stated Client 1 had a big purple bruise to his right hip. On 5/9/17 at 1740 hours, an interview with DCS 2 was conducted. DCS 2 stated when Client 1 came home from the hospital on XXXXXXX17, Client 1 could not walk. DCS 2 further stated Client 1 had a large bruise on his right upper leg. DCS 2 stated she called RN 2 to report the bruise and RN 2 stated she would arrange for a doctor's appointment for Client 1. DCS 2 stated she documented the incident on the Shift Communication form. However, DCS 2 stated when DCS 2 left the facility at 2200 hours; the RN had not seen Client 1. Further review of the clinical record showed a Shift Communication form dated 4/11/17. The documentation showed Client 1 came back to the facility at 1745 hours with a big bruise on the right leg. The documentation also showed DCS 2 called RN 2 to notify her. However, there was no documented evidence the RN had assessed Client 1 after Client 1 was discharged from the hospital to address Client 1's inability to walk after the seizure and the big bruise reported by the DCS. On 5/9/17 at 1750 hours, an interview with Client 3 was conducted. Client 3 stated Client 1 could not walk after his seizure on 4/11/17. Client 3 further stated he had observed the staff putting Client 1 on a wheelchair and feeding him. Client 3 stated he had observed Client 1 trying to stand up once, but Client 1 could not stand up. On 6/7/17 at 0800 hours, an interview with the House Leader was conducted. The House Leader acknowledged on 4/11/17, DCS 2 noticed a large bruise on Client 1's right hip, documented on a Shift Communication form, and called RN 2. The House Leader stated when she left the facility a couple of hours later, the RN had not seen Client 1. On 6/7/17 at 0900 hours, an interview with RN 2 was conducted. RN 2 was asked if she had assessed Client 1 after the DCS reported Client 1 had a large bruise on his right hip on 4/11/17. RN 2 stated she "thinks" she did; however, RN 2 acknowledged there was no documentation of any RN assessment on 4/11/17. When asked if they investigated the cause of the large bruise on Client 1's right hip and the decline in ambulatory status, RN 2 acknowledged there was none. When asked if she developed written care plans related to Client 1's new problems and changes in condition, RN 2 acknowledged there was none. During a later interview with RN 2 on 6/7/17 1100 hours, RN 2 was asked if she conducted an in-service training for staff on how to care for Client 1 after his change of condition from being ambulatory to nonambulatory. RN 2 replied she did, however; acknowledged there was no documented evidence of an in-service training. On 6/12/17 at 1530 hours, a telephone interview with DCS 2 was conducted. DCS 2 stated RN 2 came to see Client 1 on 4/17/17. DCS 2 further stated RN 2 asked DCS 2 to pull back the covers from Client 1 to look at Client 1's right lower leg. DCS 2 stated she asked RN 2 why Client 1 could not walk and RN 2 replied she did not know. The facility failed to ensure the RN conducted a thorough assessment of Client 1 to address the large bruise to the client's right upper leg. The RN failed to reassess Client 1 as per the physician's instruction, when Client 1 had exhibited manifestation of pain and had a decline in his ambulatory status. These failures resulted in Client 1 not receiving care and treatment to address pain and decline in his ambulatory status. The above violations, either jointly, separately, or any combination had a direct or immediate relation to patient health, safety, or security.
060001078	INDEPENDENT OPTIONS, INC. MARK LANE I	060013448	A	23-Aug-17	YLR511	16146	On 6/5/17, a complaint was received by the California Department of Public Health, Licensing and Certification Program (CDPH, L&C) regarding Client 6 being physically assaulted by Clients 1 and 4 on 5/14/17 and 12/24/16 respectively. The complainant stated the facility's staffing was inadequate to supervise the clients and only one staff member was at the facility with five to six clients on the weekends. On 6/6/17 at 0710 hours, an unannounced visit was made to the facility to investigate the complaint. The facility is a licensed Intermediate Care Facility for Developmentally Disabled/Habilitative (ICF/DD-H) for six clients. At the time of the complaint investigation, the facility had a census of five clients (Clients 1, 2, 3, 4, and 5). One client (Client 6) was removed from the facility on XXXXXXX17, and formally discharged on XXXXXXX 17. Client 1 had diagnoses including mild intellectual disability, anxiety disorder, intermittent explosive disorder, and depression. Client 1 had a behavior plan for noncompliance. On 5/16/17, a new behavior plan for physical aggression was started for Client 1. Client 2 had diagnoses including mild intellectual disability, depression, and pervasive developmental disorder. Client 2 had behavior plans for physical aggression, verbal aggression, and property destruction. Client 3 had diagnoses including mild intellectual disability, impulse control disorder, and bipolar disorder. Client 3 had a behavior plan for temper outbursts. Client 4 had diagnoses including moderate intellectual disability, depression, disruptive behavior disorder, and schizoaffective disorder. Client 4 had behavior plans for temper outbursts and physical aggression. Client 5 had diagnoses including moderate intellectual disability, attention deficit disorder, and autism. The discharged client (Client 6) had diagnoses including moderate intellectual disability, attention deficit disorder, autism, and generalized anxiety. Client 6 had behavior plans for temper outbursts, physical aggression, and property destruction. a. On 6/6/17, review of the facility's General Event Reports (GER) was conducted. The following was identified: - Review of the GER dated 6/28/16, showed Client 1 started a physical fight with Client 2. - Review of an additional GER dated 6/28/16, showed Client 2 sustained a small cut on his right eyebrow and another cut on the left side of his face on the left side of his left eyebrow as a result of the physical altercation with Client 1. - Review of the GER dated 7/27/16, showed Client 4 got into a physical altercation with another client (Client 2) and Client 4 sustained a scratch on the lower right side of his lip. - Review of the GER dated 5/14/17, showed Client 1 punched Client 6 in the face. - Review of an additional GER dated 5/14/17, showed Client 6 sustained a 1 and 1/2 inch laceration on his forehead and a small scratch on the bridge of his nose as a result of Client 1 punching him in the face. During an interview with Client 1 on 6/6/17 at 0722 hours, Client 1 stated he had punched Client 6 in the nose, hit Client 2 in the face and broke his glasses, and hit Client 4 on the top of his head. During an interview with Client 2 on 6/6/17 at 0730 hours, Client 2 stated Client 4 had ripped his (Client 2) T-shirt that he was wearing a long time ago. When Client 2 was asked if Client 1 had hit him and broke his glasses as stated by Client 1, Client 2 verified Client 1 had hit him in the head once, a long time ago, with a closed hand and it gave him a headache and broke his glasses. During an interview with Client 4 on 6/6/17 at 0745 hours, Client 4 verified Client 1 had hit him on the head. During an additional interview with Client 2 on 6/6/17 at 0755 hours, Client 2 stated that on one occasion, when Client 5 had entered Client 4's bedroom, Client 4 hit Client 5 in the back of the head. On 6/6/17 at 1055 hours, an interview was conducted with the Registered Nurse (RN). When the RN was asked if Client 1 had ever hit another client prior to the incident on 5/14/17, she stated not to her knowledge. The RN stated Client 1 had gotten irritated and started an argument with another client when that other client had touched Client 1's stuff, but he had not hit anyone before. However, review of the GER dated 6/28/16, showed Client 1 started a physical fight with Client 2 resulting in Client 2 sustaining a small cut on his right eyebrow and another cut on the left side of his face on the left side of his left eyebrow. When the RN was asked if anyone else had hit Client 6 prior to the incident on 5/14/17, she stated she did not think so. The RN stated most of the clients did not know what they were doing so she would not call it abuse because of their level of functioning. The RN added if the client knew what he did and one client hit another client she would classify it as assault and not abuse. If the hitting was targeted and repeated, the RN stated she would identify that as abuse. On 6/6/17 at 1146 hours, an interview was conducted with the Qualified Intellectual Disabilities Professional (QIDP). The QIDP stated the incident on 5/14/17, was the first incident in which Client 1 hit another client so she notified the behavior consultant and requested a behavior plan for physical aggression be implemented. The QIDP stated Client 1 had been in fights before, but had never thrown the first punch. However, review of the GER dated 6/28/16, showed Client 1 started a physical fight with Client 2 on 6/28/16. When the QIDP was asked if she completed a report regarding the incident between Clients 1 and 6 on 5/14/17, she stated she did not. When the QIDP was asked if she had interviewed the other clients, she stated she did, but did not document the interviews. When the QIDP was asked what constituted physical abuse, the QIDP stated touching, pinching, pushing, pulling, hitting, scratching, and throwing items at others. However, the QIDP stated the incident on 5/14/17, was just an altercation between two clients. On 6/6/17, an email was received from Client 6's conservator which included a photograph reportedly taken on 12/24/16. The photograph showed several scratches and cuts to Client 6's right periorbital area (the area around the eye consisting of the eyelids and surrounding area), glabella (the skin between the eyebrows and above the nose), nose, and right upper lip. The email showed on 12/24/16, the conservator arrived at the facility to pick up Client 6 for a home visit and observed the injuries to the client's face. When he observed the injuries, he asked Direct Care Staff (DCS) 3 what had happened to Client 6. DCS 3 was unable to explain how Client 6 sustained his injuries. The conservator took a photograph of Client 6's injuries and emailed it to the QIDP and RN requesting for information on how Client 6 sustained his injuries. On 12/26/16, the QIDP called the conservator and informed him Clients 4 and 6 had a physical altercation in which Client 4 had jumped on Client 6 resulting in the injuries. Review of the GERs, Clinician Reports, Human Rights Committee(HRC) meeting minutes, psychiatrist's progress notes, and documentation received from Client 6's conservator showed the following were the documentation of physically abusive behaviors manifested by Clients 1, 2, and 4, directed towards staff and Clients 1, 2, 4, 5, and 6: In June 2016: - One incident of Clients 1 and 2 hitting each other in the face on 6/28/16. In July 2016: - One incident of Client 2 hitting Client 4 in the face on 7/27/16. - Client 4 had one physical altercation with Client 2. In August 2016: - Client 4 had one episode of physical aggression directed towards an unidentified client. In October 2016: - Client 4 had two episodes of hitting an unidentified staff in the head. In December 2016: - Client 4 had one episode of punching Client 6 in the face on 12/23/16. In January 2017: - Client 2 had one incident of pushing DCS 5 down on the floor on 1/24/17. In February 2017: - Client 4 had one episode of hitting Client 5 in the arm on 2/28/17. - Client 4 had one episode of physical aggression towards Client 6. In May 2017: - Client 1 had one episode of punching Client 6 in the face on 5/14/17. On 6/14/17 at 1035 hours, an interview was conducted with the QIDP. When the QIDP was shown the photograph received from Client 6's conservator, she stated she recalled the incident between Clients 4 and 6 that had happened on 12/23/16. The QIDP verified Client 4 had punched Client 6 in the face and caused the injuries shown in the photograph. According to the Centers for Medicare and Medicaid Services (CMS), abuse refers to the ill-treatment, violation, revilement (speak abusively), malignment (speak about someone in a spitefully critical manner), exploitation and/or otherwise disregard of an individual, whether purposeful, or due to the carelessness, inattentiveness, or omission of the perpetrator. Physical abuse refers to any physical motion or action, (e.g., hitting, slapping, punching, kicking, pinching, etc.) by which bodily harm or trauma occurs. Review of the facility's undated policy and procedure (P&P) titled Prevention of Abuse, Neglect, and Mistreatment showed in part: the facility Administrator or other management personnel will immediately initiate an investigation of any alleged incident of abuse. In cases when client to client abuse has been witnessed or in cases when management staff directly witness abuse, an investigation will not be conducted, but a thorough report will be completed by the management staff which will include the action taken to protect/respond/prevent, and report. b. On 7/10/17, an Entity Reported Incident (ERI) was received by the CDPH showing Client 2 had punched Client 4 in the head several times on 7/9/17 at 1100 hours. The facility staff separated Clients 2 and 4 from each other and took Client 2 outside. While Client 2 was outside with the staff, Client 2 pushed the staff to the ground, went back into the house, and physically assaulted another client, Client 1. Client 2 punched Client 1 in the head and chest several times breaking Client 1's glasses and causing a scrape on his upper chest. Client 1 hit Client 2 causing an abrasion on his glabella, three abrasions under the left upper arm close to the axilla, and a scrape on his right upper chest. Client 4 was transported to the emergency room where he received 10 staples to close a laceration on the left side of his head. On 7/12/17 at 0724 hours, an unannounced visit was made to the facility to investigate the ERI. The facility housed five clients (Clients 1, 2, 3, 4, and 5) at the time of the visit. The House Leader answered the door and DCS 2 was observed sitting at the desk facing the computer. Clients 1, 4, and 5 were observed to be sitting on the couches in the living room and Client 2 was in his bedroom lying on his bed. All of the clients were awake, ambulatory, and waiting to go to their day programs. The House Leader stated Client 3 had already left the facility for work. On 7/12/17 at 0725 hours, Client 4 was interviewed. When asked what had happened on Sunday (7/9/17), Client 4 stated Client 2 had hit him in the head, the police came, and he went to the hospital in the ambulance. Client 4 showed the surveyor the stapled laceration on the left side of his head. On 7/12/17 at 0730 hours, an interview was conducted with the House Leader. The House Leader stated she was not at the facility at the time of the incident. The House Leader stated Client 2 had been staying at a hotel since the incident on 7/9/17, and they had placed Client 2 on a one to one supervision. The House Leader stated Client 2 only returned to the facility every morning at 0600 hours to get ready to go to the day program. On 7/12/17 at 0732 hours, an interview was conducted with Client 2. A two centimeter abrasion was observed at the base of his right middle finger and a one centimeter abrasion was observed on his glabella. Client 2 verified he received the abrasions during his altercation with Clients 1 and 4 on 7/9/17. When the client was asked if he had any other injuries, he stated he had a scratch on the right side of his neck. Client 2 verified he punched Client 4 in the head three times and the staff had tried to stop him. Client 2 stated Client 1 had tried to bite him on the neck so he punched Client 1 in the face. Client 2 stated Client 1 hit him in the face a couple of times. Client 2 stated he had been staying at a hotel and had a one to one staff at all times since the incident on 7/9/17. Client 2 stated he returned to the facility at 0600 hours daily to eat breakfast, take his medications, and repack his backpack for the next night. Client 2 stated he stayed in his bedroom until his job coach picked him up around 0830 hours. The client stated that when his job coach dropped him back off at the facility around 1400 hours, his one to one staff took him to the hotel. On 7/12/17 at 0740 hours, an interview was conducted with Client 1. When Client 1 was asked what had happened on Sunday morning, he stated he came out of his bedroom and saw Client 2 punching Client 4 in the face. Client 1 stated Client 2 ran towards him and started punching him in the face, and broke his glasses. Client 1 stated that Client 2 punched him in the face three to four times and also punched him on his left shoulder about two times causing soreness. Client 1 stated he punched Client 2 a few times in the face too. On 7/12/17 at 0805 hours, an interview was conducted with DCS 2. DCS 2 stated that either she or the House Leader had taken Client 2 to a hotel daily when he returned from the day program, the client spent the night at the hotel, and returned to the facility in the morning at 0600 hours. DCS 2 stated when Client 2 returned to the facility in the morning he ate breakfast, took his medications, repacked his backpack, and then stayed in his bedroom until his job coach picked him up. When DCS 2 was asked if she had been trained on how to provide one to one supervision, she stated she had not. On 7/12/17 at 0835 hours, Client 4 was observed to walk into the hallway and stand in front of his bedroom door. At that time Client 2 was observed to come out of his bedroom, pass Client 4 in the hallway, and talked to the House Leader who was in the dining room. The House Leader was unable to see down the hallway from the dining room. DCS 2 was sitting at the desk and was unable to see down the hallway. On 7/12/17 at 0915 hours, an interview was conducted with the Director of Health Services. The Director of Health Services stated the facility had an emergency IDT meeting on 7/10/17, and a plan had been put into place for Client 2 to have one to one staff supervision and he would stay at an alternate location with a staff member until Client 2's discharge from the facility could be put into place. The Director of Health Services stated on 7/11/17, the QIDP had informed Client 2's Service Coordinator at RCOC (Regional Center of Orange County) a new placement was needed for the client immediately. The Director of Health Services was informed of Clients 2 and 4 being in the hallway next to each other this morning without Client 2's one to one staff supervision. The Director of Health Services was asked to submit an immediate Plan of Correction to show how the facility was going to ensure the safety of the clients. The facility failed to ensure Clients 1, 2, 4, 5, and 6 were not subjected to physical abuse from Clients 1, 2, and 4. As a result, Clients 1, 2, 4, 5, 6, and staff were subjected to being attacked and physically abused on numerous occasions by Clients 1, 2, and 4. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.
630011211	IN GOOD HANDS HOME ICF/DD-H	070011428	A	29-May-15	SQQ511	6443	Welfare and Institutions Code 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to ensure Client 1's right to be free from harm. On 2/25/15 at 2:10 p.m., Client 1 fell while walking on the facility's driveway after she was dropped off from the day program. Client 1 was transferred to an urgent care clinic where an X-ray (imaging that creates picture of the inside of the body) revealed a fractured left hip. Client 1 was admitted to a hospital and had a total hip replacement operation (a surgery to replace the ends of both bones in a damaged joint to create new joint surfaces). Client 1 had diagnoses including mild intellectual developmental disabilities (a disability characterized by significant limitations in both intellectual functioning and in adaptive behavior which covers many everyday social and practical skills) and schizotypal personality (a disorder characterized by odd behaviors, feelings, perceptions and ways of relating to others that interfere with one's ability to function). The comprehensive functional assessment (CFA, an assessment tool) dated 1/10/14 indicated Client 1 was able to walk but needed supervision because of her unsteady gait, assistance with walking in the community, assistance with bathing (getting in and out the bathtub) and supervision to reconnect Client 1 to reality due to her mental condition.After Client 1's discharge from the hospital, Client 1 was transferred to a rehabilitation facility (a facility that seeks to help individuals recover from a variety of ailments) and stayed for three weeks. Client 1 was transferred back to the facility on 3/27/15 with a recommendation to use a front wheel walker (a tool used for support to maintain balance or stability while walking) at all times. The facility's incident report log indicated Client 1 had a history of a fall on 1/16/14 at the day program while crossing the parking lot during an outing and sustained a scraped right forehead and cheek, a bruised (skin discoloration) lip and a broken tooth. A tooth extraction was necessary following the fall.During an interview on 3/12/15 at 7:40 a.m. with direct support professional A (DSP A) who was at the door of the facility on the day of the 2/25/15 incident, she stated she saw the bus driver and another male DSP hold Client 1's arms because she could not walk. She had a skin tear on her forehead and was bleeding. DSP A stated the facility staff did not pick up the clients at the roadside (curb) after the day program. DSP A stated this had always been the practice of the facility. During an interview with the qualified intellectual disabilities professional (QIDP) on 3/12/15 at 8:15 a.m., she stated the facility had no policy and procedure regarding the clients' transportation. She stated there was a verbal understanding the DPTS (Day Program transportation staff) would assist the clients to the facility's door. She stated she had not investigated the incident on 2/25/15 and was not aware of the day program's policy and procedure regarding the clients' transportation. The QIDP stated she would communicate with the day program regarding Client 1's needs and safety for transportation.During an observation of Client 1 on 4/16/15 at 7:35 a.m., she was sitting in the living room drawing on a piece of paper. Client 1 knew she had surgery but could not remember the incident. She also knew she had to use a walker.During an interview on 4/16/15 at 7:50 a.m. with the DPTS who was with Client 1 during the accident, she acknowledged she did not supervise Client 1 and she was not informed Client 1 needed supervision while walking. The DPTS stated she was helping another client in a wheelchair when the incident occurred.During an interview with the day program driver (DPD) on 3/16/15 at 8 a.m., he stated he saw Client 1 on the ground in the driveway lying on her left side and saying she could not walk. The DPD and another DSP helped the client up from the ground and into the facility. The DPD also stated he only assists the clients when they are getting out of the van. During an interview on 4/16/15 at 11:10 a.m. with the QIPD, she stated she communicated via email on 3/13/15 with the day program facility and a regional center case manager (RCCM, responsible for Client 1) regarding Client 1's fall. The email indicated the regional center had a contract with a day program transportation service to provide "curb to curb" service which included the following: 1. The facility staff was responsible to hand off responsibility for the clients to the DPTS at the curb prior to the clients entering the transportation vehicle in the morning,2. the DPTS would turn the clients over to the DPS (Day Program staff) at the curb at the day program facility,3. the DPS would escort the clients to the transportation vehicle at the curb after the day program in the afternoon and;4. the DPTS would drop the clients off at the facility and the facility staff would meet the clients at the curb as they exited the transportation vehicle and be responsible for the clients.The facility and day program did not have coordination of the transportation services, including supervision of clients. There were no existing procedures for the facility at the time of the fall.The facility failed to ensure the client's right to be free from harm. The client who needed supervision and assistance with walking because of unsteady gait was dropped off, unassisted and unsupervised from the day program transportation. The client sustained a fractured left hip injury from this incident. The violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result for Client 1.
090000015	Imperial Heights HealthCare & Wellness Centre, LLC	090013030	A	16-Aug-17	LM5Y11	18015	Federal Regulation, Long Term Care Facilities 483.25 Quality of Care Each resident must receive and the facility must provide the necessary 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. 483.25 (h) Accident Hazards/Supervision/Devices The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 5/19/16 at 4 P.M., an unannounced visit was conducted to investigate a complaint alleging that Resident A ingested hand sanitizer and was transferred to the local acute hospital on XXXXXXX 16, where she died the next day. Resident A was an 82 year old resident who was found by certified nursing assistant (CNA 1) trying to get out of bed and holding a bottle of hand sanitizer in her hand. The bottle of hand sanitizer had been poured out onto the bed sheets and possibly into the resident's mouth. Based on observation, interview, and record review, the Department determined that the facility failed to provide Resident A with necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being to meet the needs of the resident by failing to ensure the resident did not obtain hand sanitizer containing ethanol (alcohol) and failed to intervene to obtain medical services for 12 hours after the incident, including but not limited to: 1. Failure to provide a comprehensive assessment by the licensed nurse (LN) 1 and LN 2 when they were informed that Resident A possibly ingested the hand sanitizer. 2. Failure to communicate to the Nurse Supervisor at the time of the incident that Resident A potentially ingested hand sanitizer. In addition, the primary physician and responsible party were not notified when the incident occurred as the policy for Unusual Occurrences Reporting, dated August 1, 2012, and a Change of Condition Notification, dated April 1, 2015, indicated. 3. Failure to call 911 immediately or seek medical consultation when the staff discovered Resident A was unresponsive. 4. Failure to implement the Physician Orders for Life -Sustaining Treatment (POLST) which included selective treatment for Resident A in a timely manner. 5. Failure to inform the receiving hospital of the reason for the transfer and, as a result, emergency care was delayed more than five hours. These failures affected Resident A's health and safety; Resident A was transferred on XXXXXXX 16, from the facility to the hospital, 12 hours after the incident occurred and expired the next day on XXXXXXX 16. According to the facility's Face Sheet, Resident A was admitted to the facility on XXXXXXX 16 from the hospital. According to the physician's "Discharge Summary" from the hospital (sending facility), dated XXXXXXX 16, Resident A was an 82 year old female admitted to the facility on XXXXXXX16. Her diagnoses included, muscle weakness, severe protein-calorie malnutrition, Cachexia (weakness and wasting of the body due to severe chronic illness), Enterocolitis (inflammation of both the small intestine and the colon) due to Clostridium difficile (an infection of the colon) and severe dementia (brain diseases that cause memory loss). The Initial History and Physical, dated 3/14/16, indicated that, Resident A had unspecified dementia without behavioral disturbance. On 5/19/16, at 4:30 P.M., an interview was conducted with certified nurse assistant (CNA) 1. CNA 1 was the caregiver for Resident A on 5/17/16 during the 3:00 P.M. to 11:00 P.M. shift of duty. CNA 1 stated that Resident A had a tab alarm clipped on her night gown that was used to alert staff if she was attempting to get out of bed unassisted. Between 8:30 P.M. and 9 P.M. on 5/17/16, CNA 1 heard the tab alarm going off in Resident A's room. CNA 1 stated that, upon hearing the alarm, she quickly went into the room and found Resident A sitting at the edge of her bed holding a 16 ounce size bottle of hand sanitizer in her hands. CNA 1 immediately took the sanitizer away from Resident A. CNA 1 observed that the sheets and blanket were wet. She looked into Resident A's mouth to see if there were any signs of sanitizer or smell of sanitizer but there was not. CNA 1 then went out to the hallway and told her LN 1 what had happened. Then both CNA 1 and LN 1 went into the room to see Resident A. LN 1 told CNA 1 to go and tell the LN 2 (Nurse Supervisor) who was working on the other side of the facility because LN 1 stated that she had never seen anything like this and did not know what to do [LN 1 was a newly hired licensed nurse]. CNA 1 stated that she went to LN 2 after LN 1 told her to and that LN 2 was busy, so she pulled her away from the nurse's station and explained what happened with Resident A. CNA 1 told LN 2 that LN 1 sent her to inform her of the incident and to find out what she was supposed to do, as she had never experienced this situation before. LN 2 asked CNA 1 if Resident A was drinking thickened liquids, and CNA 1 responded, "No, I did not see her drink anything". LN 2 told CNA 1, " Don't worry, she (Resident A) will be okay, just monitor her". There was no documented evidence that LN 1 and LN 2 performed a physical assessment of Resident A, after they were informed that Resident A may have ingested hand sanitizer. There was no documentation in Residents A's clinical record or elsewhere for PM shift (3 PM - 11-PM) regarding this incident. There was no documented evidence of shift report or shift change endorsement conducted by the LN 1 and LN 2 found in the records or their statements. There was no incident report found in the facility's incident log concerning this incident. On 5/19/16 at 6:15 P.M., a joint interview with LN 2 and the Director of Nurses (DON) was conducted. LN 2 stated, "I remember CNA 1 coming to me and telling me that Resident A was drinking a lot. I asked her if Resident A was okay and CNA 1 said yes. I told her to keep an eye on her, thinking it was a drinking problem. After that, I did not hear any more about Resident A, thinking everything was okay". When the LN 2 was asked if she had checked on Resident A anytime during the working shift, since it would have been her responsibility to directly observe Resident A in order to validate the information collected by CNA 1, she replied, she did not because she thought everything was okay. LN 2 stated she did not hear CNA 1 tell her anything about hand sanitizer. LN 2 further stated that she knew nothing of the incident until she was called at home by the night shift nurse at about 5:45 A.M. on 5/18/16. The DON acknowledged that no documentation regarding the incident involving Resident A was available as no input was put into Resident A's clinical record or elsewhere. On 5/19/16, at 6:20 P.M., LN 1 was asked if she had documented anything about the incident in Resident A's medical record. LN 1 stated, "That staff had been instructed by the DON to not document anything until something went "wrong or bad". A review of the policy and procedure entitled 24 Hour Communication Log, Policy, "the facility will utilize a 24-hour report system in the form of a "24 Hour Communication Log" ("log") as a means of communicating changes in condition, other important aspects of residents care, and census information." Section C. "The Licensed Nurse (LN) will record changes that include but are not limited to: ...iii. Incidents that require follow up (falls, bruises, skin tears, etc.)" A review of the policy and procedure entitled Unexplained Injuries- Investigation, Purpose, "To protect the health and safety of residents by ensuring that all unexplained injuries are promptly and thoroughly investigated and addressed." Then, the section Procedure, "an injury of unknown source is defined as an injury that meets both of the following conditions: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of: the location of the injury." A review of the policy and procedure entitled Change of Condition Notification, Procedure, "It is the responsibility of the person who observes the change to report the change to the Licensed Nurse. III. A licensed Nurse will notify the resident's Attending Physician and legal representative or an appropriate family member when there is an: A. Incident/accident Involving the resident; B. An accident involving the resident which results injury and has the potential for requiring physician intervention." A review of a report, completed by the DON, entitled, Suspected Dependent Adult/Elder Abuse, dated 5/18/16 at 3:21P.M., was conducted. The report indicated "LVN (licensed vocational nurse - LN 1) did not report or document the allegation of Resident A drinking hand sanitizer to the MD (medical doctor), DON or Administrator. Resident A was assessed by RN (registered nurse - LN 2) but information was not recorded. MD was not...or family was not notified in timely manner. RN (LN 2) didn't follow up with LVN (LN 1) for additional info such as assessment, treatment and notifying MD, etc." The personnel file for LN 1 was reviewed and indicated that LN1 had been employed elsewhere prior to coming to this facility as a licensed vocational nurse (LVN) since 6/1999. The experience documented on this application indicated that LN 1's experience included, evaluating patient care needs and prioritizing needed treatments. In addition, assessed patients, documenting their medical histories and daily changes. A review of the facility's job description entitled, RN Supervisor, under General, "Evaluate emergencies and assist in implementing emergency measures. Assist the Charge nurse on Investigation of alleged abuse or unusual occurrence as outlined within our established policies and procedures." A review of the facility's job description, titled, "Charge Nurse", was reviewed on 5/19/16, at 6:45 P.M. The requirement dictated the designated nurse to be a licensed vocational nurse or a registered nurse. The DON stated, "That in her absence the charge nurses were to function as supervising nurses". A concurrent record review and joint interview was conducted with the DON on 5/19/16, at 6:27 P.M. The facility's job description for LN indicated "rounds were to be performed to review physical, medical and emotional status and to implement required nursing interventions...investigation of accidents and unusual occurrences were to be written and reported to the Director of Nurses. In addition, notification to the physician and resident's responsible party of any resident accidents/incidents. Fill out and complete Incident report forms on all such occurrences and chart such information in the residents' medical records as outlined in the facility's established policies and procedures (P&P). Give nursing reports upon reporting in and ending shift duty hours." In addition, the job description for the Director of Nurses was reviewed during this time. The job description indicated, "Written and oral reports/recommendations to the Administrator, that concerned the operation of the nursing service department was to be done. Completing medical forms, reports, evaluations, studies, charting as necessary. Ensure that direct nursing care be provided by a licensed nurse. Review nurse's notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care and that such care is provided in accordance with the resident's wishes. Monitor nursing personnel to ensure that they are following established safety regulations in the use of equipment and supplies. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Ensure that the facility's policy and procedures governing advance directives are reviewed with the resident and/or representative." The DON acknowledged that LN 2 and LN 1 did not follow their job description. On 5/19/16 at 4:30 P.M., Resident A's clinical record was reviewed with the DON. A care plan for Resident A, dated 3/11/16, indicated that Resident A had a cognitive deficit, communication deficit, limited mobility, and a lack of awareness which placed her at risk for injury. The approaches to address the issues included, remove hazards from the environment, answer call light promptly, and check the resident every 2 hours. The DON was asked how Resident A was able to access the hand sanitizer; the DON stated that she did not know how Resident A was able to obtain it. The DON acknowledged that the action performance of 2 hour rounds was not effective and did not prevent the incident from happening. Documented evidence of the 2 hour rounds was requested but not provided. The care plan was not followed as documented. The Physician Orders for Life-Sustaining Treatment (POLST - form signed by a legally recognized decision maker regarding resuscitative measures for the individual who is the subject of the form) for Resident A, dated 3/14/16, indicated "Do not attempt resuscitation/DNR, Allow Natural Death. Selective Treatment: goal of treating medical conditions while avoiding burdensome measures. In addition to treatment in Comfort-Focused Treatment, use of medical treatment, IV antibiotics, and IV fluids as indicated. Do not intubate...Transfer to hospital only if comfort needs cannot be met in current location." The DON acknowledged that Resident A was involved in an unusual incident and the facility should have notified the attending physician and obtained direction from the physician. The DON acknowledged that Resident A's condition was not related to a natural cause. A review of the Emergency Department (ED) Physician Assistant's statement dated 5/18/16 at 9:28 A.M., indicated that Resident A was transported to the emergency room from the facility by emergency medical service (EMS) with no information other than there was low blood pressure and Resident A was non- responsive. The emergency room physician contacted Resident A's primary physician and was told that comfort measures were the only measures to be implemented. At 1:40 P.M., 5 hours 30 minutes later, the emergency room staff received a call from the DON at the skilled nursing facility (SNF) informing them that they [SNF Staff] had just discovered that there was a possibility that Resident A could have ingested an unknown amount of hand sanitizer. A review of the laboratory report, result time at 1:33 P.M., on 5/18/16. Collection Time of specimen was at 12:30 P.M. Results obtained at 1:33 P.M. Result of 738 Ethanol (alcohol). Normal parameters (0 -10) milligrams per deciliter. According the ED attending note, dated 5/18/16, the ED physician did not feel comfortable limiting Resident A to comfort measures in light of the severe ethanol toxicity nor would it be right to call the incident a natural death. Per the ED attending note, dated 5/18/16 at 8:30 A.M., indicated "We reviewed the patient's care. In light of the severe ethanol toxicity, we are no longer comfortable limiting her to comfort measures nor would it be right to call this allowing a natural death. Therefor we will pursue a maxillary aggressive resuscitation short of cardiopulmonary resuscitation (CPR) and intubation." However, Resident A expired on XXXXXXX16 at 8:30 A.M., pronounced by the ED physician. A review of the County Coroner's report, dated 10/14/16 was conducted on 11/1/16. It indicated that the results of the Autopsy Report listed the cause of death as (A) Acute Ethanol Intoxication. Other conditions; Arteriosclerotic Cardiovascular Disease On 11/23/16 at 2 P.M., the DON was interviewed, she acknowledged the following: 1. The facility failed to provide services that were necessary to prevent physical harm to Resident A. 2. The facility nursing staff had knowledge that Resident A may have ingested hand sanitizer containing ethanol (alcohol) and did not intervene to obtain medical services until 12 hours later. 3. The facility failed to provide comprehensive assessment by LN 1 and LN 2 when Resident A possibly ingested the hand sanitizer. 4. The facility failed to communicate among the care providers at the time of the incident. In addition, the primary physician and responsible party were not notified timely when the incident occurred as the policy indicated. No incident report completed by the LN as the facility job description of the charge nurse indicated. 5. The facility failed to call 911 immediately or seek medical consultation when the staff discovered Resident A was unresponsive by the unusual incident. The facility failed to implement the POLST which included selective treatment for Resident A in timely manner. 6. The facility failed to provide the transfer information to the receiving hospital. The hospital staff did not know why Resident A was transferred from the nursing facility. As a result, emergency care was delayed more than 5 hours. The facility failed to provide services that were necessary to prevent physical harm to Resident A. The facility nursing staff had knowledge that Resident A may have ingested hand sanitizer containing ethanol and did not intervene to obtain medical services in timely manner. The facility did not ensure the LNs followed their job descriptions to meet the current nursing standard practices. As a result Resident A suffered with acute ethanol intoxication and died on XXXXXXX16 at the hospital. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical hard would result. 1
220001020	Idylwood Care Center	220012750	B	23-Nov-16	FR8511	7306	F323 - 483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide adequate supervision and toileting to prevent falling consistent with the resident's assessment needs and plan of care for Resident 10. This resulted in Resident 10 sustaining a concussion with headaches. Review of Resident 10's clinical record indicated she was admitted to the facility on 10/10/13 with diagnoses of Bipolar Disorder (extreme mood swings from depression to mania), Schizoaffective Disorder (a brain disorder that distorts the way a person thinks), Personality Disorder (a class of mental disorder), and age-related osteoporosis without current pathological fracture. Her minimum data set (MDS, an assessment tool) dated 9/27/16 indicated a BIMS (Brief Interview for Mental Status) score of 13, which means cognition is intact but she had indicators of hallucinations and delusions. Resident 10 also required assistance from the nursing staff with her activities of daily living (ADL) especially in toilet use (one person physical assistance). Resident 10 had falls on the following dates: 12/29/15 trying to get on the toilet; 3/29/16 found sitting next to her bed; 6/23/16 fell in the bathroom; 7/25/16 fell by reaching for a soda; and 10/9/16 tripped on her foot and fell at the nurses' station. Review of Resident 10's clinical records indicated Resident 10 had a fall incident on 12/29/15. Review of Resident 10's "Interdisciplinary (IDT, team members from different departments who are involved in the care of residents) Progress Notes" dated 12/30/15 indicated the IDT reviewed the fall incident on 12/29/15. They reassessed, with the resident present, her bed area and the bathroom environment. IDT recommended putting the resident on a toileting schedule every two hours to assist the resident with toileting as needed; replace the grab bar in the bathroom with a longer one to provide more area of support. Review of Resident 10's clinical record revealed no evidence of "Bowel & Bladder Toileting Record" was initiated after the fall on 12/29/15. Review of Resident 10's long term care plan for risk for falls initiated 12/30/15 indicated interventions which included encouraging the resident to use grab bars in and outside of bathroom, over-the-toilet commode, and transfer pole next to her bed to aid with transfer. Review of Resident 10's clinical record indicated Resident 10 had a fall incident on 3/30/16. Resident 10's IDT note dated 3/30/16 indicated Resident 10 felt very dizzy when she got out of bed, and fell. The IDT recommended installing a transfer pole next to her bed to assist her with her transfers. Review of Resident 10's "Change of Condition Follow up Note" from 3/29/16 through 4/2/16, and "Nurses Note" dated 3/29/16 through 4/3/16 did not indicate the two hourly toileting schedule was done, nor were the transfer pole and over-the-toilet commode initiated. Review of Resident 10's clinical record revealed no evidence of "Bowel & Bladder Toileting Record" was initiated after the fall on 3/29/16. Review of Resident 10's "Fall Risk Assessment" dated 3/29/16 under the section "Systolic Blood Pressure" (blood pushed through the arteries to the rest of the body) indicated there was no noted drop of blood pressure between laying and standing positions, but there was no documentation of the recorded blood pressures taken while Resident 10 was in the laying and standing positions. Review of Resident 10's clinical record showed no evidence of any neurological evaluation flow sheet (neuro checks) was initiated after an unwitnessed fall when Resident 10 felt dizzy on 3/29/16 at 10:15 a.m. Review of Resident 10's physician's progress notes dated 6/23/16 indicated under chief complaint: "fall. I was at nursing station when resident came and informed she had a fall hitting her head. She slipped and fell and hit her head in [sic] the bathroom floor. She was shaky and said she felt very dizzy. She complained of dizziness after the fall h/o trauma to head; send to emergency room for further evaluation and possible computer tomography head". Review of Resident 10's acute care emergency department note dated 6/23/16 indicated under HPI (history and physical information) "per patient, she tripped over her foot and fell when going to the bathroom, hit the right side of head". Small superficial bump on right scalp. DDX [discharged diagnoses] concussion". Review of Resident 10's physician's progress notes dated 6/27/16 indicated under chief complaint: "pain on head. Resident had a fall two days ago and she is still concerned about pain in her head when she touches the scalp where she hit her head". During an observation on 11/1/16, at 11:30 a.m. Resident 10's room did not have a transfer pole installed next to her bed and no over-the-toilet commode in the bathroom. During another observation on 11/2/16, at 7:40 a.m. Resident 10's room did not have a transfer pole next to her bed. During an observation on 11/4/16, at 9:30 a.m. and 1:30 p.m. Resident 10 did not have an over-the-toilet commode in the bathroom. During an interview on 11/2/16, at 1:45 p.m. the assistant director of nursing (ADON) stated when the care plan had an intervention for having a transfer pole and an over-the-toilet commode for Resident 10, it was expected the equipment should be in the resident's room. She also stated if a fall occurs due to dizziness, an orthostatic blood pressure (measure blood pressure in sitting and standing) should be taken. The ADON concurrent checked Resident 10's chart and was not able to find the orthostatic blood pressure results for the dates of the falls. During an interview on 11/4/16, at 8:55 a.m. the ADON stated if a resident was put on a two hourly toileting program a "Bowel and Bladder Toileting Record" form should be completed. The toileting should be done for 72 hours and the licensed nurse should evaluate it, and document the outcome. The ADON confirmed no evidence was in the chart that the IDT discussed to stop or continue this intervention. Review of the facility's Fall Prevention and Management policy dated 9/2013 indicated "resident is to be placed on observation of vital signs, pain, and other post-fall complications. Fall details, assessment findings, interventions and notifications are to be documented in resident's clinical record and care plan accordingly". Review of the facility's Orthostatic Blood Pressure policy dated 9/2013 indicated "the nurse shall perform and document orthostatic blood pressures when any resident experiences signs of orthostatic hypotension (i.e. dizziness when standing, etc.). Documentation of orthostatic blood pressures may be on a special form, medication administration record or nurse's notes in the resident's medical record". The facility failed to provide adequate supervision and toileting to prevent falling consistent with the resident's assessment needs and plan of care for Resident 10. This resulted in Resident 10 sustaining a concussion with headaches. This failure had a direct or immediate relationship to the health, safety, or security of residents.
240001511	Ituma	240009411	B	27-Jul-12	GFMK11	11548	REGULATION VIOLATION: Welfare & Institutions 4502 Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse or neglect.Based on observation, interview and record review, the facility failed to protect one of six clients (Client A) from physical abuse when he was witnessed to have his arms pulled behind his back, kicked and then had ice tea thrown at him by a staff member (Staff 1), while on an outing to the park. Client A was a 22 year old male admitted to the facility on August 10, 2009, with diagnoses to include: autism (a mental introverted state often accompanied by speech disturbances and repetitive movements); attention deficit hyperactivity disorder (ADHD); mixed receptive /expressive language disorder (interference in messages received and ability to send messages); severe mental retardation (IQ in 20-34 range); seizure disorder convulsions) and hypertension (High blood pressure. Client A had been displaying increasingly aggressive behaviors and was on Zyprexa and Haldol (antipsychotic medications used to control behavior), and Restoril (a hypnotic given at bedtime to aid in sleeping). Client A was under the ongoing care of a psychologist, neurologist and medical doctor who were working towards diagnosing the increased aggressive behaviors. Client A was non-verbal.On March 12, 2012 at 2:30 PM, an unannounced visit was made to Client A's group home to investigate a complaint of alleged physical abuse by a staff (Staff 1) towards Client A that took place on February 24, 2012. The facility notified the Department of the allegation 15 days after the alleged incident had occurred. During an interview with the facility manager (FM)/administrator at 2:45 PM when asked what had occurred he stated, "A staff reported from a company [used name of company] on February 28, 2012 that one of her staff had reported seeing an interaction that didn't seem appropriate. I referred her to our administrator." The FM continued, "Staff 1 [used his name] had kicked Client A [used name] in the upper torso and thrown a drink on him. Our administrator interviewed Staff 1 and Staff 2 who were at the park and they denied it happened. They said that Client A had been aggressive toward Staff 1 and grabbed the ice tea spilling on both Staff 1 and himself. We checked Client A on February 28 and did not find any marks on him. Staff 1 was suspended and resigned on March 4, 2012." A review of a typed timeline dated February 24, 2012 through March 8, 2012 listed the various interviews the administrator conducted as well as the outcomes. The timeline showed that it was not until March 9, 2012 that the Department was notified of the alleged abuse.During a review of Client A's clinical record on March 12, 2012 at 3:30 PM, there was no documentation found regarding the incident at the park and no documented evidence of Client A being checked for any injuries related to the abuse allegation.A typed document written by Staff 1 dated February 24, 2012 at 1:45 PM was not found in the clinical record; however, was forwarded to the Department on March 14, 2012. Documentation described the incident as told by Staff 1. The group had gone to the park and when returning to the area to pick up their back packs and go to the van to come home, Staff 1 described the following. "... [Client A's name] started attacking me, trying to scratch and bite me. I was holding my water jug with ice tea, and was trying to take a drink when he tried to grab the jug. [Client A's name] knocked the jug out of my hand drenching both of us with ice tea. I started backing up to evade his scratches, keeping my arms out to keep him away telling him no biting, and no scratching. I was able to get his sweatshirt and pull the sleeves down over his hands so he couldn't scratch but he continued trying to bite. I got behind him holding his hands down at his side and escorted him to the vehicle." A review of Staff 1's employee file on March 12, 2012 at 3:30 PM reflected that he had been employed with the home since September 7, 1999. He had received initial and annual training in abuse recognition and prevention. He received Pro-Act training (the use of an individualized plan of behavioral tools to promote safety that uses physical restraint as a last resort for assaultive behaviors). Single person restraint is not part of this program at any time. The employee file did not contain any documentation of Staff 1 being suspended. It did contain the note indicating he was resigning as of March 4, 2012. On March 12, 2012 at 4:00 PM, Client A was observed lying on the couch. Client A appeared well groomed and repeatedly vocalized inaudible sounds in an effort to get staff's attention. Client A was observed to "bury" himself under the sofa pillows, then sit up, and then repeat the behavior. On March 13, 2012 at 3:45 PM, during a phone interview with the administrator of Company 1, the administrator stated, "My staff (Witness 1 and Witness 2) were at the park with the day program (DP) doing a 2:1 behavior monitoring on another person who attends the DP with the clients from the facility's homes. It was the transition time when they are packing up to leave and Client A became increasingly aggressive and was aiming it at Staff 1 who told him, "You are not going to scratch me". Staff 1 then put Client A's arms behind his back to get control. He pushed Client A away from him and kicked him. Client A turned around and Staff 1 was holding his drink. Client A was heading towards him for the drink and Staff 1 threw the drink in his face getting him wet. He laughed and then someone grabbed Client A by the shirt and escorted him to the car to go home." The administrator said when she found out on February 28, 2012 she immediately called the home of Client A, and was told they would investigate. I then contacted the over-site agency for the developmentally developed client, who told me she was calling Adult Protective Services (APS) and the local police) to report". During a phone interview with Witness 1 on March 14, 2012 at 8:00 AM, he stated, "At approximately 1:30 PM, we were getting ready to exit the park and go back to the house where our client gets picked up. Client A was aggressive towards Staff 1 who put Client A's hands behind his back and then pushed him away from himself. I saw Staff 1's left leg kick Client A's left side. Then Client A came back at Staff 1 who had a drink in his hand. Staff 1 stated, "You are not getting my drink" and threw it in Client A's face. Client A's shirt was wet. Staff 1 laughed and then someone escorted Client A to the vehicle. I came back and told my supervisor. I called and reported it to the PD as well who said, "Thank you for reporting it". Then on Wednesday, February 29, 2012, the administrator from the home interviewed me and Witness 2 separately. She tried to discredit my story saying Staff 1 had a broken foot. I told her I clearly saw it. I saw Staff 1 raise his foot and kick Client A. I was about 15 feet away on a higher elevation then where he was standing and had a clear view." During a phone interview with Witness 2 on March 14, 2012 at 12:00 PM, she reported in detail the same scenario as Witness 1 had reported. She added that she "believed Staff 2 saw the whole thing because when a client gets out of control we all stop and kind of gather around to help. Staff 2 was standing right by the car. When the administrator from the home interviewed me on Wednesday she told me they were doing an investigation and said it shouldn't happen. She then told me that Staff 1 had a leg injury so she didn't know how it could happen." During the interviews with both Witness 1 and Witness 2 when asked if the ice tea could have been splashed onto Client A as he tried to grab it from Staff 1, both adamantly said, "No, he threw it at him and started laughing." On March 15, 2012 at 10:00 AM, a review of the self report from the home administrator showed that the timeline received on March 13, 2012 by facsimile (FAX) had additional documentation that included a statement regarding Staff 1, who she described as "... a very large, significantly overweight individual with a history of high blood pressure and gout. It would be virtually impossible for him to kick his leg high enough to strike someone in the upper torso." In addition, the initial document indicated that Staff 1 had resigned because "the accidental spilling of the ice tea was being blown way out of proportion and he wasn't going to be part of a witch hunt." This was the same wording found on the document about Staff 1's resignation dated March 4, 2012, which was noted in the employee file. However, the data sent to the Department on March 9, 2012, indicated Staff 1 resigned for the following reason. "...stated due to his health concerns (high blood pressure), he was resigning after 13 years with the company...he said he wasn't guilty and that this whole thing was just wrong". A review of the facility's policy and procedure titled, "Abuse Reporting Overview", undated, under number 9, listed, "A staff member is found to have used extreme or unnecessary force while physically redirecting a consumer. Staff member will be terminated, and appropriate agencies will be notified". During a phone interview with the administrator from the home on March 14, 2012 at 8:45 AM, she stated she did not think her staff (Staff 1) was capable of kicking, especially the upper torso. When the incident reports from the two witnesses were reviewed with her it was pointed out that neither Witness 1 nor Witness 2 had stated "upper torso" in their reports. When asked why there was no documentation of the suspension of Staff 1 in his file she stated, "I have it with me, I'll FAX it." A review of all documentation faxed on March 9, 2012 and again after the phone interview with the home administrator on March 14, 2012, showed that a copy of the suspension letter for Staff 1 had not been provided as requested. When interviewed on March 14, 2012, the administrator of the home stated she had written it on her timeline not on a disciplinary form. She stated that Staff 1 was suspended on February 28 and February 29, 2012. The administrator stated, "He showed up and worked at one of the other homes on March 1, 2012 for five hours. When I received the incidents from company 1 on March 2, 2012, and the statements showed this may be abuse and not just an inappropriate behavioral intervention, I told Staff 1 [used his name] that he was suspended until the investigation was complete. He resigned on March 4, 2012". The facility failed to ensure that Client A was consistently protected from physical abuse. Client A sustained physical abuse from Staff 1 on February 24, 2012. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patient or residents.
250001382	INDIO NURSING AND REHABILITATION CENTER	250013310	B	18-Jul-17	FY5S11	3730	HSC 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. HSC 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. On December 19, 2015, Resident A reported to the facility charge nurse that CNA 1 (Certified Nursing Assistant 1) mistreated her by striking the resident with a urine cylinder (a container to measure urine). There was no indication the facility followed up on the reported alleged abuse. The facility failed to report to the California Department of Public Health, Ombudsman, and Local Enforcement Agency immediately, or within 24 hours. On April 18, 2016, at 1:40 p.m., an unannounced visit was made to the facility to investigate a complaint of alleged abuse involving one facility staff person on December 19, 2015, when Resident A reported an incident of mistreatment by the facility staff. On April 18, 2016, Resident A?s record was reviewed. Resident A was admitted to the facility on XXXXXXX 2011, with diagnoses that included mood disorder and COPD (chronic obstructive pulmonary disease- respiratory problem). A document titled, ?Progress Notes- Initial Change of Condition- Emotional Distress,? dated December 9, 2015, indicated, PT (patient) reported to this writer that previously assigned CNA 1 had mistreated her, Pt noted to be upset, full body check completed. Noted small dime size redness to right index finger, no swelling noted, not warm to touch, pt stated redness due to urine cylinder? abuse coordinator (Administrator) made aware.? On April 18, 2016, at 1:50 p.m., an interview was conducted with Resident A. Resident A was able to recall the alleged incident on December 19, 2015. Resident A stated the incident happened during the time when the CNA was providing care to her. The CNA hit her on the hand with the urine cylinder. She further stated, ?He hit me!? On April 18, 2016, at 2:25 p.m., an interview was conducted with the Administrator and Director of Nursing (DON) regarding the alleged abuse. The Administrator stated the incident of abuse was not reported to the California Department of Public Health, Ombudsman, and local enforcement agency. The incident of alleged abuse was not reported to the California Department of Public Health, Ombudsman, and Local Enforcement Agency per facility's policy and procedure. On April 18, 2016, the facility?s policy and procedure titled, ?Abuse and Neglect Prohibition Policy,? updated on January 1, 2013, was reviewed. The policy indicated: ?Policy. It is the policy of (Facility Name) to ensure that violations by anyone in the facility involving mistreatment, neglect, or abuse of any kind, including injuries of an unknown source, or intentional misappropriation of resident property are reported immediately to the abuse coordinator within 24 hours. The facility administrator will report all allegations of abuse to the state in accordance with the state law. ...G. Reporting and Response. 1. The facility will report all allegations and substantiated occurrences of abuse, neglect, and misappropriation of property to the state agency and law enforcement officials as designed by state law..." Therefore, it was determined the facility failed to report to the California Department of Public Health (CDPH) immediately, or within 24 hours, an alleged incident of physical abuse or mistreatment for one Resident (Resident A). The failure of the facility to report the alleged physical abuse or staff mistreatment placed all patients at the facility in potential danger to their health, safety, and security.
250001382	INDIO NURSING AND REHABILITATION CENTER	250013311	B	18-Jul-17	FY5S11	4333	483.13 (c) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. 483.13 (c)(2)The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (according to the State survey and certification agency). On December 19, 2015, Resident A reported to the facility charge nurse that CNA 1 (Certified Nursing Assistant 1) mistreated her by striking her with a urine cylinder (a container to measure urine). There was no indication the facility followed up on the reported alleged abuse. The facility failed to implement their policy and procedure for abuse by failing to conduct an investigation into Resident A's report of mistreatment by the facility staff. On April 18, 2016, at 1:40 p.m., an unannounced visit was made to the facility to investigate a complaint of alleged abuse involving one facility staff person on December 19, 2015, when Resident A reported an incident of mistreatment by the facility staff. On April 18, 2016, Resident A's record was reviewed. Resident A was admitted to the facility on XXXXXXX 2011, with diagnoses that included mood disorder and COPD (chronic obstructive pulmonary disease- respiratory problem). A document titled, "Progress Notes- Initial Change of Condition- Emotional Distress," dated December 9, 2015, indicated, PT (patient) reported to this writer that previously assigned CNA 1 had mistreated her, Pt noted to be upset, full body check completed. Noted small dime size redness to right index finger, no swelling noted, not warm to touch, pt stated redness due to urine cylinder... abuse coordinator (Administrator) made aware." On April 18, 2015, at 1:50 p.m., an interview was conducted with Resident A. Resident A was able to recall the alleged incident on December 19, 2015. Resident A stated the incident happened during the time when the CNA was providing care to her. The CNA hit her on the hand with the urine cylinder. She further stated, "He hit me!" On April 18, 2016, at 2:25 p.m., an interview was conducted with the Administrator. The Administrator stated she knew about the incident but had viewed it as more a customer service issue rather than a case of abuse. The Administrator reviewed Resident A's record and attempted to find an investigation of the alleged abuse. The Administrator was unable to find any documented evidence of an investigation conducted regarding the alleged abuse for Resident A. The Administrator further stated, "It was just a customer service issue and not an abuse." She also stated that she "thinks" there was an investigation conducted regarding the incident but it was not completed. There was no documentation to reflect an investigation was conducted or completed by the facility after Resident 1's report of alleged abuse. On April 18, 2016, the facility's policy and procedure titled, "Abuse and Neglect Prohibition Policy," updated on January 1, 2013, was reviewed. The policy indicated: "Policy. It is the policy of (Facility Name) to ensure that violations by anyone in the facility involving mistreatment, neglect, or abuse of any kind, including injuries of an unknown source, or intentional misappropriation of resident property are reported immediately to the abuse coordinator within 24 hours. The facility administrator will report all allegations of abuse to the state in accordance with the state law. ...E. Investigation. 1. The facility will conduct an investigation of an alleged abuse/ neglect or misappropriation of resident property in accordance with state law..." The facility failed to implement their policy and procedure to ensure an alleged incident of physical abuse or mistreatment of Resident A was conducted. This facility failure placed all facility residents at risk for abuse and at increased risk for physical and emotional harm. The above violations either jointly, separately, or in any combination had a direct or immediate relation to patient health, safety, or security.
910000050	INGLEWOOD HEALTH CARE CENTER	910010467	B	13-Feb-14	SKKI11	3921	483. 25(h)F323 Accidents (2) each resident receives adequate supervision to prevent accidents. On March 12, 2010, at 2:00 p.m., an unannounced visit was made to the facility to investigate the facility?s reported incident dated February 26, 2010. The patient?s left foot fell off the wheelchair footrest and was dragged on the ground by the transport van driver. Based on observation, interview, and record review, the facility failed to ensure Patient A?s feet were properly positioned on the wheelchair footrest before the van driver wheeled the patient into the facility. As a result, Patient A's left foot was turned under, and was dragging on the ground when the van driver wheeled her into the facility, causing abrasions to her left 3rd, 4th, and 5th toes.Patient A was an 82-year-old female admitted to the facility on March 13, 2009, with diagnoses that included cerebrovascular accident (stroke), with left hemiparesis (weakness on one side of the body) , and hypertension (high blood pressure). The Minimum Data Set, a standardized assessment and care screening tool, dated February 19, 2010, indicated the patient?s cognitive skills for daily decision-making were moderately impaired. She was assessed as requiring total assistance with locomotion on and off the unit. The primary mode of locomotion was by wheelchair wheeled by others. There was loss of functional limitation in range of motion to both sides with partial loss of voluntary movement to her legs and feet including the hips/knees and ankles/toes. The Licensed Nurses Notes dated February 26, 2010, at 12:55 p.m., indicated Patient A was brought back to the facility from an appointment and the RNA (restorative nursing assistant) noted the van driver was wheeling Patient A in a wheelchair into the facility, with her left foot turned under/backwards, and dragging on the ground. The patient?s left foot was assessed with foot swelling and the third, fourth, and fifth toes were bleeding. First aid was provided by the treatment nurse.On March 12, 2010, at 2:00 p.m., during an interview, the RNA said she left Patient A in the van with the driver, while she went into the facility. Upon her return to the van, the driver had pushed the patient into the facility (approximately 50 feet from curb side to front door). At that time the RNA noticed the change in Patient A?s facial expression, however the patient did not complain of any discomfort. The RNA stated that she should have checked the patient?s positioning before leaving the patient in the van. On March 12, 2010, at 2:20 p.m., during an interview Patient A was asked what happened during the incident. She replied that she did not know what happened, and did not feel her foot come off the footrest. Patient A stated that she was told by a nurse (Patient A could not recall the nurse name) that her foot was injured, and the nurse applied a bandage to her foot. During the interview Patient A was asked to move her left foot. The patient was not able to move her foot. On December 23, 2013, at 4:20 p.m., during an interview with the director of nurses (DON), he stated the facility?s policy is to provide supervision and assistance to the patient when a family member is unavailable to accompany the resident. The DON stated the RNA should have checked the patient?s position to ensure that her feet were on the wheelchair footrests. The facility failed to ensure Patient A?s feet were properly positioned on the wheelchair footrest before the van driver wheeled the patient into the facility. Patient A had functional limitation in range of motion to both sides with partial loss of voluntary movement to her legs and feet. As a result the van driver wheeled the patient into the facility with her left foot dragging on the ground causing abrasions to the left 3rd, 4th, and 5th toes. The above violation had a direct relationship to the health, safety, or security of Patient A.
910000050	INGLEWOOD HEALTH CARE CENTER	910010499	B	27-Feb-14	EKX611	7016	Code of Federal Regulations Section 483.25F309 Each resident must receive and the facility must provide the necessary 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. Based on observation, interview, and record review, the facility failed to ensure Resident 9, who was severely impaired in cognition, received pain medication one hour prior to the treatment of pressure ulcers (open wounds that form whenever prolonged pressure is applied to skin covering bony areas) as ordered by the physician, and failed to assess and monitor the effectiveness of the pain medication before and during pressure ulcer treatment. As a result Resident 9 was observed flinching with facial grimacing, throughout the treatment, complaining of pain and that she was scared. The licensed vocational nurse (LVN 1) did not stop to assess the need for intervention to relieve the resident's pain. On October 23, 2013 at 8:26 a.m., Resident 9 was observed lying in bed with contractures (abnormal shortening of the muscle tissue) to both lower extremities (legs). The resident was frowning, had facial grimaces and stated she was in pain.On October 23, 2013, at 10:36 a.m., Resident 9 was observed in bed crying, and when asked why she was crying she stated she was scared of the treatment. The licensed vocational nurse (LVN 1) was observed at the resident's bedside preparing for the resident's wound treatment. LVN 1 was observed during the treatment of the resident's hips and sacral (tailbone area) pressure ulcers. When LVN 1 removed the soiled dressing from the resident's right foot, which was discolored almost black, the resident began to cry. She had facial grimacing, and she flinched pulling her foot away from the nurse. LVN 1 asked the resident if she was in pain, and the resident nodded her head. At that time LVN 1 stated that the resident had received the scheduled pain medication prior to her treatment, and LVN 1 continued treatment to the resident's foot. The resident was asked by the evaluator if the pain medication helped, and the resident stated "no." The resident was observed flinching throughout the treatment, but LVN 1 did not stop providing the treatment, and reassess the possible need for more intervention. A review of Resident 9's admission record indicated the resident was readmitted to the facility on June 21, 2013, with diagnoses that included cerebrovascular accident (stroke) with hemiplegia (inability to move one side), dementia (cognitive and intellectual deterioration), and pressure ulcer to the hip and limb.The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated September 28, 2013, indicated Resident 9's cognition was severely impaired and she was totally dependent on staff with her activities of daily living, except in eating. The resident was incontinent of bowel and bladder, had functional limitation in range of motion (full movement potential of a joint, usually the range of flexion and extension) to upper (arms) and lower extremities. The MDS also indicated the resident had pain frequently and the pain intensity was moderate, and had a Stage III pressure ulcer (full thickness skin loss involving damage or necrosis (death tissue) of subcutaneous tissue) and Stage IV pressure ulcer (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structure). A review of the physician's order dated September 12, 2013 indicated the following pain medications:1. Hydrocodone/Acetaminophen (Norco) 5/325 one tablet by mouth one hour prior treatment.2. Tylenol (Acetaminophen) 325 milligram (mg), take two tablets (650 mg) by mouth every four hours as needed for mild pain. Not to exceed three grams of Acetaminophen per 24 hours.3. Hydrocodone/Acetaminophen (Norco) 5/325 one tablet by mouth every six hours as needed for moderate to severe pain.On September 20, 2013, the physician had ordered to continue the Santyl ointment treatment to the resident's left hip, sacral area and right fifth metatarsal (little toe) pressure ulcers daily for 30 days. The Nurse's Notes (notes) dated October 23, 2013, at 7:35 a.m., indicated the charge nurse was called to Resident 9's room. The resident verbalized and/or complained of pain, with a pain rating scale of 7 over 10 (a scale from 0 to 10 with 10 being the worst pain a person could experience) to her lower extremities. The documentation indicated the resident received Norco 5/325 mg at 6 a.m., was repositioned with help, and the resident verbalized feeling better.The notes indicated at 8 a.m., the charge nurse went back to the resident's room, at which time the resident had no facial grimacing and was watching T.V. At 8:25 a.m., the charge nurse was called back into the resident's room. The resident complained of pain, was repositioned and the resident verbalized feeling better. There was no documentation of a pain assessment for the resident's level of pain or location of the pain before or after the resident was repositioned. At 8:50 a.m., the resident complained of pain and Norco 5/325 mg scheduled to be given one hour prior to treatment was given.However, the treatment observation was done on October 23, 2013, at 10:36 a.m., which was one hour and 46 minutes after the pain medication was administered.When interviewed on October 24, 2013, at 10:50 a.m., LVN 1 admitted the resident's foot was painful to the touch. LVN 1 stated she should have stopped the treatment when the resident complained of pain during treatment, assess and check the resident's pain medication.According to the facility policy and procedure titled pain management revised date November 18, 2008, indicated to assess residents who have wound care orders for pain prior to the treatment, and to provide pain medication as ordered, at least 30 minutes before the treatment. Use the nonverbal indicators on nonverbal residents or residents lacking the mental capacity to use the pain rating scale. Record the follow-up observations (pain after interventions) one-hour post intervention. Record the location/cause of the resident's pain, and if there is an order to medicate the resident 30 minutes before the treatment, document the pain before the medication is given and during/after therapy. Therefore, the facility failed to ensure Resident 9, who was severely impaired in cognition, received pain medication one hour prior to the treatment of pressure ulcers as ordered by the physician, and failed to assess and monitor the effectiveness of the pain medication before and during pressure ulcer treatment. As a result Resident 9 was observed flinching with facial grimacing, throughout the treatment, complaining of pain and that she was scared. LVN 1 did not stop to assess the need for intervention to relieve the resident's pain. This violation had a direct relationship to the health, safety and security of Resident 9.
910000041	IMPERIAL CREST HEALTH CARE CENTER	910011064	A	15-Oct-14	UR9311	7736	45 CFR 483.25 F309 Quality of Care Each resident must receive and the facility must provide the necessary 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. On August 16, 2013, the Department of Public Health received an Entity Reported Incident alleging a resident suffered a fractured to his left pinky finger. On August 29, 2013, at 3:50 p.m., an unannounced visit was made to the facility to investigate the allegation.Based on observation, interview, and record review, the facility failed to: 1. Intervene when one of three sampled residents (1) repeatedly requested for certified nursing assistant (CNA 1) to not be assigned to Resident 1 due to CNA 1 being rough when providing care.CNA 1 roughly grabbed the phone away from Resident 1 resulting in Resident 1's fractured left fifth finger with skin laceration. Resident 1 was transferred to the hospital emergency room with pain level of ten on a scale of 10/10 (10 means the worst pain Resident 1 ever experienced). A splint was applied to Resident 1's fractured finger and a repair of the skin laceration requiring six sutures. This prevented Resident 1 from attaining his highest physical, mental, and psychosocial well-being.On September 24, 2013, at 2:20 p.m., Resident 1 was observed in bed receiving oxygen through a nasal cannula (device for delivering oxygen by way of two small tubes that are inserted into the nostrils) and watching television. Resident 1's right and left hand were contracted (loss of normal movement to the joint). During a concurrent interview, Resident 1 stated that he used to be able to bend and extend his left little finger and now he could not. When asked Resident 1 what happened to his left pinky finger, he stated, ?CNA 1 hurt me; she broke my finger.? According to Resident 1's admission record, he was originally admitted to the facility on October 1, 2005, with diagnoses that included central cord syndrome/C1-C4 (cervical/spinal cord injury characterized by weakness in the arms, hands, and legs), quadriparesis (weakness of all four limbs), and chronic obstructive pulmonary disease (COPD) exacerbation (lung disorder with increasing severity of symptoms which include increase of shortness of breath).The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated November 10, 2013, indicated Resident 1 was able to make daily decision with no short or long term memory problem. He was totally dependent on staff for activities of daily living (ADLs), such as transfers, dressing, and toilet use. Resident 1 was not ambulatory, utilized a wheelchair for mobility. Resident 1 had impairment of range of motion (movement of a joint) to both upper and lower extremities.A review of the facility's Incident Report dated August 5, 2013, indicated at 6:00 a.m., CNA 1 attempting to clean Resident 1, but the resident refused by asking CNA 1 to come back later at 6:30 a.m. According to this report, Resident 1 was angry. CNA 1 moved Resident 1's bedside table and was getting Resident 1's mobile phone out of the way. It was documented Resident 1 said, "Do not touch me" and slapped CNA 1 at the right side of her face. It was documented Resident 1 called 911 (emergency number) and was transferred to the hospital. A review of the Multidisciplinary Progress Record dated August 5, 2013; Resident 1 was transferred to the hospital.According to the hospital History and Physical Record dated August 5, 2013, indicated Resident 1 was admitted to the emergency room with left fifth finger pain. Resident 1's finger was repaired with six sutures and was place on a splint due to the fracture. Resident 1 was started on antibiotic (agent that either kills or inhibits the growth of a microorganism) Keflex 250 milligrams (mg) four times a day for seven days.A review of Resident 1's x-ray of the left hand indicated there was an acute (new) fracture of the fifth proximal phalanx (fifth digital bone). According to the hospital Triage Assessment dated August 5, 2013, at 7:14 a.m., Resident 1 had a pain scale of 10/10. During an interview with Resident 1 on September 24, 2013, at 2:45 p.m., he stated that on August 5, 2013, CNA 1 came into his room at about 6 a.m. He was lying on his right side. CNA 1 wanted to turn him on his back and to clean him up however, he told her to come back at 6:30 a.m. because he was not done having a bowel movement in his diaper (disposable adult brief). CNA 1 left and came back at about 6:15 a.m. Resident 1 told CNA 1 to come back at 6:30 a.m. CNA 1 got upset and said, "I will clean you up right now." Resident 1 said he was lying on his right side holding on the phone with his left hand when CNA 1 roughly snatched the phone away and the same time, he heard a pop sound.Resident 1 stated he swung his left hand to try to get CNA 1 away from him, but he only barely touched her shoulder. Resident 1 stated he noticed his left fifth finger bleeding with skin hanging down from his finger, so he called 911. Resident 1 said in the past, he had complained to the director of nursing (DON) and the director of staff development (DSD) about CNA 1 being rough when providing care and requested not to assign her to take care of him, however CNA 1 was still being assigned to him. During an interview with DSD on February 25, 2014, at 9:20 a.m., she stated Resident 1 was very alert and in the past had made multiple complaints against CNA 1 for being rough while providing care to him. DSD stated that Resident 1 had made several requests in the past to not be assigned to CNA 1; however, because of staffing issues it was not always possible.On March 7, 2014, at 7:25 a.m., during an interview with the registered physical therapist (RPT), she stated Resident 1's hands were contracted and could not fully extend his right and left fingers unless assisted.On March 7, 2014, at 8:10 a.m., an interview was conducted with the director of nursing (DON). When the DON was asked if Resident 1 ever complained to her about CNA 1 being rough with him when providing care she stated, "Yes, but I don't believe him because he complains all the time."On March 10, 2014, at 11:05 a.m., during an interview with CNA 1 via telephone, she stated that on August 5, 2013, Resident 1 had asked her to come back at 6:30 a.m. to help him however, she told him that she needed to clean him up. CNA 1 stated she moved Resident 1's side table away and that was when Resident 1 slapped her.A review of the Notice of Employee Reprimand dated April 19, 2013, indicated CNA 1 was suspended due to multiple complaints of nursing care by residents complaining of rough care and attitude. The document indicated the types of violation by CNA 1 included the following: 1. Violation of Policy/Procedures 2. Failure to Follow Job Description 3. Inappropriate behavior 4. Unprofessional behavior According to the Notice to Employee as to Change in Relationship, dated March 6, 2014, CNA 1 was discharge/terminated on March 6, 2014.A review of the facility's undated policy and procedure titled, "Prevention of Resident Abuse and Mistreat", indicated this facility will provide a safe environment as free of hazards and injury as possible.The facility failed to: 1. Intervene when Resident 1 repeatedly requested for CNA 1 to not be assigned to Resident 1 due to CNA 1 being rough when providing care.The above violation presented either imminent danger that serious harm would result, or a substantial probability that serious physical harm would result and did result to Resident 1.
910000041	IMPERIAL CREST HEALTH CARE CENTER	910011505	B	26-May-15	992V11	5940	?72520. Bed Hold (a) lf a patient of a skilled nursing facility is transferred to a general acute care hospital, as defined in Section 1250 (a) of the Health and Safety Code, the skilled nursing facility shall afford the patient a bed hold of seven (7) days, which may be exercised by the patient or patient's representative. On December 14, 2012, timed at 9:11 a.m., the Department received a complaint indicating a patient (Patient A) was transferred to the General Acute Cate Hospital (GACH) on December 4, 2012. The patient was treated for scabies (an easily spread skin disease caused by a very small type of mite, causes severe itching and underwent a right hip surgical repair. On December 10, 2012, six days later, the Skilled Nursing Facility (SNF) was informed of the patient's need for discharge and the SNF verbally accepted the patient back to the facility. However, once the patient was transferred back by ambulance, the facility refused the patient and sent him back to the GACH. On December 31, 2012, at 8:05 a.m., an unannounced complaint investigation was conducted. On November 19, 2014, a follow-up visit was made. The facility's staff failed to: 1. Follow its policy and procedure regarding the seven-day bed hold. 2. Re-admit Patient A to the facility within the seven-day bed hold, after receiving treatment from a GACH. A review of Patient A's Admission Face Sheet indicated the patient had resided at a Board and Care facility from April 12, 2011 through November 29, 2012, prior to an admission to the skilled nursing facility (SNF). The 71 year-old male was admitted to the SNF on November 29, 2012, with diagnoses that included resolving pneumonia (common lung infection caused by bacteria, virus or fungi), chronic obstruction pulmonary disease (COPD) exacerbation (sudden worsening of shortness of breath, quality and color of phlegm that may be triggered by an infection), schizophrenia (mental illness that involves false beliefs and suspicions that someone or something is trying to harm them) and psychosis (loss of contact with reality that usually include false beliefs about what is taking place or who one is). A review of a Minimum Data Set (MOS), an assessment and care screening tool, dated December 4, 2012, indicated Patient A was "modified independent" in daily decision-making, was non-ambulatory, and required limited assistance with most of his activities of daily living. According to a nurse's note, dated December 3, 2012, and timed at 4 p.m., Patient A complained of right leg pain and the patient stated he had a fall at the Board and Care (B/C) facility six weeks prior to the admission. The patient stated the B/C facility would not listen to him when he complained of pain. The patient's physician was called and ordered an x-ray. Another nurses' note, dated December 4, 2012, and timed at 11 a.m., indicated the patient had a right hip fracture. The patient's physician was again notified and ordered to transfer the patient to the GACH for further evaluation and treatment. Patient A was transported to the GACH on December 4, 2012 at 5:10 p.m. A review of pictures taken at the GACH, dated December 5, 2012, indicated the patient had a reddened prickly rash on the lower abdomen, coccyx/posterior thigh, left chest area and right lower leg with scratch marks. The rash was diagnosed as scabies. Patient A was placed in isolation and received two treatments with Elimite (a topical scabicidal agent for the treatment of infestation with Sarcoptesscabiei [scabies]). According to the GACH records, Patient A underwent a surgical repair of the right hip fracture on December 6, 2012 and treatment of scabies. On December 10, 2012, six days after admission to the GACH, Patient A was ready for discharge. The GACH's staff notified the SN F's RN supervisor (Staff 1) of the pending discharge and condition of the patient. Staff 1 informed the GACH to transfer the patient back. However, according to the GACH's records, an hour later, the patient's physician called the GACH and stated, "The director of nurses (DON) at the SNF refuses to accept the patient and he was returning back to the GACH." According to a letter, dated December 11, 2012, written by the GACH's case manager, the SNF's DON was called and was informed that the patient's transfer was within the seven-day bed hold and she stated, "He has scabies and I can't put him in a room with another patient." On January 3, 2013, at 10:30 a.m., during an interview, Staff 1, the SNF's RN supervisor stated she received a call from the GACH and they indicated the patient was on his way back to the facility. Staff 1 stated, "I told them Okay," and 20 minutes later they were here with the patient. Staff 1 was asked if Patient A was on a seven-day bed hold and she stated, "Yes." Staff 1 stated she called the patient's physician and he stated he had spoken to the GACH's social worker and informed them the patient was returning to the GACH. During a concurrent interview, the DON stated the physician did not think Patient A was appropriate for their facility, since he was alert and could take care of his own needs. The DON stated the patient should be back at the board and care facility. A review of the SNF's undated policy and procedure, titled, "Admission and Discharge for Bed Holds," indicated if a resident of the facility was transferred to a general acute care hospital, as defined in Section 1250 (a) of the health and Safety Code, the facility shall afford the resident a bed hold of seven (7) days that may be exercised by the resident or the resident's representative. The facility failed by not: 1. Following its policy and procedure regarding the seven-day bed hold. 2. Re-admitting Patient A to the facility within the seven-day bed hold, after receiving treatment from a GACH. The above violation had a direct relationship to the health, safety, or security of Patient A.
910000041	IMPERIAL CREST HEALTH CARE CENTER	910012633	B	6-Oct-16	W3M811	9002	F309 CFR 483.25 Each resident must receive and the facility must provide the necessary 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. Based on observation, interview and record review, the facility failed to provide the necessary care and services to Resident 1 by failing to: 1) Ensure Resident 1 was assessed for continuous itching and scratching to her chest, abdomen, left arm, and the back of her head. 2) Ensure Resident 1 was administered Benadryl (medication for itching) as ordered and implement nonpharmacological interventions to decrease the itching. 3) Ensure Resident 1 was provided with lotion and moisturizer for application after her bath to reduce the intense itching. This resulted in continuous intense itching, discomfort and distress to Resident 1which resulted in her crying. During an initial tour of the facility on August 16, 2016, at approximately 3 p.m. Resident 1was observed continuously scratching her chest, abdomen, left arm, and the back of her head. The resident had a black substance underneath her fingernails. The resident slid her head from side to side across the pillow, in what appeared to be an attempt to scratch the back of her head. Resident 1 was observed frowning, grimacing, moaning and groaning, and appeared to be uncomfortable. On August 17 at 8:20 a.m., the surveyor observed Resident 1 scratching her chest and abdomen continuously. At the same time the resident would slide her head from side to side across the pillow in an attempt to scratch the back of her head. Resident 1 was observed frowning, grimacing, moaning and groaning, and appeared to be uncomfortable. On August 17, 2016 at 10:20 am, during a bed bath Resident 1 was observed again continuously scratching her body. Employee 2 stated the resident had scratch marks on her chest and under her left breast. The chest area had two to three scratches measuring one to two inches in length. Under the left breast the scratch measured approximately two to three inches in length. In both areas the scratches were reddened and raised. Employee 2 used a liquid soap/body wash to bath Resident 1. However the soap was not completely rinsed off. Upon completion of the bath the resident had facial grimacing, was heard moaning, and looked very uncomfortable. A review of the physician's telephone order dated August 17, 2016 at 2:50 p.m., indicated to administer Atarax (anti-itch medication) 50 milligram (mg) to Resident 1 through her gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition, water, and medication directly to the stomach) every six hours as needed for itching. On August 17, 2016 at 4:35 p.m., Resident 1 was observed scratching her chest, abdomen, left arm, and sliding her head across the pillow looking extremely uncomfortable. Employee 3 asked Resident 1 if she would like lotion applied for the itching, the resident responded ?Yes?. Employee 3 checked the resident's drawer but there was no lotion or any type of protective skin barrier available for use. When the itching was reported to the charge nurse Employee 3 was informed Atarax had been ordered, (August 17, 2016, at 2:50 p.m.) but had not been delivered from the pharmacy yet. On August 19, 2016, at 9:45 a.m., Resident 1 was still scratching her chest and abdomen, sliding her head from side to side across the pillow and had tears in her eyes. When asked if the scratching was uncomfortable for her, she responded "yes." When asked if the staff applied lotion or moisturized her skin, she responded "no." Resident 1 was unable to speak in complete sentences. On August 19, 2016, approximately 2 p.m., when asked how it felt to shower, and have her hair shampooed, Resident 1 grabbed and held on to the Evaluator?s hand with tears in her eyes. A review of the medical records indicated Resident 1 was admitted to the facility on XXXXXXX 2016, with diagnoses that included End Stage Renal Disease (ESRD) which required dialysis, sepsis, diabetes, pressure ulcer, anemia, below the knee amputee and had a gastrostomy tube. A resident care plan dated August 2, 2016, addressed Resident 1 needing dialysis. The nursing interventions included providing the resident with good skin care. The Minimum Data Set assessment (MDS, a resident assessment and care planning tool) dated August 4, 2016, indicated Resident 1 was totally dependent on the staff for activities of daily living including bathing and personal hygiene. A review of the Certified Nursing Assistant notes for August 2016 indicated Resident 1 was provided a bed bath most of the time. The label on the shampoo/body wash used by the CNA's to bath the resident indicated the product should be rinsed off thoroughly. It was documented in the notes Resident 1 was dependent on the staff for grooming and hygiene. The multidisciplinary progress record (licensed nurse?s notes) from August 16 through August 19, 2016, did not contain documentation to indicate the licensed staff evaluated or assessed Resident 1's skin. There was no indication the licensed staff attempted to find out the cause of Resident 1?s itching or attempted non pharmacological interventions to decrease or stop the itch. The multidisciplinary progress record (licensed nurse?s notes) dated August 17, 2016, at 2:30 p.m., indicated Resident 1 was observed scratching and complaining of itching. The record indicated the physician ordered Atarax 50 mg every six hours as needed for the itch on the same day on August 17, 2016, at 2:50 p.m. However, Resident 1 had a previous order dated July 28, 2016, for Benadryl 25 mg every six hours as needed for itching. There was no documented evidence Resident 1 had been offered or administered Benadryl during the observations conducted on August 16, 2016, through August 19, 2016, prior to the Atarax being ordered. On August 19, 2016, at 9:30 a.m., during an interview with Family Member 1 while at Resident 1?s bedside, he stated he noticed the resident was always scratching all over her body, and was constantly rubbing her head side to side across the pillow. Family Member 1 stated it seemed like the resident's head itched a lot and may need to be shampooed. On August 19, 2016, during an observation in the presence of Employee 5, Resident 1 continued scratching, and looked uncomfortable. Employee 5 stated the CNA's should have reported the continuous itching to the licensed staff, who should have moisturized the resident's skin. Employee 5 stated she rotated the assignment for CNA's providing care for Resident 1 but could not explain why Resident 1 received such poor care On August 22, 2016 at 4:05 p.m., Employee 1 stated he made rounds approximately every four to six hours to see if the residents are comfortable, safe and if basic hygiene was being provided. Employee stated he had observed poor quality of care with some residents but had not discussed the concerns at the quality assurance meetings. Employee 1 could not explain why the licensed staff did not evaluate/assess Resident 1's continuous itching and discomfort and agreed non-pharmacological interventions should have been attempted (moisturizing/repositioning/out of bed) in addition to ordering medication. According to the National Kidney foundation, many dialysis patients have itchiness and dry skin. It is called uremic pruritus. Itchy skin is different for everyone, and it can happen at any time of day, on any part of the body, and be a bother for some more than others. Some dialysis patients say they feel itchy in one area, and others feel itchy all over. What?s important is trying to understand what may be causing it and finding the best way to manage it. Useful tips include to: ?Try to figure out what is causing the itching. Is it better at some times than others? What helps or makes it worse? Tell your healthcare team what changes you feel and see with your skin. ?Find a good skincare routine, with daily cleansing and moisturizing. Ask your healthcare team which moisturizers work best for your symptoms. ?Don?t scratch your skin! Scratching tends to make the itching worse, and may even damage the skin and lead to infection. (https://www.kidney.org/atoz/content/dialysis-dry-itchy-skin)). The facility failed to: 1) Ensure Resident 1 was assessed for continuous itching and scratching to her chest, abdomen, left arm, and back of head. 2) Ensure Resident 1 was administered Benadryl (medication for itching) as ordered for itching as needed. 3. Implement nonpharmacological interventions to decrease Resident 1?s itching. 3) Ensure lotion and moisturizer was available for application to Resident 1?s skin after her bath to reduce the intense itch. The above violations had a direct relationship to the health, safety, and security of Resident 1.
910000041	IMPERIAL CREST HEALTH CARE CENTER	910012838	A	27-Dec-16	None	9828	F223 The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. F323 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Based on observation, interview and record review, the facility failed to ensure Resident 1 and 2 were free from sexual abuse. Resident 1 and 2 were physically touched and exposed to inappropriate sexual behavior by Resident 3. This resulted in Resident 1 and 2 feeling emotionally distressed, not feeling safe and had the potential of being exposed to the human immunodeficiency virus (HIV- a permanent viral infection that causes progressive failure of the immune system). An unannounced complaint visit was conducted on October 3, 2016 at 11:05 a.m., regarding an alleged rape of Resident 1 by Resident 3 on September 29, 2016 at 10:45 a.m. A review of Resident 1's admission records indicated she was admitted on XXXXXXX, 2014 with diagnoses that included intracranial hemorrhage (bleeding within the skull), dysphagia (difficulty swallowing) with gastrostomy (opening into the stomach for nutritional support) and lesion (abnormal damage in tissue) at C7 level of the cervical spinal cord. a. During an interview on October 3, 2016 at 11:50 a.m., Resident 1 was able to state her name, date of birth, her present location and her reason/purpose for being at the facility. Resident 1 stated that a man (Resident 3) whom she had never seen before came into her room; she asked the resident what he was doing in her room. Resident 1 stated Resident 3 came towards her and touched her breast. Resident 1 stated Resident 3 ?did his business? and she began to cry and told him to get off her. Resident 1 was asked to explain ?did his business? the resident stated "rape". During the same interview, when asked how the incident made her feel, Resident 1 was observed being tearful and stated that she wanted to die while making a gesture with her right index finger sliding across her throat. Resident 1 stated that Resident 3 is ?tall and black" and she was afraid of him. Resident was observed being tearful, agitated and slapping her side using her right hand while recounting events. Resident 1 was asked if she felt safe at the facility, she stated ?No.? During an interview on October 3, 2016 at 1:00 p.m., the social services director (SSD) stated certified nurse assistant 1 (CNA 1) reported that Resident 1's room door was partially closed and upon entering the residents? room she observed Resident 3 standing at the foot of Resident 1?s bed with his penis exposed. The SSD stated Resident 1 was more tearful than normal after the incident. During an interview on October 3, 2016 at 3:50 p.m., CNA 3 stated that she was not present during the time of the incident however she observed Resident 1 crying while explaining the incident. During an interview on October 5, 2016 at 1:00 p.m., licensed vocational nurse 1 (LVN 1) stated that she was working as a charge nurse at the day of the incident when CNA 1 came running out of Resident 1's room and stated that Resident 3 was standing on the side of the bed exposing himself. LVN 1 stated when she entered the room; Resident 1 was making continuous hand gestures, was visibly upset and emotional. During an interview on October 5, 2016 at 1:10 p.m., CNA 2 stated a few minutes after CNA 1 had come out of Resident 1's room she walked in and observed Resident 1 lying on the bed with her diaper off and the lower part of her body was exposed. CNA 2 stated that Resident 1 was crying, trying to catch her breath and trying to explain what happened to her, she stated "he raped me, he raped me". During an interview on October 13, 2016 at 12:20 p.m., CNA 1 stated on September 29, 2016 at approximately 10 a.m., she noticed Resident 1's call light was on and the door was closed. CNA 1 stated she knocked on the door and tried to open it but noticed the bedside table was located behind the door. When CNA 1 pushed the door open she heard crying and observed Resident 3 standing with an exposed penis between Resident 1's legs. Resident 1?s legs that were hanging off the bed, her diaper was off and lying on the bed. CNA 3 pulled Resident 3 out from the room. CNA 3 further stated that Resident 1 was crying and breathing really hard and stated "fucker, fucker, rape, rape". A review of the general acute care hospital (GACH?s) emergency department transfer report authenticated on XXXXXXX 2016 indicated Resident 1 was transferred from facility with complaints of rectal and vaginal pain after an alleged sexual assault. The report further indicated that Resident 1 was sexually assaulted by a gentleman who indicated that he did sexually abuse her, did not use protection and has a history of AIDS and sexual abuse. A review if the GACH?s emergency department discharge report authenticated on XXXXXXX, 2016 indicated a diagnosis of sexual assault. b. During an interview on October 3, 2016 at 3:30 p.m., Resident 2 was lying on the bed, non-verbal but able to answer questions with hand gestures and head movements. In the presence of the resident's family member and the Director of Nurses (DON), asked Resident 2 if Resident 3 was observed in her room, Resident 2 gestured by touching her right breast. Resident 2 lifted her left arm and kicked out with her left leg then gestured by pressing the call light. Resident 2 was asked the person that touched her breast was an African American man the resident nodded her head up and down, indicating yes. When asked if the man had touched her, she nodded her head up and down, indicating yes. Resident 2 was asked what occurred after the man had touched her, Resident 2 gestured pointing to bed A (Resident 1). The family member stated that Resident 2 was upset at the time of the incident. A review of Resident 2's admission record indicated admission on August 4, 2011 and re-admitted on XXXXXXX 2016 with diagnoses that included aphasia (impaired speech), hemiplegia and hemiparesis (paralysis of one side of the body) of the right dominant side and muscle weakness. A review of Resident 2's MDS dated July 15, 2016 indicated the resident was cognitively intact.
920000078	IMPERIAL CARE CENTER	920008894	B	12-Jan-12	0RNT11	3938	Title 22, Division 5, Chapter 3, Article 6 - 72601((a) Alterations to existing buildings licensed as skilled nursing facilities or new construction shall be in conformance with Chapter 1, Division 17, Part 6, Title 24, California Administrative Code and requirements of the State Fire Marshal. On June 16, 2011, at 1:30 p.m., an unannounced visit was made to the facility to investigate a complaint regarding ongoing alterations to the facility without permits and/or approvals from the Office of Statewide Health Planning and Development (OSHPD). Based on observation, interview and record review, the facility failed to comply with the requirement from OSHPD, the authority having jurisdiction for alteration and construction work in healthcare facilities by: 1. Installing a gate in front of the exit corridor without permits or approval from OSHPD. 2. Installing various delayed egress locking mechanisms on exit doors and gates without obtaining permits or approvals from OSHPD. 3. Replacing the emergency power generator without review or acceptance from OSHPD. 4. Noncompliance with OSHPD Fire Marshal Fire and Life Safety Report from October 12, 2010, to May 31, 2011. During a tour of the facility on June 16, 2011, the Evaluator observed the following: A. A wrought iron gate, with a magnetic locking device in the fire resistive access corridor that reduced the width of the corridor and obstructed the path of egress.B. Magnetic lock devices on the side exit doors.C. The two exterior side gates that lead to public way were locked. D. A temporary emergency power generator. During an interview with the Administrator, she stated that the facility was ?getting bids? from outside companies to submit plans of the required work to be done to OSHPD for approval. She stated there was no approval documentation onsite from OSHPD for the temporary emergency power generator. A review of the OSHPD Field Visit Report dated May 31, 2011, indicated: 1. On October 12, 2010, the OSHPD Fire Marshal visited the facility and discussed the blocked exits and work that had been done without permits or approval from OSHPD.2. On December, 15, 2010, the OSHPD Fire Marshal met with a facility representative and discussed the work that had been performed at the facility without OSHPD permits and approvals.3. On February, 2011, the OSHPD Fire Marshal met with a facility representative and discussed the work that had been performed at the facility without OSHPD permits and approvals.4. On May 31, 2011, no progress was noted, and now the facility had installed magnetic locking hardware without permits and/or approval from OSHPD. 5. As noted and discussed with the facility representative on October 12, 2010, and multiple field visits since that date, no temporary generator had been provided, and the new generator had been placed in service without OSHPD review or acceptance in the temporary location. Since no attempt had been made by the facility to correct and/or rectify the above noted noncompliance, a Voluntarily Stop Work was requested until an adequate temporary generator has been provided and accepted by OSHPD. The facility failed to comply with the requirement from the Office of Statewide Planning Health Planning and Development, the authority having jurisdiction for alteration and construction work in healthcare facilities by: 1. Installing a gate in front of the exit corridor without permits or approval from OSHPD. 2. Installing various delayed egress locking mechanisms on exit doors and gates without obtaining permits or approvals from OSHPD. 3. Replacing the emergency power generator without review or acceptance from OSHPD. 4. Noncompliance with OSHPD Fire Marshal Fire and Life Safety Report from October 12, 2010, to May 31, 2011. These violations had a direct relationship to the health, safety, and security of all patients of the facility.
920000078	IMPERIAL CARE CENTER	920008895	B	12-Jan-12	OVV911	3391	Title 22, Division 5, Chapter 3, Article 6 - 72601((a) Alterations to existing buildings licensed as skilled nursing facilities or new construction shall be in conformance with Chapter 1, Division 17, Part 6, Title 24, California Administrative Code and requirements of the State Fire Marshal. On June 16, 2011, at 1:30 p.m., an unannounced visit was made to the facility to investigate a complaint regarding alterations to the facility without permits or approvals from the Office of Statewide Health Planning and Development (OSHPD). Based on observation, interview and record review, the facility failed to comply with the requirements from OSHPD, the authority having jurisdiction for alteration and construction work in healthcare facilities and to meet the standards for the prevention of fire and for the protection of life and property against fire by: 1. Removing approximately two feet of the lower level fire resistive corridor walls and vertical openings (elevator shaft and stairway) in the basement area without permits or approval from OSHPD. 2. Covering the wall and ceiling including the fire protection sprinkler system, smoke detector, and the fire alarm manual pull stations in the basement area, with plastic sheets, leaving the area unprotected against fire.During the tour of the facility on June 16, 2011, the evaluator observed maintenance workers repairing the basement areas from a previous incident of a sewage leak that occurred on June 14, 2011. The evaluator observed, approximately two feet of the lower level fire resistive corridor walls and vertical openings (elevator shaft and stairway) in the basement area were removed. The evaluator also observed exposed electrical boxes and wiring. In addition, the walls and ceilings, including the fire protection sprinkler system, smoke detectors, and the fire alarm manual pull stations in the basement area were covered with plastic sheets, increasing the flame spread factor and leaving the area without a fire protection system and separation of hazardous areas such as medical records storage room, water heater rooms, and main electrical room. The kitchen was also housed in the basement. During an interview with the maintenance supervisor, he stated there was no one in the basement areas at night, and the repair work had been ongoing since June 14, 2011. The facility initiated a fire watch after the evaluator expressed concerns regarding the covering of the fire protection system and partial removal of the fire resistive walls during repair work in the basement area. The facility failed to comply with the requirements from OSHPD, the authority having jurisdiction for alteration and construction work in healthcare facilities, and to meet the standards for the prevention of fire and for the protection of life and property against fire by: 1. Removing approximately two feet of the lower level fire resistive corridor walls and vertical openings (elevator shaft and stairway) in the basement area without permit or approval from OSHPD. 2. Covering the wall and ceiling including the fire protection sprinkler system, smoke detector, and the fire alarm manual pull stations in the basement area, with plastic sheets, leaving the area unprotected against fire. The above violations had a direct relationship to the health, safety, and security of all patients of the facility.
920000078	IMPERIAL CARE CENTER	920013278	B	13-Jun-17	SXWH11	4173	483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident?s symptoms. 483.12(a) The facility must- (a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; On 5/3/17, at 10:15 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding an altercation between Resident 1 and Certified Nurse Assistant 1. Based on interview and record review, the facility failed to ensure written policies and procedures that prohibit abuse of residents were implemented including: 1.Failure to uphold a resident's right to be free from abuse or willful infliction of injury resulting in physical harm, pain, or mental anguish. As a result, on 4/20/17, CNA 1 was observed pulling Resident 1?s hair and slapping the resident. Resident 1 was transferred to the general acute care hospital for evaluation and 5150 (when a person, as a result of a mental health disorder, is a danger to others, or to himself or herself, or gravely disabled). A review of the clinical record indicated Resident 1 was admitted, on XXXXXXX 17, with diagnoses including unspecified psychosis (exhibiting personality changes and thought disorder), muscle weakness, hypertension (high blood pressure), major depressive disorder (persistent feeling of sadness, loss of interest), and anxiety. A review of the facility investigation, dated 4/20/17, at 6:25 p.m., indicated certified nurse assistant (CNA 1) reported to the registered nurse supervisor (RN 1) that Resident 1 became aggressive and scratched CNA 1. Resident 1's daughter, who stopped by to visit, reported to RN 1 that Resident 1 was slapped and kicked by CNA 1. CNA 1 was placed under suspension pending investigation. The facility investigation indicated CNA 2 was present during the alleged event and confirmed Resident 1's statement about being hit, however there were no apparent injuries noted for Resident 1. On 5/3/17, at 10:57 a.m., during an interview, CNA 3 stated nursing assistants have a buddy system. CNA's enter in pairs to address the needs of certain residents who may require more assistance. CNA 3 stated staff recently received an in-service on abuse prior to the date of the incident. During a phone interview, on 5/3/17, at 12:45 p.m., CNA 2 stated during the time this incident took place, Resident 1 asked for assistance to return to bed. CNA 1 and CNA 2 were working together for Resident 1 during diaper change. Resident 1 then became aggressive and scratched CNA 1. CNA 1 then pulled Resident 1's hair, and then both proceeded to slap each other. CNA 2 then told CNA 1 to leave the room and notify RN 1. A review of the in-service records indicated, on 4/19/17, from 3 p.m. to 4 p.m., staff watched a video titled, "Elder Abuse and Prevention." CNA 1 was included in the attendance sign in sheet. The video covered the types of abuse, how to report, and who was responsible for reporting. During an interview, on 5/5/17, at 2:20 p.m., the Administrator of the facility / Abuse Coordinator stated and confirmed the abuse did occur. A review of the undated facility policy titled, "Abuse & Mistreatment of Residents," indicated the purpose was to uphold a resident's right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion. The policy defined "Abuse" as willful infliction of injury, unreasonable confinement, or punishment with resulting physical harm or pain or mental anguish. The facility failed to ensure written policies and procedures that prohibit abuse of residents were implemented including: 1.Failure to uphold a resident's right to be free from abuse or willful infliction of injury resulting in physical harm, pain, or mental anguish. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.
920000078	IMPERIAL CARE CENTER	920013418	B	8-Aug-17	RW6F11	6044	F-205 483.15 (b) Notice of bed-hold policy and return- (1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies- (i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under ? 447.40 of this chapter, if any; (iii) The nursing facility?s policies regarding bed-hold periods, which must be consistent with paragraph (c)(5) of this section, permitting a resident to return; and (iv) The information specified in paragraph (c)(5) of this section. (2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (e)(1) of this section. On 6/20/17, at 11 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Admission and Discharge Rights. Based on interview and record review, the facility failed to ensure its bed-hold and re-admission policies were implemented by failing to: 1. Provide Resident 1 and/or Family Member 1 with a written notice specifying the duration of the bed-hold policy at the time of transfer for hospitalization. 2. Hold the bed for seven days when Resident 1 was transferred to a general acute care facility (GACH) on XXXXXXX17 for behavior evaluation. 3. Allow Resident 1 to return and resume residence in the facility when the resident was ready for discharge from the GACH, one day after transfer and within the seven day bed-hold period on 6/16/17. As a result, Resident 1 remaining in the GACH for several days while the staff at the GACH found another placement at another skilled nursing facility (SNF). According to the Admission Face Sheet, Resident 1 was admitted to the facility on XXXXXXX17 with the diagnoses including schizophrenia (severe mental disorder in which people interpret reality abnormally), diabetes (high blood sugar), hypertension (high blood pressure), and anxiety (nervousness) disorder. Family Member 1 was listed as the resident's guarantor (responsible party). The nursing Admission Assessment dated 6/5/17 indicated Resident 1 was alert, disoriented, unable to walk, needed physical assistance with transfers, personal hygiene, and bathing. A review of the Physician's Order dated 6/15/17, indicated to transfer Resident 1 to a GACH emergency room for a psychiatric evaluation. There was no physician's order for a seven-day bed hold. Further review of Resident 1's clinical record disclosed no evidence of a written notification to Family Member 1 regarding seven days bed-hold, the facility's Bed-hold policy upon or after Resident 1 was transferred to the GACH. During an interview on 6/20/17 at 11:25 a.m., the director of nurses (DON) stated when a resident is transferred to a GACH, a Notification of Bed-Hold is provided and within seven days, the facility is required to accept the resident back. The DON confirmed a Bed-hold notice was not provided to Resident 1 or to Family Member 1. During an interview on 6/20/17 at 12 p.m., the assistant DON (ADON) stated she did not fill out the Notification of Bed Hold when the resident was transferred on XXXXXXX 17, because the psychiatrist was not going to readmit the resident. The facility's policy and procedure titled, "Bed Hold Notification," dated 1/2004 indicated the facility shall inform the resident, or the resident's representative, in writing of the right to exercise the bed hold provision under the state plan (7 days for California), at the time of admission, and at the time of transfer for hospitalization or therapeutic leave. A copy of this notice shall be a part of the resident's health record at the time of transfer. On 6/20/17 at 12:50 p.m., during an interview, the Administrator stated the psychiatrist recommended not accepting the resident back to the facility and the Notification of Bed Hold was not given to the resident. The administrator further stated, "I understand that this is against our policies and guidelines but I can't accept the resident back. That is the reason a bed hold notice was not filled out." A review of the Discharge Summary from the GACH indicated on 6/16/17 the resident was ready for discharge back to the facility. A review of the GACH Progress Note by a case manager, dated 6/19/17 indicated Resident 1 had discharge order and the facility was refusing to take the resident back due to his aggressive behaviors. On 7/19/17, a Refusal to Readmit Appeal was conducted by the California of Department of Health Services Office of Administrative Hearing. The Appeals Decision Order dated 7/27/17 indicated the facility failed to offer Resident 1 a written bed-hold notice and ordered the facility to readmit Resident 1. The facility failed to ensure its bed-hold and re-admission policies were implemented by failing to: 1. Provide Resident 1 and/or Family Member 1 with a written notice specifying the duration of the bed-hold policy at the time of transfer for hospitalization. 2. Hold the bed for seven days when Resident 1 was transferred to a general acute care facility (GACH) on 6/15/17 for behavior evaluation. 3. Allow Resident 1 to return and resume residence in the facility when the resident was ready for discharge from the GACH, one day after transfer and within the seven day bed-hold period on 6/16/17. As a result, Resident 1 remaining in the GACH for several days while the staff at the GACH found another placement at another skilled nursing facility (SNF). The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.
940000115	IMPERIAL HEALTHCARE CENTER	940008612	A	06-Feb-12	J9D911	9752	Title 22 72311. Nursing Service - General (a) Nursing service shall include, but not limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon 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. 72315. Nursing Service-Patient Care. (f) Each patient should be given care to prevent formation and progression of decubiti, contractures and deformities. Such care should include: (4)Using pressure-reducing devices where indicated.On 2/23/11, at 11:40 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient 1?s quality of care. Based on interview and record review, the facility failed to provide treatment and services to prevent formation and progression of a pressure sore to the coccyx (tailbone) area for Patient 1, who entered the facility without a pressure sore, by failing to: 1. Provide pressure relieving surfaces in the bed and on the chair as a preventive measure. 2. Provide an on going accurate skin assessment to promptly identify pressure sore development. 3. Accurately assess a pressure sore?s stage and location.Patient 1 developed a Stage III pressure sore to the coccyx that measured one centimeter (cm) by one cm which required inpatient and outpatient wound care. The National Pressure Ulcer Advisory Panel and the facility?s policy, define a Stage III pressure sore as full thickness of skin loss with subcutaneous fat that may be visible. Slough (dead tissue) may also be present and may include undermining and tunneling. On 2/23/11, a review of the clinical record revealed Patient 1 was an 82 years old female, admitted to the facility from an acute care hospital on 1/6/11, with diagnoses that included status post left hip open reduction and internal fixation (ORIF) surgery to repair a left femur neck fracture, hypertension, obesity and diabetes mellitus. The initial data collection nursing assessment and nursing note dated 1/6/11, indicated the patient had no pressure sores on admission, but had two surgical wounds with staples to the left hip, one measuring 3.5 cm with four staples and the other measuring six cm with eight staples.A Braden Scale for Predicting Pressure Sore Risk form dated 1/6/11, had a total score of 16. The Braden Scale includes the risk factors of sensory perception, moisture, activity, nutrition and friction and shear. The patient was assessed at risk for skin breakdown. (According to the Braden Scale, a total score of 9 or less indicates very high risk for development of pressure sore; a total score of 10 to 12 indicates high risk; a total score of 13 to 14 indicates moderate risk; and a total score of 15 to 18, indicates at risk).A care plan dated on admission, 1/6/11, disclosed the patient was at risk for break in skin related to a Braden Scale score of 16 and bladder incontinence. The interventions indicated to keep the patient clean and dry after incontinent episodes, and to reposition every two hours in bed and in chair. The interventions did not include providing pressure relieving surfaces in bed and/or on the chair. A plan of care dated 1/8/11, developed for the patient?s altered skin due to two surgical wounds, immobility, low hemoglobin, problem with friction and shear, incontinence, diabetes, obesity and hypertension had a goal to minimize further skin breakdown within the next 21 days. The approaches included to monitor body for skin breakdown, encourage fluid intake, and provide wound care treatment as ordered. The interventions did not include providing pressure relieving surfaces in bed and/or in the chair. According to the Patient ADL (activities of daily living) Score form from 1/12/11 to 1/18/11, the patient required limited assistance with transfers, bed mobility, toilet use and walking. According to the nurses? notes from 1/6/11 to 1/16/11, the patient was receiving and tolerating physical and occupational therapy five times a week since 1/7/11. The daily nursing notes did not reflect an ongoing assessment of the patient?s skin for skin breakdown. The nursing Weekly Summary form dated 1/10/11, indicated the skin condition was good and no pressure sores were identified. A nurse?s note dated 1/16/11, documented the physician ordered (at 3 p.m.) a treatment with Calmoseptine (a topical moisture barrier) daily to buttocks for skin maintenance and a daily treatment with Santyl ointment (active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level) and to cover with Allevyn dressing (absorbent dressing) to an open sore on the sacral (above the coccyx) area which measured 3.4 cm in length, 0.9 cm in width with no depth and had 80 percent (%) yellow slough and 20% granulating tissue (soft pink fleshy projections that form during the healing process in a wound that does not heal by primary intention). A Pressure Ulcer Status Record form dated 1/16/11, documented the patient had a Stage II pressure sore to the sacral area, first observed 1/16/11. However, the form described a Stage II pressure sore as a partial thickness loss of skin layers that presents clinically as an abrasion, blister, scab or shallow crater. There was no documentation addressing the fact that the pressure sore was identified when there was already a 20% formation of healing tissue with 80% dead tissue.A plan of care dated 1/16/11, developed for the open sore to the sacral area, included in the approaches to monitor the body for skin breakdown, encourage fluid intake and provide a pressure reduction mattress.The Weekly Skin Integrity Data Collection dated 1/10/11, indicated the skin was intact and the patient had (surgical) incision sites to the left hip. The Weekly Skin Integrity Data Collection dated 1/17/11, a day after the patient?s pressure sore was identified, Licensed Vocational Nurse 1 (LVN 1) documented that other than the incision sites to the left hip, the patient?s skin was intact. Further record review indicated on 1/17/11, the patient was diagnosed with a urinary tract infection per laboratory test result and developed nausea and vomiting. On 1/18/11, a laboratory tests result suggested dehydration and the physician ordered the patient transferred to an acute care hospital for further evaluation. There was no documented evidence before the patient?s transfer to the acute hospital on 1/18/11, that a pressure relieving mattress was provided as stated in the plan of care developed on 1/16/11. According Acute Care Hospital 1 clinical record, with an admission dated 1/18/11, the patient was diagnosed with severe dehydration and sepsis secondary to acute pyelonephritis (kidney infection). The skin assessment including photographic records, indicated upon arrival to the emergency room, on 1/18/11, the patient had a Stage III/IV pressure sore to the coccyx (not in the sacral area as assessed by the facility), the size of the pressure sore was not stated. The patient was assessed as having a Braden Scale score of 9 (very high risk).On 2/23/11, at 4:10 p.m., during an interview, LVN 1 stated according to his nursing notes, other than the hip incision sites, the skin was intact on 1/17/11. According to the facility?s Pressure Ulcer Care Guide, Pressure Ulcer Prevention revised 10/7/10, protocols for prevention of skin breakdown included the use of an anti-pressure device in bed and on chairs. According to the Centers for Medicare and Medicaid Services (www.cms.gov) air-fluidized beds, are covered by Medicare to be used for patients with Stage II and IV pressure sores due to these surfaces being the most effective and appropriate support surfaces for Medicare patients with Stage II and IV pressure sores. On 2/23/11, at 3:30 p.m., during an interview, the Assistant Director of Nursing stated patients at risk for pressure sore development should be provided with pressure relieving mattress, such as an alternating pressure pad (APP) overlay mattress.On 4/12/11, at 3:10 p.m., during an interview, Registered Nurse 1 (RN 1) stated patients with diagnosis of diabetes are prone to skin breakdown and poor wound healing. Preventive interventions included the use of a pressure relieving mattress. On 4/12/11, at 4:05 p.m., during an interview, Treatment Nurse 1 (TN 1) stated the facility has an available APP mattresses for use with patients at risk for skin breakdown. TN 1 could not explain why Patient 1 was not provided with the APP mattress on or after 1/16/11. TN 1 further stated when a pressure sore has slough, it will be considered a Stage III pressure sore and a low air loss mattress would be appropriate, not an APP mattress. The facility failed to provide treatment and services to prevent formation and progression of a pressure sore to the coccyx for Patient 1, who entered the facility without a pressure sore, by failing to: 1. Provide pressure relieving surfaces in the bed and on the chair as preventive measures. 2. Provide an on going accurate skin assessment to promptly identify pressure sore development. 3. Accurately assess a pressure sore?s stage and location. Patient 1 developed a Stage III pressure sore to the coccyx that measured one centimeter (cm) by one cm which required inpatient and outpatient wound care.The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Patient 1.
940000065	INTERCOMMUNITY CARE CENTER	940009760	B	27-Feb-13	YPQR11	3565	72541 ?Unusual Occurrences Occurrences such as epidemic outbreaks, poisoning, 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 Marshall. On 1/17/13, at 12:55 p.m., an unannounced visit was made to the facility to investigate a complaint related to quality of care.Based on interview and record review, the facility failed to report an unusual occurrence that involved Patient 1 to the Department within 24 hours by failing to: Report that on 12/25/12 at 7:30 p.m., Patient 1 was noted missing and after a search throughout the facility the patient was not found. The police department was notified and a missing person report was filed. As of 2/7/13, the patient had not been found. According to Patient 1?s closed clinical record review, the Admission and Discharge Summary sheet (face sheet) indicated the patient was a 62 years old male, admitted to the facility on 6/22/12, with diagnoses including dementia (a loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior.), paranoid schizophrenia [is a schizophrenia subtype in which the patient has false beliefs (delusions) that somebody or some people are plotting against them or members of their family] and hypertension (high blood pressure). The admission Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 7/4/12, disclosed the patient was able to communicate his needs, had memory problems, was able to walk independently and needed assistance with personal hygiene and bathing. According to the nursing notes on 12/25/12, at 7:30 a.m., the patient was not located and after searching the facility; a missing person police report was filed. According to the facility?s investigation report, the patient was last seen by a nursing staff on 12/24/12 at 9:30 p.m. According to the facility?s undated nursing policy and procedure on unusual occurrences, occurrences which threaten the welfare, safety, or health of patients, personnel, or visitor are reported by the facility for within 24 hours either by telephone (and confirmed in writing) or by fax to the Local Health Officer and the Department of Health Services.On 2/7/13 at 2:30 p.m., during an interview, the administrator and the director of nursing were unable to provide documented evidence the Department was notified of the missing patient. The facility failed to report an unusual occurrence that involved Patient 1 to the Department within 24 hours by failing to: Report that on 12/25/12, at 7:30 p.m., Patient 1 was noted missing and after a search throughout the facility the patient was not found. The police department was notified and a missing person report was filed. By 2/7/13, the patient had not been found. The above violation had direct or immediate relationship to the health, safety or security of Patient 1.
940000065	INTERCOMMUNITY CARE CENTER	940011250	A	05-Feb-15	C9MU11	11938	72523. Patient Care Policies & Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved The Department received a complaint allegation on September 19, 2012, alleging a patient?s (Patient A) urinary catheter was pulled by a nurse, which ripped the patient?s urethra (a tube that allows urine to pass out of the body) causing him to bleed and be hospitalized for three days. An unannounced complaint investigation was initially conducted on September 21, 2012, and a follow-up investigation was conducted on September 5 and 8, 2014.Based on interview and record review, the facility?s staff failed to: Follow its written policy and procedure when inserting an indwelling urinary catheter into Patient A.As a result of the licensed nurse not following the facility?s policy regarding urinary catheters insertion, Patient A had to be transferred to a general acute care hospital (GACH) after sustaining a rupture urethra, with bladder distention, and excessive bleeding from the urethra meatus, requiring intravenous (IV) pain medication. Patient A required surgery (cystoscopic transurethral resection [a slender cylindrical instrument for examining the interior of the urinary bladder as a surgical procedure that is used both to diagnose bladder cancer and to remove cancerous tissue from the bladder] and hospitalization for six (6) days.A review of Patient A?s Admission Face Sheet indicated the patient was a 55 year-old male, who was admitted to the facility on June 16, 2009. The patient?s diagnoses included advanced Alzheimer?s (the most common form of dementia, exhibited with memory loss and other intellectual abilities serious enough to interfere with daily life), scoliosis (curvature of the spine), chronic obstructive pulmonary disease (COPD/respiratory disease which causes difficulty in breathing), and diabetes mellitus (a disease resulting in the inability of the pancreas to secrete enough insulin resulting in high blood sugars). A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated March 6, 2012, indicated Patient A was dependent on staff for all activities of daily living, including personal hygiene. According to the MDS, Patient A was frequently incontinent (inability to control) of bowel and bladder.A review of a licensed nurses? note, dated March 5, 2012, and timed at 12 p.m., indicated the patient had an open area (small superficial area/diaper irritation) to the scrotum.According to the note, the physician was notified and an order was given to insert an indwelling urinary catheter (Foley/a tube placed through the urethra into the bladder to drain urine) for ?wound healing.? The licensed nurse transcribed the order on the treatment sheet, dated as March 5, 2012. According to the treatment record for March 2012, on the 5th, the indwelling catheter was inserted for wound healing.A review of an article with references from the Journal of Wound, Ostomy and Continence Nursing, for the year 2007, titled, ?Indwelling Catheter Indications and Care? indicated the presence of Stage III or IV pressure ulcers, that are not healing because of the continual urine leakage was an indication for a short-term catheter placement. However, Patient A had a superficial opened area on the scrotum.A review of a licensed nurses? note, dated March 6, 2012, and timed at 11:30 AM, indicated the patient was up in Geri (reclining) chair and appeared to be very anxious. Patient A was noted by various certified nursing assistants (CNAs) attempting to tug at the indwelling catheter and diaper area.A review of another licensed nurses? note, dated March 6, 2012, and timed at 1 p.m., indicated the patient was taken to his room and placed into bed. According to the note, Patient A was noted with bleeding from the catheter site, after the patient?s hands were noted holding the indwelling catheter. The physician was called immediately and ordered was given to discontinue the catheter. According to the note, the catheter was removed by the nurse and there was gross amount of bleeding with clots from the penis. The physician was subsequently notified again at 1:27 PM and ordered for the patient to be transferred to the GACH.A review of a the GACH?s emergency room (ER) note, dated March 6, 2012, indicated the patient presented after a catheter was inserted and removed and there was bleeding from the urethra. The patient exhibited pain and was given morphine sulfate 5mg IV push. The ER assessment included to rule out urethral tear. According to the note, a Foley catheter placement was attempted, but there was blood return with resistance with the inability to inflate the balloon.The patient was examined by an urologist (a physician who specializes in the urinary tract) on March 6, 2012. The urologist documented after the examination, ?At the time of evaluation, the patient had a second attempt to place a Foley catheter, and the Foley could not go into the bladder. Because of this, a retrograde urethrogram (an examination of the urethra by X-ray imaging) was obtained, and showed there was a moderate degree of obstruction in the area of the bulbous urethra, with obvious extravasion (leakage of a fluid, in the case of inflammation) which is consistent with a urethra laceration and tear. The note indicated, the patient apparently had a possible urethral stricture, and the Foley catheter balloon may have been inserted into the bulbous (resembling a bulb especially in roundness or the gross enlargement of a part) urethra and then inflated.?The urologist?s consultation report, dictated on March 6, 2012, at 10:06 PM, indicated the patient apparently had a urethral stricture and the catheter?s balloon may have been inserted into the bulbous urethra and inflated. The physical examination revealed the patient had a mass in the bulbous urethra. The diagnostic impression was a bulbous urethra laceration and a possible urethral stricture. Patient A underwent a transurethral resection and incision of the urethral stricture was performed with a placement of an indwelling urinary catheter with noted urinary retention.The GACH?s Discharge Summary, dictated on March 12, 2012, indicated the patient?s discharge diagnoses included urethral laceration, secondary to Foley trauma; urinary retention, secondary to occluding blood clots; gross hematuria secondary to the above; urethral stricture and benign prostate hypertrophy (noncancerous enlargement of the prostate [a walnut-sized gland located between the bladder and the penis] gland). Patient A was discharged back to the SNF facility on March 12, 2012, six days after admission to the GACH.According to a Nursing Services Manual, with references that included the Centers for Disease Control and Association of Practitioners in infection control guideline, dated year 2005, indicated the smallest size catheter size should be used to prevent trauma and provide good drainage, which is usually 4-18 French.On September 5, 2014, at 1:15 p.m., LVN 1 wrote the following declaration regarding the insertion of the indwelling urinary catheter on March 6, 2012 for Patient A: ?I inserted the Foley Catheter until urine began to come out of the catheter end. I pushed the Foley catheter further back to where the line of the catheter indicated to stop and I couldn?t push anymore. I then inflated the catheter balloon with saline syringe and attached the Foley bag. The patient did seem a bit uncomfortable with the Foley catheter in place, but I taped the catheter to the side of his leg which seemed to offer some relief.?According to the above written declaration, after LVN 1 obtained an initial flow of urine during the catherization on March 6, 2012, the catheter was advanced to the point where it could not be ?pushed anymore.? LVN 1 documented the patient (Patient A) appeared to be ?uncomfortable? after the catheter?s balloon was inflated. However, there was no documentation in the chart the indwelling catheter was re-adjusted or removed, as stipulated in the facility?s policy, until after Patient A was noted with bleeding from the penis.A review of the facility?s undated policy and procedure, titled, ?Catheterization,? indicated the catheter should be inserted into a male?s urethra until urine begins to flow out of the catheter. If the catheter cannot be advanced after the initial flow of urine is obtained, the angle of the penis should be adjusted and another attempt should be made to advance the catheter further. If the catheter still cannot be advanced, the procedure should be stopped and the physician notified.The director of nursing (DON) was asked on September 5, 2014, at 2 p.m., if she would advance an indwelling urinary catheter until an obstruction or pressure was felt and then inflate the balloon. The DON stated it had been many years since she inserted a catheter. The DON stated the facility does not usually admit patients with, nor do they insert indwelling urinary catheters. The DON stated she would make sure that LVN 1 does not insert any indwelling urinary catheters in the future in the facility. The DON referred the evaluator to the director of staff development (DSD) for further questioning regarding proper insertion of the indwelling catheter.On September 5, 2014, at 2:30 p.m., the DSD was interviewed and asked if a licensed nurse should advance a urinary catheter pass the point there was urine flow. The DSD stated she would instruct licensed nurses to advance the catheter until urine return was obtained, then advance the catheter a ?little bit? further to the pre-marked line on the catheter and then inflate the balloon. The DSD was then asked what the nursing action should be if the catheter insertion met a barrier, which prevented further advancement, she stated, ?I would stop the procedure and notify the doctor.?The facility?s in-service education records were reviewed on September 8, 2014, there was no evidence the licensed nursing staff was in-serviced or trained on the proper insertion and care of indwelling urinary catheters.During a subsequent interview, on September 8, 2014, at 11:30 a.m., the DSD verified the facility had not provided the nursing staff any training or checked skills inventory regarding indwelling urinary catheters insertion to the nursing staff.On September 8, 2014, during the review of the facility?s orientation package for all licensed nurses, there was no evidence the licensed nurses were skilled checked for the placement of indwelling urinary catheters. A review of LVN 1?s employee file on the same day indicated LVN 1 had not been assessed of her knowledge and skill level of in inserting indwelling urinary catheters before LVN 1 inserted the urinary catheter into Patient A.The licensed vocational nurse (LVN 1), who inserted the indwelling urinary catheter into Patient A, was interviewed on September 12, 2012, at 11:35 AM. During the interview, LVN 1 made the following statements: ?During the insertion of the patient?s urinary catheter, I pushed until I got pressure then I inflated the balloon on the 20 Fr (French) size catheter. When she was asked why she used a 20 Fr, LVN 1 stated, ?I used a 20 Fr catheter, because that was all we have (in the facility) and it?s the same one we use for gastric tubes.? The facility failed by not: Following its written policy and procedure when inserting an indwelling urinary catheter into Patient A.The above violations either jointly, separately, or in any combination presented an imminent danger that serious physical harm would result and was a direct cause of serious physical harm to Patient A.
940000065	INTERCOMMUNITY CARE CENTER	940011606	A	10-Jul-15	E2EP11	6739	?F323 ? 483.25 (h) Accidents The facility must ensure that (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The Department received an entity reported incident (ERI) on 12/1/14, regarding a resident (Resident 1) going missing on 12/1/14. The ERI indicated the facility notified the police Department. The facility failed by: 1. Not providing a safe and secure environment for Resident 1. 2. Not supervising Resident 1, who had a history of elopement. 3. Not developing a plan of care and conducting a risk assessment. 4. Not having established policy and procedure on elopement risk assessment and prevention.These failures put Resident 1, who did not have the ability to make decisions, required assistance with daily care, had a diagnosis of seizures (episodes of disturbed brain activity), with a history of elopement, at risk for serious injury and harm, including death. As of 2/4/15, according to the facility?s staff, Resident 1 had not been found.A review of Resident 1's clinical records indicated he was a 47 year-old male who was admitted to the locked facility, which provided therapy for substance abuse, mental illness and or other behavioral problems on 10/2/13. His diagnoses included dementia (a loss of brain function that occurs with certain diseases and which affects memory, thinking, language, judgment, and behavior), history of traumatic brain injury secondary to being assaulted with a baseball bat with multiple skull fractures and bleeding, aphasia (a language disorder that affects a person's ability to talk and understand the spoken word) and seizure disorder (episodes of disturbed brain activity that cause changes in attention or behavior). A Minimum Data Set (MDS), an assessment and care screening tool, dated 12/21/14, indicated Resident 1 usually had the ability to understand, but could not speak, but the staff could understand him sometimes. The MDS indicated the resident had both short and long-term memory problems and was moderately impaired in daily decision-making. According to the MDS, Resident 1 required supervision with ambulation off the unit and required extensive assistance (staff provided weight bearing support) with dressing, hygiene, and bathing. On 12/2/14 at 11 a.m., the director of nurses (DON) stated Resident 1 was last seen on 12/1/14 at 5 a.m. in the winter dining room. On 12/2/14, at 6:45 a.m., the staff members were not able to locate Resident 1 for breakfast and then notified the DON. The DON stated they searched the facility and the perimeter and drove around in the community searching for Resident 1. The DON stated they notified the Police Department and the Department of Public Health. The DON stated the staff found a wheelchair next to the storage shed and they believed Resident 1 used it as a climbing device to jump over the chain-linked fence to the outside of the facility.At 11:30 a.m., on 12/2/14, during a tour of the facility and the surrounding grounds accompanied by the DON, there was a large plastic trash can that was not secured on the barbeque patio and could be moved and used as a climbing device. The perimeter was fenced in with a chain link fence approximately eight feet high separating the facility from a freeway. However, a section of the fence, by an electric pole in Station A?s patio, was only approximately six feet high. By the barbeque patio, next to the side of the building, there were two large storage sheds. According to the DON, that was where they found the wheelchair that they believe Resident 1 used to climb unto the storage shed in order to jump over the chain-linked fence to the outside of the facility. The two storage sheds created a blind spot where a resident could jump the fence and not be seen. The roof of the large storage shed was broken on the corner and the top of the chain link fence was bent on the same side. The DON stated there were surveillance cameras by the sheds, but she had not been able to access them for several weeks and they have not developed a system to monitor the activities captured on the cameras. The DON stated they had not developed a system for the staff members to make rounds outside the facility in order to secure the perimeters.During an interview, on 12/2/14, at 12 p.m., the social service director (SSD) stated Resident 1 was known to have walked away from another facility prior to his admission to the facility. The SSD stated that was why the discharge planner from the previous hospital wanted Resident 1 admitted to a locked unit. When the SSD was asked why, she stated Resident 1 was not able to care for himself and needed supervision, which included watching the resident so he would not walk away from the facility. A review of a social work discharge planning note, dated 10/8/13, indicated Resident 1 had a history of walking away from a facility and that he required supervision with a structured environment. A re-evaluation discharge planning note, dated 1/17/14, indicated the resident required supervision due to his history of walking away from facilities.A review of an untitled care plan, dated 10/15/13, indicated Resident 1 needed supervision, oversight, cuing, and assistance with his activities of daily living (ADLs) due to the effects of dementia and history of traumatic brain injury, seizure disorder and aphasia. The short-term goal was to assist the resident with ADLs to help maintain a comfortable and safe status. The staff?s action/approaches were to provide assistance as needed. There was no documented evidence in Resident 1's clinical records of elopement risk assessments and there was no plan of care developed to address Resident 1's risk for elopement and preventive measures to be implemented. On 12/2/14 at 12:20 p.m., after a review of Resident 1's clinical records, the DON stated there was no care plan for elopement risk and there were no elopement risk assessments conducted. The DON stated the facility did not have a policy and procedure on elopement, assessment and prevention.On 2/4/15 at 10 am, during a telephone interview, the SSD stated Resident 1 was never found. The facility failed by: 1. Not providing a safe and secure environment for Resident 1. 2. Not supervising Resident 1, who had a history of elopement. 3. Not developing a plan of care and conducting a risk assessment. 4. Not having established policy and procedure on elopement risk assessment and prevention.The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result.
940000065	INTERCOMMUNITY CARE CENTER	940011958	B	12-Jan-16	JTSS11	4314	CFR 483.13(c)(4) F225:The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). HSC: 1418.91 Reports of incidents of alleged abuse or suspected abuse of residents (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility and to the department immediately, or within 24 hours. On 5/7/15 at 1 p.m., an unannounced complaint investigation was conducted at the facility regarding an incident of alleged resident to resident sexual abuse. The facility failed to: 1. Report an abuse allegation incident to the Department (State licensing and certification agency) immediately or within 24 hours of the incident. A review of the Record of Admission indicated Resident 1 was admitted to the facility on 5/7/04 and was readmitted on 1/20/14, with diagnoses that included schizophrenia (a mental disorder with abnormal social behavior and inability to recognize what is real), depression (persistent feelings of sadness), and dementia (loss of brain function). A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 1/20/15, indicated the resident was moderately impaired in daily decision making, sometimes understood and sometimes understands others.On 5/7/15 at 1:45 p.m., during a telephone interview, certified nursing assistant (CNA 1) stated that on 4/10/15 around 4 p.m., Residents 1 and 2 were observed in a hallway leading to an outside patio from the main hallway between Nursing Stations A and B. As CNA 1 approached the hallway, Residents 1 and 2 appeared to be separating from each other and Resident 2 appeared to be zipping up his pants. Resident 1 in turn was noted to be in the process of standing up from a leaning-forward position. CNA 1 stated Resident 1 had tears running down her face but did not see any sexual contact between the two residents. CNA 1 stated she then went to report the incident to the charge nurse who was a licensed vocational nurse (LVN 1). On 5/7/15 at 2:05 p.m., during an interview, LVN 1 denied ever receiving a report of alleged sexual abuse involving Residents 1 and 2 on 4/10/15.On 5/7/15 at 3:50 p.m., the registered nurse (RN 1) supervisor stated she received a report on 4/10/15 from a staff member alleging that Resident 2 touched Resident 1 inappropriately but could not recall which staff member. According to RN 1, the residents had already separated from each other when she arrived and Resident 1 seemed fine. RN 1 questioned Resident 2 regarding the incident and the resident denied the allegations. RN 1 stated she did not suspect abuse based on her observations and stated there was no further investigation into the incident. RN 1 did not attempt to interview Resident 1 and did not report the incident.A review of the Record of Admission indicated that Resident 2 was a 44 year old male, who was admitted to the facility on 4/9/15, with diagnoses that included old head injury and seizure disorder (episodes of uncontrolled electrical activity in the brain).On 5/12/15 at 11:45 a.m., during an interview, the director of nursing (DON) stated the facility did not conduct an investigation regarding the allegation of sexual abuse between Residents 1 and 2 on 4/10/15 and the incident was not reported. The DON stated the staff should have reported the incident and an investigation should have been conducted.The undated facility policy and procedure titled, "Abuse Investigation Procedure", indicated all reports of resident abuse shall be promptly and thoroughly investigated and if abuse was determined to have occurred, the findings will be reported to authorities within twenty-four hours.The facility failed to: 1. Report an abuse allegation incident to the Department (State licensing and certification agency) immediately or within 24 hours of the incident. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.
940000065	INTERCOMMUNITY CARE CENTER	940012126	A	29-Mar-16	M8BV11	13298	F309 ?483.25 Each resident must receive and the facility must provide the necessary 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.The Department received an anonymous telephone complaint on 10/23/13, alleging that at 12 midnight (24:00 hours) on 10/9/13, a certified nursing assistant ([CNA] not named) reported to the charge nurse, a licensed vocational nurse ([LVN] not named) that a resident (Resident 1) was weak, pale, and vital signs were not detected, but the charge nurse did not do anything, and instead waited until 4 a.m. to look at the resident. The complainant alleged a registered nurse supervisor ([RN] not named) was then notified and called a transport ambulance, instead of 911 emergency services.On 11/1/13 at 7:30 a.m., an unannounced complaint investigation was initiated.The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of Resident 1, including failures to: 1. Promptly assess Resident 1?s condition to ensure the airway was patent, (open and unobstructed), after vomitus was seen on the resident?s bed clothing, and the resident had gurgling breathing and became unresponsive.2. Call an emergency service 911 timely.These deficient practices resulted in a delay in Resident 1?s care and services from 911 paramedics, who did not arrived to the facility until 5:27 a.m. on 10/10/13. Resident 1 was transferred to a general acute care hospital (GACH) and expired several hours later from cardiopulmonary failure (a sudden stop in effective blood circulation due to the failure of the heart to contract effectively or at all), and septic shock (a widespread infection causing organ failure and dangerously low blood pressure).A review of Resident 1's Admission Face Sheet indicated Resident 1 was an 85 year-old female who was admitted to the facility on 4/2/09. Resident 1?s diagnoses included dementia (decline in mental ability, severe enough to interfere with daily life), diabetes mellitus (high blood sugar), hypertension (high blood pressure), and glaucoma (a group of eye conditions that can cause blindness).A review of Resident 1?s Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/5/13, indicated the resident had short and long-term memory problems, was moderately impaired in cognitive skills for daily decision-making, and required extensive assistance from staff for eating and personal hygiene.On 11/1/13 at 9:20 a.m., a review of the facility?s previously recorded closed-circuit television camera, dated 10/10/13, with the facility?s director of nurses (DON), revealed the following: At 3:30 a.m., CNA 1 and LVN 1 were both entering Resident 1's room and they both quickly left the room. Both CNA 1 and LVN 1 were observed entering and leaving Resident 1?s room several times thereafter.At 3:40 a.m., LVN 1 was observed leaving Resident 1?s room and going to the nurses? station and was seen looking at a clinical record.At 3:46 a.m., an oxygen concentrator (a medical device used to deliver oxygen) was observed taken into Resident 1?s room.At 3:58:26 a.m., RN 1 (night supervisor) was observed entering Resident 1?s room. At 3:58:40, RN 1 was observed leaving Resident 1?s room and going to the nurses? station, while speaking to other staff members. At 5 a.m., a non-emergency transport team (non-paramedic) was observed talking to LVN 1. One of the non-emergency transport team was seen entering Resident 1?s room and minutes later he was seen coming out of the room.At 5:05 a.m., the non-emergency transport team member was seen being given a finger pulse oximeter (measures the proportion of oxygenated blood [necessary to carry oxygen to the body?s organs and tissues]). A few minutes later he was observed walking out of Resident 1?s room and speaking to LVN 1. Also on the closed-circuit video, observed with the DON, prior to the paramedic?s transfer of Resident 1 to the GACH, LVN 1 was observed giving Resident 1 fluids, while on the paramedic?s gurney being taking out the facility, although Resident 1 had recently vomited and was unresponsive.A review of the non-emergency transport team patient care record, dated 10/10/13, indicated they were dispatched at 4:16 a.m., and arrived at the facility at approximately 5:02 a.m. Resident 1?s chief complaint was listed as shortness of breath (SOB) and altered level of consciousness ([ALOC] is any measure of arousal other than normal). A review of the non-emergency/ambulance service Resident 1?s care record, dated 10/10/13, indicated Resident 1 was found with SOB and was unresponsive. The resident?s vital signs were recorded as following: At 5:05 a.m.: pulse 136, respiration 48, and blood pressure 84/42. At 5:10 a.m.: pulse 140, respiration 50, and blood pressure 80/38. At 5:15 a.m.: pulse 146, respiration 54, and blood pressure 76/34.Normal reference ranges (NRR) for vital signs are pulse 60-100 beats per minute (bpm); respiration 12-20 per minute and blood pressure 120/80. The non-emergency transport team?s note also indicated they refused to transport Resident 1, because it was an emergency situation and they were not qualified to transport the resident. The non-emergency transport team?s note indicated they called 911. According to the non-emergency transport team, the paramedics arrived on the scene (at the facility) on 10/10/13 at 5:17 a.m., and the paramedics left transporting Resident 1 at 5:42 a.m., on 10/10/13.A review of the licensed personnel weekly progress note, dated 10/10/13, and timed at 4 a.m., indicated the facility?s staff made rounds and saw the resident in bed, alert with some confusion. The notes indicated there was no complaint of pain, but the resident was observed with black color vomitus, and had a cough with congestion (abnormal accumulation of fluid, in a body part, organ, or area). There was no documented evidence that Resident 1 was assessed by the facility?s licensed nurses to check the resident?s lungs and heart sounds.A review of the licensed personnel weekly progress note, dated 10/10/13, and timed at 4 a.m., indicated Resident 1?s physician was called and an order was received and carried out. The facility?s staff called a non-emergency ambulance service on 10/10/13. According to the note, Resident 1?s vital signs were documented as following: temperature was 97.7 (NRR= 98.6 Fahrenheit [F]), pulse 88; and respiration was 24; with a blood pressure of 100/60 millimeters (mm) of mercury [hg]. The licensed personnel weekly progress note, dated 10/10/13, and timed at 5 a.m., initially indicated the non-emergency ambulance drivers arrived to transfer the resident to (to a named GACH?s) Emergency Department (ED) for evaluation, but were unable to ?handled the resident,? and called 911. On the same day at 5:30 a.m., the note indicated, ?911 arrived and transferred the resident to GACH.?On 11/1/13 at 3:25 p.m., during a telephone interview, RN 1 stated she went to Resident 1?s room and she appeared to be ?kind of sick and weak.? When RN 1 was asked if she had assessed Resident 1?s vital signs (temperature, heart rate, respiratory rate and blood pressure), RN 1 stated, ?No, because the LVN stated she had already done it.? RN 1 stated she did not access the resident?s oxygen level, because the resident was having breathing problems. RN 1 stated she did not perform the assessments, because LVN 1 had checked everything. RN 1 stated since LVN 1 was already involved and had called the resident?s physician, she continued to make her rounds. A review of the 911 report, dated 10/10/13, indicated the paramedics were dispatched at 5:16 a.m., and arrived on the scene at 5:27 a.m. They found Resident 1 with ALOC, with a low blood pressure ([B/P] of 78/32), an increased heart rate of 136-138 bpm, and a fast respiratory rate of 40 breaths per minute. The report indicated the following observations about the resident: * Coffee ground emesis (black or dark brown granular vomit), * Glasgow Coma Scale score of 3 ([GSC] a neurological assessments of impairment of consciousness level in response to defined stimuli [normal is 15; eye-4; motor-5; and verbal-6]), * ?hot? to touch, * right lung wheezes with rhonchi (continuous low pitched, rattling lung sounds that often resemble snoring with obstruction or secretions in larger airways being frequent causes of the rhonchi), and * Abnormal electrocardiogram (a test that checks for problems with the electrical activity of the heart).According to the paramedic?s report, Resident 1 was given 15 liters of oxygen via a face mask, and was started on intravenous fluids ([IVF] into the vein to deliver fluids and medications). A review of the paramedic?s incident report, dated 10/10/13, indicated it was written due to the facility?s failure to call 911 first. The incident report indicated they (paramedics) were called to the facility at 5:16 a.m., after the facility called a non-emergency ambulance to treat an unconscious resident. The paramedic?s report indicated they provided ALS (advance life support) to Resident 1 who was found unconscious and in supine (face upward) position.A review of the GACH?s records, dated 10/10/13, indicated Resident 1 arrived at the emergency department (ED) at 5:55 a.m., with ALOC, difficulty breathing, fever of 105.1 F per rectum (NRR is 100 F per rectum), pulse rate of 136 bpm, and B/P of 118/49, after receiving IVF, and vomiting (described as coffee ground substance). The ED notes indicated the facility?s staff stated Resident 1 had coffee ground emesis and an altered mental status for one and half hours prior to the paramedic?s arrival. The GACH?s note indicated the resident was having difficulty in breathing with a fever because of possible aspiration (when food, saliva or vomit is breathed into the lungs, instead of being swallowed into the esophagus [food tube] and stomach) of coffee-ground substance that was suctioned from the resident?s right lung. The ED physician?s note, dated 10/10/13, and timed at 8:22 a.m., indicated the physician had spoken to the resident?s family and the family decided to make the resident a DNR status (do not resuscitate [no CPR]) in order to keep the resident comfortable. The resident was pronounced deceased on 10/10/13 at 11:08 a.m.On 6/5/15 at 1:33 p.m., during a telephone interview, CNA 1 described Resident 1?s usual condition as being alert, but confused. CNA 1 stated on the day of the incident (10/9/13), during her second run observing the residents, she found Resident 1 sitting up in her bed at a 30 degree angle. CNA 1 stated the resident was pale and had brown color vomitus on her bedclothes. CNA 1 also stated the resident was making a "gurgle" sound, which was further described as ?blowing into a cup of water with a straw.? CNA 1 stated the resident did not respond to her name, even while she was being cleaned. CNA 1 stated she notified LVN 1 and LVN 1 asked her (CNA1) to take the resident?s vital signs. CNA 1 stated when Resident 1 was initially found unresponsive she did not call 911, because LVN 1 was in charge and took care of those things.On 6/9/15, at 7:09 a.m. and 2:42 p.m., during an interview, LVN 1 stated when she found Resident 1 with vomitus on her clothing the resident was ?responsive.? LVN 1 stated she called the physician and received an order to transfer the resident to a GACH, so she called a non-emergency ambulance company, but the non-emergency ambulance took about half an hour to get to the facility. LVN 1 stated, once the ambulance company arrived, they refused to transfer Resident 1, because the resident's blood oxygen saturation level (measure of the amount of oxygen carried in the hemoglobin, part of the red blood cells) was too low. LVN 1 stated when the 911 paramedics arrived, the resident was still ?sleepy,? and her pupils were constricted (constricted pupils are often caused by stroke, drug use, and/or head injuries). But LVN 1 indicated constricted pupils meant the resident was ?alright.? [sic]. LVN 1 was asked about the fluids she gave Resident 1 while being ?sleepy,? and she stated she gave the resident fluids because the resident was thirsty.A review of Resident 1?s death certificate indicated the resident died on 10/10/13 at 11:08 a.m., with the immediate cause of death listed as cardiopulmonary failure and septic shock. The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, of Resident 1, including failures to: 1. Promptly assess Resident 1?s condition to ensure the airway was patent, (open and unobstructed), after vomitus was seen on the resident?s bed clothing, and the resident had gurgling breathing and became unresponsive.2. Call an emergency service 911 timely.The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result.
940000065	INTERCOMMUNITY CARE CENTER	940012148	B	29-Mar-16	UM8U11	6344	F-223 CFR 483.13(b) - Abuse The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. On 9/15/15, at 7:20 a.m., an unannounced visit was made to the facility to investigate a report of Resident A's allegation of verbal and physical abuse perpetrated by Certified Nursing Assistant 1 (CNA 1). Based on interview and record review, the facility failed to ensure the resident had the right to be free from verbal and physical abuse by failing to: Ensure that Resident A was not verbally abused by CNA 1, who at first was heard by Resident C yelling back at Resident A in her room when Resident A pulled CNA 1?s hair and knocked her cell phone to the floor causing the phone to chip. Later, CNA 1was seen via a recorded video footage, throwing a liquid (suspected to be a fruit juice) from a plastic cup at Resident A, after Resident A hit CNA 1 again in the hallway near the nurses station B.On 9/15/15, a review of the clinical record indicated Resident A was a 66 year old female, re-admitted to the facility on 2/4/14, with diagnoses that included Paranoid Schizophrenia, Alcoholic Dementia, History of Etoh Abuse and History of right Hip Surgery.The readmission Minimum Data Set (MDS - a standardized assessment and care plan tool), dated 8/11/15, indicated that Resident A had long/short-term memory problems, moderately impaired in cognitive skills for daily decision-making, sometimes made himself understood, and sometimes able to understand others. The resident was able to ambulate (walks) in room and corridor but required extensive assistance with dressing, personal hygiene and bathing.On 9/15/15, at 9:25 a.m., during an interview in the presence of Employee 3, the evaluator noted that Resident A was unable to respond due to confusion. At 12:35 p.m., during an interview, Resident B (Resident A?s roommate) was also unable to respond to the question on the abuse incident due to confusion. At 12:55 p.m., Employee 1 stated in an interview that Resident C reported that she heard that CNA 1 and Resident A were fighting.A review of the facility's investigation report indicated that Employee 1 revealed in a written statement dated 8/31/15, that at about 9:45 a.m., while he was painting the door in Room 35, he heard CNA 1 and Resident A having an argument behind closed door in the resident?s room. Employee 1 stated he reported the incident to CNA 2. In an interview on 9/15/15, at 1:30 p.m., CNA 2 stated that she reported Employee 1?s statement to Employee 2. On 9/15/15, at 1:40 p.m., Resident C was observed sitting in front of nurses station B with a family member visiting. The resident was alert and oriented. A review of the clinical record indicated that Resident C was a 57 year old Spanish speaking female, admitted to the facility on 11/18/13. At 1:50 p.m., during an interview Resident C started she heard a resident and a staff member yelling at each other and she relayed the incident to Employee 1. The interview was interpreted from Spanish to English by Resident C?s family member.According to Employee 2?s statement and written declaration provided to the evaluator on the same date 9/15/15, at 2:00 p.m., CNA 1 was found standing in front of Resident A?s bed in Room 36 behind closed curtain with her arms extended and projected towards the front of Resident A who was sitting in her bed with her arms projected and extended towards the front of CNA 1. The declaration further indicated that CNA 1 reported to Employee 2 that Resident A had pulled CNA 1?s hair and knocked her cell phone to the floor causing the phone to chip (damage). During an interview on 9/15/15, at 3:20 p.m., Employee 4 stated that the abuse incident was captured on the facility?s recorded video camera on 8/31/15. The recorded incident occurred in the hallway near the facility?s nurse?s station B and revealed that Resident A got into verbal altercation with CNA 1 and Resident A hit CNA 1. The CNA became upset, poured some juice into a cup, chased Resident A down the hallway near station B and threw the juice at the resident. A non-verbal angry expression (as indicated in the recorded video footage) was noted on Resident A after CNA1 threw the juice at her. A review of the initial care plan on behavior and communication problem, dated on 1/23/08 and 10/8/12, indicated Resident A was hyper-verbal and resistive to care. Her speech was inappropriate and rambling. The resident exhibited sudden mood swings, was verbally abusive and had history of physical aggressive behavior. The care plan intervention required that nursing staff must approach Resident A calmly and use simple language to let the resident know what they want or expect from her. The staffs were expected to pay attention to the resident?s non-verbal cues, changes in mood, behavior, habits and facial expressions. There was no evidence showing that CNA 1 followed the above behavior and communication care plan interventions.According to the Misconduct Allegation referral letter sent from California State Department of Public Health; dated, 9/2/15, regarding incidence of staff to resident verbal and physical abuse. The facility determined to terminate CNA 1?s employment after completion of their investigation.The facility's undated policy and procedure on Abuse Prevention and Investigation of Residents indicated that the facility will not condone resident abuse by anyone including staff members, other residents and volunteers, staffs of other agencies serving the resident, family members, legal guardians, sponsors, friends or other individuals. The facility failed to ensure that the resident had the right to be free from verbal and physical abuse by failing to: Ensure that Resident A was not verbally abused by CNA 1, who at first was heard by Resident C yelling back at Resident A in her room when Resident A pulled CNA 1?s hair and knocked her cell phone to the floor causing the phone to chip. Later, CNA 1was seen via a recorded video footage, throwing a liquid (suspected to be a fruit juice) from a plastic cup at Resident A after Resident A hit CNA 1 again in the hallway near the nurses station B.The above violation had direct or immediate relationship to the health, safety, or security of Resident A.
940000115	IMPERIAL HEALTHCARE CENTER	940012278	A	26-May-16	QO1S11	11090	F 323 ? ?483.25 (h) Accidents The facility must ensure that ? (1) The resident environment remains as free from accident hazards as is possible: and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The Department received an entity reported incident (ERI), alleging that a resident (Resident 1), was being transferred to the bed by a certified nursing assistant (CNA1) using a mechanical lift and slipped out of the sling and fell to the floor. Resident 1 struck her head and back resulting in bleeding. Resident 1 was transferred to a general acute care hospital (GACH) via 911 paramedics for further evaluation. The facility failed to ensure the residents environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to: 1. Failure to follow its policy and procedure regarding transfers with mechanical lifts. 2. Failure to ensure the correct size sling was used for Resident 1 to prevent accidents. 3. Failure to follow Resident 1?s assessment (Minimum Data Set [MDS; a standardized assessment and care planning Tool]) that indicated the resident required a two-person physical assist in transferring. CNA 1 used a larger sized sling on the Hoyer lift (an assistive device that allows residents to be transferred between the bed and chair) and transferred Resident 1 on 10/29/14, from the wheelchair to the bed alone, instead of using a two-person assist, as per the facility's policy. While Resident 1 was being transferred from the wheelchair to the bed, the resident slipped out of the sling and fell to the floor. These failures resulted in Resident 1 sustaining a left femur (thigh bone) fracture; requiring a transfer to a GACH and admitted for 12 days, and undergoing surgery to repair the femur fracture. A review of Resident 1's Admission Face sheet indicated Resident 1 was a 68 year-old female who was admitted to the facility on XXXXXXX. Resident 1's diagnoses including infantile cerebral palsy ([C/P] is a group of disorders that affect a person's ability to move and maintain balance and posture. The disorders appear in the first few years of life) and congenital hydrocephalus (buildup of excess fluid/water in the brain at birth). A review of Resident 1's Annual Minimum Data Set (MDS), dated 8/9/14, indicated Resident 1 had the ability to be understood and understand others. According to the MDS, Resident 1 was totally dependent on staff and required a two-person physical assist for transferring. A review of Resident 1's weight chart indicated on 9/1/14, the resident weighed 157 pound (lbs). A review of the first report sent to the Department, from the facility's former administrator (Administrator 1), dated 10/30/14, indicated that on XXXXXXX, at 8 p.m., while CNA 1 transferred Resident 1 from the wheelchair to the bed using a mechanical lift. Resident 1 slipped out of the Hoyer lift's sling and fell to the floor. Resident 1 struck her head and back resulting in bleeding. According to the report, the facility's staff called 911 and the paramedics transferred Resident 1 to a GACH?s emergency room for further evaluation. A review of a second report from Administrator 1, dated 11/4/14, indicated that the facility investigated the incident. The report concluded that CNA 1 did not follow the facility's protocol, by failing to ask for assistance in using the mechanical lift to transfer Resident 1. The maintenance staff inspected the mechanical lift on 10/30/14 and was found to be free of defects and was functioning properly, according to the manufacture's standards. The facility's investigative report indicated CNA 1 was suspended and received an in-service, on 10/30/14, for the proper procedure for transferring residents, using a two-person assist prior to CNA 1 returning to full duties. On 11/14/14, at 3:10 p.m., during an interview, CNA 1 stated in the past, she had transferred Resident 1 with the Hoyer lift by herself many times without any problems. CNA 1 stated on the day of the incident, Resident 1 requested to be transferred from the wheelchair to the bed using the Hoyer lift. CNA 1 stated she did not ask for help. CNA 1 stated she lifted Resident 1 up, moved the resident's legs to the right side of the Hoyer lift, and then closed the legs of the Hoyer lift. CNA 1 stated that while she was closing the legs of the Hoyer lift, Resident 1 slipped out of the sling and fell to the floor. CNA 1 stated, ?I think the sling was too big for her." On 11/14/14, at 4 p.m., during an interview, CNA 2 stated staff members needed to take extra precaution when using the Hoyer lift to transfer Resident 1. CNA 2 stated Resident 1 had left-sided weakness with paralysis of the legs (the loss of the ability to move legs). CNA 2 stated there must be two staff members to transfer Resident 1 with the Hoyer lift. CNA 2 stated one staff member needed to control the Hoyer lift, while the other staff member maneuvered and held the resident to make sure the resident did not fall. On 11/14/14, at 4:14 p.m., during an interview, CNA 3 stated many CNAs in the facility take the chance to transfer residents with the Hoyer lift by themselves due to the facility's shortness of staff. During a concurrent interview, CNA 4 stated it was sometimes difficult to find available staff to help in transferring residents. CNA 4 stated that was why she transferred residents with the Hoyer lift many times by herself. A review of a nurse's notes, dated 10/29/14, and timed at 8 p.m., indicated Resident 1 slipped out of the Hoyer's lift sling while being transferred. The charge nurse, a licensed vocational nurse (LVN 1) found Resident 1 lying flat on the floor. According to the nurse's note, Resident 1 complained of generalized pain of 6/10 on a pain scale of 0-10 (0= no pain, 10= worst pain) and had minimum bleeding to the right side of Resident 1's head. A review of Resident 1's physician's order, dated 10/29/16, and timed at 8:15 p.m., indicated to transfer Resident 1 to a GACH emergency room via 911 for status-post fall, for further evaluation. A review of the Resident 1's history and physical (H/P) from the GACH, dated 10/30/14, indicated Resident 1 had a mechanical fall and sustained a left hip sub-capital femur fracture (the fracture line extends through the junction of the head and neck of the femur [long bone]). The H/P indicated Resident 1 had pain of 5/10 on a scale of 0 to 10 when no movement occurs (5= distressing pain). A review of the GACH's operation room (OR) report, dated 11/9/14, indicated Resident 1 had a surgical procedure that replaced one half of the hip joint with a prosthetic/artificial body part, while leaving the other half intact [hemiarthroplasty]). According to the OR report, Resident 1 was transferred to the post-anesthesia care unit (PACU) after the surgery. A review of the GACH's discharged summary, dated 11/11/14, indicated Resident 1 was admitted in the hospital for 12 days, undergoing a left hip hemiarthroplasty on 11/9/15 secondary to a left hip femoral neck fracture. On XXXXXXX, Resident 1's condition was stable, and Resident 1 was transferred to another hospital for continuing care (a subacute [between acute and chronic] for rehabilitation). A review of Resident 1's clinical record indicated, the resident was readmitted to the facility on XXXXXXX. On 3/30/16, at 2:10 p.m., during an observation, Resident 1 was sitting in the activity room, playing bingo with other residents and the facility's activity staff. At 2:15 p.m., on 3/30/16, during an interview, Resident 1 stated, "About a year ago, a CNA dropped me, while she was transferring me by herself." Resident 1 stated CNA 1 used the big green sling to transfer her and stated she knew the sling was too big for her because she could feel it. Resident 1 stated she fell right through the front with her head hitting the floor first. Resident 1 stated usually there were three staff members to transfer her (one to watch and two to help with the transfer). Resident 1 stated on the day of the incident, she asked CNA 1 where the other staff members were to help with the transfer and CNA 1 stated, "We don't need them, there is nobody around anyway." On 3/30/16, at 3:35 p.m., a review of CNA 1's employee file indicated she was hired to the facility on 2/27/12, and CNA 1 gave a written resignation letter and the last date of employment was 1/14/15. A further review of CNA 1's employee file indicated she was suspended on 10/30/14, for not following the facility's procedure/protocol, for Residents 1?s transfer with the mechanical lift resulting a fall with a fracture. According to CNA 1's record of counseling and write-up, indicated she had an in-service on 5/12/14, regarding the requirement for a two-person physical assist to transfer residents with mechanical lifts. The write-up indicated Resident 1 was injured due to CNA 1's unsafe practice. On 11/4/14, CNA 1 received a final written warning regarding Resident 1 sustaining injury as a result of CNA 1 not following the facility's procedure for transfer with a mechanical lift with a two-person assist. On 3/30/16, at 3:35 p.m., during an interview, the facility's current administrator (Administrator 2) was asked why the investigation report did not indicate the Hoyer lift's sling size as a variable in Resident 1's fall. Administrator 2 stated he was not sure. On 3/30/16, at 4 p.m., during an inspection of the facility's Hoyer lifts' slings, with the central supply staff, the facility had four sling' sizes [XL] extra-large, with maximum load of 660 lbs.,[L] large, with maximum load of 550 lbs., [M] medium, with maximum load of 450 lbs., and [S] small, with maximum load of 350 lbs. A review of the facility's undated policy and procedure titled, "Mechanical Lifts/Slings: Monitoring Function," indicated the facility was a non-lift facility, so mechanical lifts will be used for transferring residents who cannot assist with transfers. The policy stipulated a two-person assist was required when using a lift to transfer residents. The facility failed to ensure the residents environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to: 1. Failure to follow its policy and procedure regarding transfers with mechanical lifts. 2. Failure to ensure the correct size sling was used for Resident 1 to prevent accidents. 3. Failure to follow Resident 1?s assessment (Minimum Data Set [MDS; a standardized assessment and care planning tool]) that indicated the resident required a two-person physical assist in transferring. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result.
940000064	INTERCOMMUNITY HEALTHCARE & REHABILITATION CENTER	940012487	B	3-Aug-16	NRJQ11	6158	F225 ? 42 CFR 483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). On 8/26/15 at 2:10 p.m., an unannounced visit was conducted at the facility to investigate an allegation of physical abuse reported to the administrator on 8/4/15 by Resident 1?s family member (FM 1) against a certified nursing assistant (CNA Based on interview and record review, the facility failed to implement its abuse prevention policy and procedure by failing to: 1. Report immediately (as soon as possible but not to exceed 24 hours after discovery of the incident) or within 24 hours of the observation, knowledge, or suspicion of the physical abuse to the Department (Licensing and Certification Program) an allegation of physical abuse by CNA 1 to Resident 1. The administrator did not report the allegation to the Department until 8/11/15, seven (7) days after the allegation was made. This deficient practice resulted in FM 1 being concerned of Resident 1 not receiving safe care and services from the facility. During a telephone interview on 8/18/15 at 10:05 a.m., FM 1 stated she spoke with the administrator and the director of nursing (DON) on 8/4/15 regarding her concern that CNA 1 was mistreating Resident 1 during a transfer through rough handling of the resident on 8/3/15. FM 1 stated CNA 1 transferred Resident 1 from the wheelchair to the bed and as a result, the resident?s head hit the bed?s side rail. During an interview, on 8/26/15 at 3:15 p.m., the administrator stated he was made aware of the incident between Resident 1 and CNA 1 that occurred on 8/3/15 and he did not report to the Department the allegation of abuse made by FM 1 on 8/4/15 until 8/11/15, seven (7) days after the incident. The administrator stated FM 1 told him again on 8/5/15 that Resident 1 was mishandled and she (FM 1) considered it as a form of abuse. The administrator stated he did not have a good excuse why FM 1?s allegation of abuse was not reported immediately to the Department. During an interview, on 8/26/15 at 3:15 p.m., the administrator stated he interviewed CNA 1 regarding the allegation made by FM 1 and CNA 1 was suspended on 8/5/15 and 8/6/15 pending the conclusion of the facility?s investigation. The administrator stated CNA 1 returned to work on 8/7/15 after the administrator had concluded that the incident on 8/3/15 was an accident and CNA 1 was given an in-service on 8/7/15. The administrator stated CNA 1 was no longer assigned to care for Resident 1. A review of Resident 1's face sheet (admission record) indicated the resident was admitted to the facility on 6/22/15 with diagnoses that included muscle weakness and congestive heart failure (CHF - a chronic condition in which the heart doesn't pump blood as well as it should). According to the admission assessment Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 6/30/15, Resident 1 was able to make his needs known and understand others. Resident 1 was moderately impaired in cognitive skills (decisions poor; cues/supervision required) and required extensive assistance (resident involved in the activity; staff provide weight-bearing support) with one person physical assist in transferring, toileting, and personal hygiene. A review of the facility?s investigation summary, dated 8/5/15, indicated FM 1 alleged CNA 1 did not support the resident?s head and his head hit the bed?s side rail with a loud noise during the transfer from the wheelchair to the bed. CNA 1 tried to apologize to FM 1 and Resident 1 but FM 1 did not feel the apology was sincere. An investigation summary, dated 8/7/15, indicated CNA 1 transferred Resident 1 from sitting in his wheelchair to sitting on the edge of his bed. CNA 1 lifted the resident?s legs from the floor to lie him down on the bed. During the process, the resident fell backwards and his head made contact with the side rail. The investigation summary indicated CNA 1 returned to work on 8/7/15. The facility concluded that the incident was an unfortunate accident and there was no willful intent to harm Resident 1. The investigation summary indicated the physician was informed and neurological checks were initiated on 8/3/15. According to the facility?s document titled ?Abuse Allegation Investigation,? completed on 8/11/15, the incident that occurred on 8/3/15 was a suspected abuse that did not result in serious bodily injury. The mandated reporter must report the incident by telephone within 24 hours to the local law enforcement agency and provide a written report to the local Ombudsman, the licensing and certification program (the Department), and the local law enforcement agency within 24 hours. A review of a letter written by the administrator to the Department, dated 8/11/15, indicated he was informing the Department of an alleged abuse on Resident 1. A review of the facility's policy and procedure titled, "Abuse Allegation Reporting," dated 7/2013, indicated incidents of suspected abuse committed against an individual who is a resident must be reported to one local law enforcement entity by phone within 24 hours and provide a written report to the local Ombudsman, the L & C Program (Licensing and Certification Program), and local law enforcement within 24 hours for non-serious bodily injury. The facility failed to implement its abuse prevention policy and procedure by failing to: 1. Report immediately (as soon as possible but not to exceed 24 hours after discovery of the incident) or within 24 hours of the observation, knowledge, or suspicion of the physical abuse to the Department (Licensing and Certification Program) an allegation of physical abuse on Resident 1 by CNA 1 The above violation had a direct or immediate relationship to the health, safety, or security of residents.
940000064	INTERCOMMUNITY HEALTHCARE & REHABILITATION CENTER	940012507	A	12-Sep-16	0RCV11	15701	F309 ?483.25 Provide Care/Services for Highest Well Being Each resident must receive and the facility must provide the necessary 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. F329 ?483.25(I) Unnecessary Drugs Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. The facility failed to provide each resident with the necessary 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 to treat an ongoing rash (over a month) and administered an unnecessary drug without an adequate indication for its use including but not limited to: 1. Failure to ensure medications administered to Resident 1 had an adequate indication for its use. 2. Failure to ensure Resident 1 was not prescribed an antipsychotic without an indication for its use. 3. Failure to ensure, once the antipsychotic medication was ordered, side effects for the medication were monitored, as stipulated in the resident?s plan of care. 4. Failure to ensure adequate care and services were rendered to treat Resident 1?s ongoing rash with severe itching. These failures resulted in Resident 1 receiving an unnecessary drug (psychotropic [any drug that alters the mind]) that had a black box warning (strictest warning put on labeling of prescription drugs that may cause serious adverse effects with potential to be fatal), which put Resident 1 at risk for serious side effects and possibly death. Resident 1 had an ongoing body rash with darkened lesions over the body, resulting in constant itching and scratching with multiple linear (in a straight line) scratches over the body, which put Resident 1 at risk for secondary infections. Resident 1 was prescribed an antipsychotic drug (Seroquel) and an antidepressant drug (Trazadone) for the rash that was diagnosed as psychogenic (a psychological [mental] origin, rather than a physical one) pruritus (severe itching of the skin). On 7/18/16 at 1:45 p.m., during a recertification survey and the facility?s initial tour, Resident 1 was observed lying in bed with red spots on his lower and upper extremities. Resident 1 was grimacing and frowning, while scratching himself on the chest, elbow, and extremity areas, constantly thrashing in bed and moving linen off his body. A review of Resident 1?s Admission Face sheet indicated Resident 1 was a 94 year-old male who was admitted to the facility on 3/22/16. Resident 1?s diagnoses included chronic obstructive pulmonary disease ([COPD] difficult to breathe), dementia (a brain condition that causes weakness and fatigue), dysphagia (difficulty swallowing) with a gastrostomy tube (a tube placed into the stomach for feeding and hydration [fluids]), and right-sided hemiplegia (weakness). A review of Resident 1?s Minimum Data Set (MDS), a resident assessment and care screening tool, dated 7/4/16, indicated Resident 1?s cognitive skills for daily decision-making were severely impaired and the resident was non-ambulatory and totally dependent on staff for all care with a one-person physical assist. According to the MDS, Resident 1 had functional limitation in range of motion of one side (right). The MDS indicated Resident 1 was non-English speaking and unable to communicate needs verbally. A review of Resident 1?s physician?s order, dated 6/30/16, indicated to start Seroquel 12.5 milligram via G-tube every night for psychogenic pruritus. Another physician?s orders, dated 7/13/16, indicated to discontinue the Seroquel 12.5 milligram (mg) via G-tube at bed time for psychogenic pruritus and the physician ordered Trazadone (anti-depressant) 25mg via G-tube at bed time for psychogenic pruritus that was started on 7/14/16 at 9 p.m. A review of Resident 1?s care plan, dated 7/4/16, with a focus; ?Resident had episodes of psychogenic pruritus, manifested by scratching until he bleeds.? The care plan indicated Seroquel 12.5 mg via GT every night was started with the resident being at risk for side effects of Seroquel. The goal was for Resident 1?s episodes of scratching to be minimized through appropriate interventions daily. The staff?s interventions included assessing Resident 1?s pain and discomfort and observe for side effects of Seroquel, which included agitation, headache, nausea, insomnia, dizziness and constipation. A review of Resident 1?s care plan, dated 7/13/16, and timed at 7:30 p.m., titled, ?Resident has depression, manifested by itchiness,? give Trazadone 25 mg via GT every night. It indicated the resident was at risk for side effects of the medication and the goal was for the resident to have less episodes of depression [sic]. The staff?s interventions included administering the medication as ordered and observe side effects and document. A review of the Medication Administration Record (MAR), for the month of July 2016, indicated Resident 1 was given Seroquel 12.5 mg via G-tube for psychogenic pruritus and to monitor for episodes of scratching every shift secondary to psychogenic pruritus. At 8:15 a.m., on 7/19/16, during a medication pass observation, Resident 1 was observed lying in bed, moving his head from side to side, as though he was scratching his head. Resident 1 was scratching his body constantly during the medication pass observation for approximately 40 minutes. Resident 1 had reddened spots visible on the front of the chest, abdomen, and right thigh with linear scratches while he was observed removing the linen off his body. The medication nurse, a licensed vocational nurse (LVN 4) stated, ?He (Resident 1) scratches himself secondary to being hot.? On 7/19/16 at 12:22 p.m., during an interview, a certified nursing assistant (CNA 1) stated she first noticed Resident 1?s rash a month or so ago. CNA 1 stated Resident 1?s rash starting on the back of the neck, across the chest, arms and down to the legs. CNA 1 stated the treatment nurse (LVN 6), and the other licensed vocational nurses were informed about the resident?s rash and were currently treating Resident 1?s rash. CNA1 stated there had not been a change in the rash. On 7/19/16 at 12:32 p.m., during an interview, LVN 6 stated Resident 1 had been seen by the dermatologist before. When asked for the physician?s consultation note, LVN 6 was unable to produce one. LVN 6 looked in Resident 1?s medical record, as well as the over flow and was not able to produce the physician?s consultation note. On 7/19/16 at 12:35 p.m., during an interview, LVN 4 stated Resident 1 had been scratching for the past month and was prescribed a psychotropic medication (any medication capable of affecting the mind, emotions, and behavior) to stop the itching. LVN 4 stated the nurses were monitoring Resident 1?s itching episodes, but not the side effects of the psychotropic medications as per Resident 1?s plan of care, which indicated to observe the side effects of the Seroquel medications. On 7/19/16 at 2:10 p.m., while at Resident 1?s bedside, observing Resident 1?s skin with a certified nursing assistant (CNA1), a dermatologist (a physician who specializes in treatment of skin disorders [Physician 1]) came into Resident 1?s room to evaluate Resident 1?s rash. At 2:50 p.m., on 7/19/16, Physician 1 stated he was called in after the survey team raised concerns about Resident 1?s rash. Physician 1 was asked if he had heard of Seroquel being used to treat skin rashes, Physician 1 was in disbelief and was shown Resident 1?s physician?s order for it, and stated, ?It was not the standard of care for a rash with itching.? A review of Physician 1?s consult report, dated 7/19/16, indicated Resident 1 was seen due to severe itching over body and receiving an antipsychotic for behavioral psychogenic as the cause for the itching. The dermatologist documented Resident 1 had multiple excoriation plagues (traumatized or abraded skin caused by scratching or rubbing) over his body in various stages of healing and hyperpigmentation (patches of skin become darker in color than the normal surrounding skin) on the left back. Physician 1?s documented plan indicated to keep Resident 1?s nails short, apply a daily moisturizer (nourishment for dry skin), and follow-up on Resident 1?s abnormal lab related to kidney impairment, which could be the cause of the chronic itching. A review of Resident 1?s laboratory results, dated 6/16/16, indicated his BUN (blood, urea, and nitrogen [primarily used, along with the creatinine test, to evaluate kidney function]) was elevated at 40 (normal reference range [NRR] 7-25 mg/dl) and the BUN/creatinine ratio was elevated at 41.2 (NRR is 10-20). A review of Resident 1?s physician?s telephone order (Physician 2), dated 7/19/16, and timed at 12:10 p.m., indicated to apply Calamine lotion (anti-itching treatment) to Resident 1?s self-inflicted scratch marks on the right upper extremity, front chest, abdomen, right thigh twice a day for 14 days for itching. Another physician?s order, dated 7/19/16, and timed at the same time (12:10 p.m.), indicated to clean the above same body areas with normal saline, pat dry, and apply a triple antibiotic ointment (a triple antibiotic of neomycin, bacitracin, and polymyxin) to the areas and leave opened to air daily for 14 days. On 7/19/16 at 3:20 p.m., Physician 1 stated he understood the survey?s team?s concern about Resident 1?s rash. Physician 1 stated he had scraped (skin testing) the resident?s skin for scabies (a condition of very itchy skin caused by tiny mites that burrow into your skin. The itching is caused by an allergic reaction to the mites), but it was negative. Physician 1 stated he would consider treating Resident 1 empirically (provided by physicians based on their observations and experience prior to a definitive diagnosis being made) with Elimite vs permethrin (anti-parasitic medications used for the treatment of scabies), but stated he would have to speak to Resident 1?s physician (Physician 2) and Resident 1?s family for approval. A review of Physician 2?s progress note, dated 7/19/16, and timed at 6 p.m., deciphered by the director of nurses (DON), indicated Resident 1 was still itching, generalized; but skin much improved. Physician 2 document the plan was to continue Trazadone (antidepressant medication) for the itching. On 7/20/16 at 10 a.m., during an interview, Resident 1?s family member (FM1) stated that she had been trying to get a dermatologist consult for Resident 1, but was unable to do so. FM1 stated she had asked the facility if she could transfer Resident 1 in a car to the dermatologist clinic to remedy the itching and scratching. FM1 stated Resident 1?s primary physician (Physician 2), indicated Resident 1?s itching and scratching were just in Resident 1?s mind. FM1 stated she was told that Seroquel would treat Resident 1?s itching and scratching behavior. At 10:30 a.m., on 7/20/16, during Resident 1?s skin and wound care observation with LVN 6, Resident 1 was observed to have many scratches on his upper chest with redden round spots on the abdomen, upper extremities, arms, lower extremities, and right thigh. At 8 a.m., on 7/21/16, Resident 1 was observed lying in bed, comfortable, no restless behaviors, no agitation, no facial grimacing or frowning. Resident 1 was relaxed and calm. On 7/21/16 at 9:20 a.m., LVN 5 stated Resident 1 looked better, less scratching and itching, and looked more comfortable after having calamine lotion added to the treatment plan for Resident 1?s itching episodes. On 7/21/16 at 10 a.m., while at Resident 1?s bedside, Resident 1 was observed resting quietly with no scratching observed. CNA 2, Resident 1?s primary care nurse for the day, stated Resident 1 had less itching and scratching episodes that morning. CNA 2 stated Resident 1 looked more calm and comfortable. On 7/21/16 at 1:55 p.m., during a telephone interview, Resident 1?s primary care physician, Physician 2, stated he was aware that Seroquel had a black box warning. Physician 2 stated, ?A fellow physician told me I should try Seroquel for the resident?s (Resident 1) rash, since I had tried other thing, but was not successful.? Physician 2 stated he had not ordered a psychiatric evaluation (mental health assessment) prior to prescribing the antipsychotic medications for Resident 1. A review of Resident 1?s July 2016 MARs indicated prior to Resident 1 receiving calamine lotion and antibiotic ointment on 7/19/16, he had many episodes of itching documented. The MAR indicated, two days after receiving the new skin treatment (Calamine/triple antibiotic) on 7/21/16, on the 7-3 shift, ?0? itching episodes documented by LVN 5. A review of Resident 1?s Medication Administration Record (MAR) indicated that Seroquel 12.5 mg which was prescribed on 6/30/16, was given to Resident 1 on 7/1/16 through 7/12/16 and discontinued on 7/13/16. A review of Daily Med (a FDA approved information on prescription drugs) indicated Seroquel was an antipsychotic given for psychotic disorder. It indicated a warning that Seroquel increases the mortality in elderly patients with dementia-related and suicidal thoughts. It also stipulated Seroquel was not approved for the treatment of patients with dementia (https://dailymed.nlm.nih.gov). A review of the facility?s undated psychotherapeutic policy indicated that psychotropic medications are to be used only for specific behaviors by a resident and documented by the facility that caused: a) Danger to self. b) Danger to other residents or staff. c) Significant interference with staff?s ability to provide care. d) Psychotic symptoms (hallucinations, paranoia, delusions) that create frightful distress in the resident. The policy also stipulated psychotherapeutic medications given should have a specific diagnosis, specific behavior, and/ or thought process justifying the need for psychotherapeutic medications and should be identified in the resident?s health record. The facility failed to provide each resident with the necessary 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 to treat an ongoing rash (over a month) and administered an unnecessary drug without an adequate indication for its use including but not limited to: 1. Failure to ensure medications administered to Resident 1 had an adequate indication for its use. 2. Failure to ensure Resident 1 was not prescribed an antipsychotic without an indication for its use. 3. Failure to ensure, once the antipsychotic medication was ordered, side effects for the medication was monitored, as stipulated in the resident?s plan of care. 4. Failure to ensure adequate care and services were rendered to treat Resident 1?s ongoing rash with severe itching. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result.
970000070	INFINITY CARE OF EAST LOS ANGELES	940012995	A	28-Feb-17	28G111	7156	?483.25(h) Accidents (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident rece8ves adequate supervision and assistance devices to prevent accidents. Based on interview, and record review, the facility failed to provide adequate supervision and assistance devices for Resident 1 by failing to: 1. Place Resident 1 in a room close to the nursing station for increased visual check and using bed mobility monitors such as bed alarm and bed sensor as per their policy and procedure. 2. Provide Resident 1 a pad alarm to remind the resident not to get up unassisted and a bed sensor to alarm the staff every time the resident tries to get up, as per physician's order. 3. Update the resident's care plan to reflect measures that would prevent future falls of same nature. Resident 1 had two prior falls on 7/16/16 and 8/16/16 before the third fall on 9/16/16. These failures resulted in Resident 1, who was assessed to be at high risk for falls, falling again on 9/16/16, where she sustained a left intertrochanteric (hip) fracture that required transport to the general acute care hospital. On 10/5/16 at 11:40 a.m., a review of Resident 1's clinical record indicated she was admitted to the facility on XXXXXXX16, with diagnoses which included muscle weakness, dysphagia (difficulty or discomfort in swallowing), bipolar disorder (a mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and difficulty walking. The Minimum Data Set (MDS/an assessment and care screening tool) dated 7/25/16, indicated Resident 1 was cognitively intact, but required a Chinese speaking interpreter. Resident 1 required extensive assistance (one person physical assist) for bed mobility, transfers, ambulation, dressing, bathing and toilet use. The initial fall risk assessment dated 4/19/16, identified Resident 1 to be at risk for falls due to multiple medications (use of three different medications that could contribute to her risk for falls) and hypnotic (medication used to induce sleep) use, inability to walk and history of fall. During an interview on 10/5/16 at 11:50 a.m., the Director of Nurses (DON) stated on 9/25/16 at around 1:15 p.m., Resident 1 had an unwitnessed fall while using a walker to go to the bathroom. The DON stated the Certified Nurse Assistant (CNA 1) heard the resident fell, ran to her side and called for help. The DON stated Resident 1 did not have a bed alarm and the bed sensor only alarmed at the nurses' station. The DON stated Resident 1 was placed closer to the nurses' station after the third fall. The DON stated Resident 1 did not complain of pain initially, but the staff called the doctor, who ordered 72 hour neuro checks, and notification of the family. The DON also stated Resident 1 went to activities the next morning after the fall and started complaining of hip pain in the presence of the physician. On 9/26/16, the physician ordered for the resident to be transferred to the general acute care hospital for a hip fracture. Resident 1?s medical record indicated she was transferred to the acute care hospital on XXXXXXX16. The X-ray result dated 9/27/16, revealed a left intertrochanteric (hip) fracture for which she underwent an open reduction and internal fixation (ORIF) of the left hip on 9/28/16. She was discharged back to the facility on XXXXXXX16, for continuity of care. On 10/5/16 at 12:05 p.m., during an interview, Resident 1's family member (FM 1) who was interpreting for Resident 1 stated Resident 1 was attempting to go to the bathroom when she fell at the foot of her bed. FM1 stated Resident 1 stated she could not remember to use the call light. During an interview on 10/12/16 at 1:37 p.m., CNA 1 stated Resident 1 was in the back hallway (in a room far from the nurses' station) when she fell. CNA 1 stated she did not hear any alarm from Resident 1's room, but heard a noise and Resident 1 called out. CNA 1 stated she was not assigned to Resident 1, but ran into the room, called for help and assisted Resident 1 back to bed with other staff members. CNA 1 also stated Resident 1 was frightened but did not appear to be in pain. On 10/12/16, a review of the physician's order dated 5/12/16 indicated Resident 1 should have hourly visual monitoring. The physician's order dated 9/2/16 indicated to monitor the pad alarm placement every shift and the order dated 9/13/16 indicated Resident 1 was to have a sensor alarm while in bed because of fall risk. However, there was no documentation in Resident 1?s medical record that hourly visual monitoring was done for the resident and that the pad alarm placement was monitored every shift. On 10/12/16, a review of the care plan titled, " Resident found sitting on the floor due to unwitnessed fall/High risk for repeated fall and injury" dated 7/1/2016, included interventions to maintain call light within easy reach and answer promptly. The care plan dated 8/31/16, titled "Actual fall," indicated interventions to maintain call light within reach, answer promptly and assist resident to bathroom. However, as per above FM 1?s interview, the resident stated she could not remember to use the call light. After the third fall on 9/16/16, a review of the care plan dated 9/25/16, titled "Actual Fall," indicated the same interventions, but it was only after the third fall that Resident 1 was placed closer to the nurses' station with frequent observations. The care plan did not indicate how frequently the resident was to be monitored. A review of the facility's policy and procedures titled, "Administrative Policies and Procedures for Long Term Care; Nursing Services, " dated 8/4/07, indicated monitoring a high risk resident may be done by placing the resident near the nurses' station for increased visual monitoring, and doing a visual check of the resident at least every 15 minutes, using mobility monitors (i.e. Voice Sentry Bed & Chair Monitoring Device, Sensor Floor Mat, Drop Seat with Alarm, Sensor Pad Alarms), others. The facility failed to provide adequate supervision and assistance devices for Resident 1 by failing to: 1. Place Resident 1 in a room close to the nursing station for increased visual check and using bed mobility monitors such as bed alarm and bed sensor as per their policy and procedure. 2. Provide Resident 1 a pad alarm to remind the resident not to get up unassisted and a bed sensor to alarm the staff every time the resident tries to get up, as per physician's order. 3. Update the resident's care plan to reflect measures that would prevent future falls of same nature. Resident 1 had two prior falls on 7/16/16 and 8/16/16 before the third fall on 9/16/16. These failures resulted in Resident 1, who was assessed to be at high risk for falls, falling again on 9/16/16, where she sustained a left intertrochanteric (hip) fracture that required transport to the general acute care hospital. The above violations had a substantial probability that death or serious physical harm could result there from and did to Resident 1.
970000070	INFINITY CARE OF EAST LOS ANGELES	940013148	B	21-Apr-17	PPI011	4111	42 CFR 483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This included but not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident?s symptoms. On 2/14/17, the Department conducted an unannounced entity reported incident (ERI) investigation at the facility. Based on interview and record review, the facility failed to protect Resident 1 from verbal abuse by failing to: 1. Ensure a certified nursing assistant (CNA 1) did not call Resident 1 ?dumb, stupid old lady? on 2/8/17 when CNA 1 responded to Resident 1?s call bell. This deficient practice had the potential to affect the emotional and psychosocial well-being of Resident 1. A review of Resident 1?s Admission Record indicated that the resident was a 64-year-old female, who was admitted to the facility on XXXXXXX15, with diagnoses that included end stage renal disease (the kidneys have stopped working requiring dialysis), left hip pain, and hypertension (high blood pressure). A review of Resident 1?s Minimum Data Set (MDS, a standardized care and screening tool), dated 11/17/16, indicated that the resident was oriented to year, month, and day. Resident 1 needed supervision with activities of daily living (ADLs) and used a walker and wheelchair for mobility. A review of the Interdisciplinary Team (IDT) Conference Notes, dated 2/8/17 at 9 a.m., indicated that around midnight on 2/8/17, Resident 1 pressed the call bell. The IDT notes indicated that CNA 1 went to Resident 1?s room and told Resident 1 to turn off the call bell and that "... I am busy." Resident 1 stated, "My mouth is dry" and the resident asked for a glass of water. CNA 1 told Resident 1 "dumb, stupid old lady" while turning off Resident 1's call bell. CNA 1 did not return to give Resident 1 a glass of water. A review of the Situation, Background, Assessment/Analysis Request (SBAR, a tool to share patient information in a clear, complete, concise and structured format; improving communication efficiency and accuracy) form, dated 2/8/17 at 2:50 p.m., indicated that Resident 1 complained that CNA 1 told her "dumb, stupid old lady" when Resident 1 asked for water at around midnight on 2/8/17. Resident 1's attending physician and next of kin were notified. On 2/14/17, at 1:50 p.m., Resident 1 refused an interview regarding the incident that happened on 2/8/17 with CNA 1. Resident 1 stated, "What for?" A lot of people had already asked questions about the incident. During an interview, on 2/14/17 at 2:02 pm, CNA 2 stated that at midnight on 2/8/17, Resident 1 called for help by using the call bell. CNA 2 stated that CNA 1 responded and told Resident 1 to turn off the call bell, and CNA 1 called Resident 1 "stupid." During an interview, on 2/14/17 at 2:35 p.m., the social services designee (SSD) stated that Resident 1 told her that Resident 1 turned on the call bell to ask for water. Resident 1 stated CNA 1 came to her room, turned off the call bell, and called her (Resident 1) "stupid." Resident 1 stated that CNA 1 did not return with the water Resident 1 requested. During a telephone interview, on 2/21/17, at 12:19 p.m., the administrator stated the facility investigated Resident 1's allegation against CNA 1. The administrator stated Resident 1 was consistent with her statements and the facility concluded that the allegation was substantiated. During an interview, on 3/20/17, at 8:32 a.m., CNA 1 stated that at around midnight, Resident 1 asked for water. CNA 1 stated she gave Resident 1 a cup of water. CNA 1 denied the allegation that she called Resident 1 "stupid". The facility failed to protect Resident 1 from verbal abuse by failing to: 1. Ensure a certified nursing assistant (CNA 1) did not call Resident 1 ?dumb, stupid old lady? on 2/8/17 when CNA 1 responded to Resident 1?s call bell. The above violation had a direct or immediate relationship to the health, safety, or security of patients.
950000100	Ivy Creek Healthcare & Wellness Centre	950009830	B	05-Apr-13	QV8M11	6055	F 314 483.25 ? A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.On 12/11/12, an unannounced annual Recertification survey was conducted at the facility. Based on observation, interview and record review, the facility failed to provide treatment and services to prevent pressure sore development for Resident 3 by failing to:1. Develop a care plan to address pressure sore prevention for Resident 3, who was assessed as being at risk for developing pressure sores, conduct weekly body checks to assess and identify the presence and development of pressure sores, and Implement the ADL (Activities of Daily Living) plan of care to turn and reposition Resident 3 every two hours. This resulted in Resident 3 developing two stage II pressures sores to the left and right buttocks. The admission face-sheet for Resident 3, indicated that the resident was initially admitted to the facility on March 9, 2009, with diagnoses that included an above the knee amputation of the right lower extremity, diabetes (high blood sugar), hypertension (high blood pressure), and legal blindness. According to the resident's initial nursing admission assessment dated March 9, 2009, Resident 3's skin was intact and had no pressure sores. On December 11, 2012, at 7:50 a.m. and 11:18 am, Resident 3 was observed lying in the same position on her back and was not turned every two hours. On December 12, 2012, at 10:38 a.m., a body check was conducted on Resident 3 by Treatment Nurse 2 in the presence of the surveyor and certified nursing assistant (CNA) 4. The body check revealed that the resident had two stage II pressure sores located on the right and left upper buttocks, which had not been assessed or identified by the licensed nurse during the weekly skin assessments. The right upper buttock pressure sore as described by the treatment nurse was a shallow open ulcer with a red wound bed that measured 0.8 centimeters (cm) in length by 0.5 cm in width and the left upper buttock was described as a shallow open ulcer with a red wound bed that measured 0.2 cm in length by 0.2 cm in width. Additionally, there were no assessments of the two pressures sores noted in the medical record.A review of the facility's skin breakdown report, dated September 18, 2012, indicated that Resident 3 had previously developed a Stage II sacrococcygeal pressure ulcer. The pressure ulcer measured 0.4 cm in length x 0.3 in width x 0.1 cm in depth and was described as having ten percent slough (a yellow or white tissue that adheres to the ulcer bed in strings or thick clumps and is indicative of full-thickness tissue loss, stage 3 or stage 4 pressure sore). According to the last documented skin breakdown report, dated October 9, 2012, the sacrococcygeal (concerning the sacrum and coccyx) pressure ulcer was healing and measured 0.2 cm x 0.2 x 0.1 cm and had no slough. However, a review of the medical record did not contain documented evidence that a continuous assessment of the pressure sore had been performed.On December 12, 2012, at 10:38 a.m., the assessment of the of the sacrococcygeal area revealed that there was only an old scar present in the location where the sacrococcygeal pressure sore had once been. On December 12, 2012, at approximately 10:40 a.m. during an interview with Treatment nurse 1, regarding the two unidentified pressure sores, she stated that there were no body-checks or assessments done because the resident's previous pressure sore had healed. She was not sure as to when the pressure sore had healed because there was no documentation in the record. The licensed vocational nurse (LVN) 2, stated during an interview on December 12, 2012, at 2 p.m., that Resident 3 was not on the two-hour turning schedule which meant, that the certified nursing assistants were not told to reposition the resident every two hours.However, a review of the Activity of Daily Living (ADL) plan of care dated July 12, 2012, indicated to turn and reposition the resident every two hours.A review of the medical record revealed that there was no other plan of care located in the medical record to address pressure sore prevention interventions for the resident, other than the ADL care plan dated July 12, 2012, which indicated to turn the resident every two hours.According to the Quarterly Minimum Data Set (MDS), a standardized assessment and care screening tool, dated September 14, 2012, Resident 3 was assessed as totally dependent on staff for all activities of daily living (ADLs), including transfers and bathing, required extensive assistance for bed mobility, usually understands others, was understood, had an impairment on one side of the upper and lower extremities and was always incontinent of urine and bowel. It further indicated that the resident had no pressure sores but was at risk of developing pressure sores and was on a turning and repositioning program. A review of the Braden Scale, used for predicting pressure sore risk dated September 14, 2012, indicated that Resident 3's score was noted as 17, which represents a mild risk for pressure sore development (a severe risk is a total score less than 9, high risk total score 10-12, moderate risk total score 13-14, and a mild risk total score 15-18). On December 12, 2012, at 12:04 p.m., during an interview with the Director of Nursing (DON), she stated that there was no documentation in the medical record of the assessment of the progression and healing of the sacrococcygeal pressure sore after the resident's pressure sore treatment was completed on October 15, 2012. She stated that she was not aware of the new pressure sores. She became aware of the sores after they were identified during the body check. She further stated there was a lack of assessment and that was why there was no documentation in the medical record. The above violations had a direct relationship to the health, safety and security of all residents.
950000100	Ivy Creek Healthcare & Wellness Centre	950010956	A	03-Sep-14	NT8N11	10995	F323 Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 1) who had a history of falls, was provided care to prevent further falls based on the resident's identified care needs by: 1. Getting Resident 1 up in a shower chair against the wishes of the resident's family 2. Not providing Resident 1 an assistive device while in the shower chair 3. Not utilizing a gurney in accordance with the facility?s policy for Resident 1 who continuously rocked back and forth and had poor sitting balance.This resulted in Resident 1 falling face forward from the shower chair to the floor, and hitting her head. Consequently the resident sustained a laceration which required seven sutures, had knee swelling, a T4 compression fracture (occurs when the bones of the spine become broken due to trauma). Prior to the accident the resident was able to turn with assistance, without pain. After the accident the resident experienced pain while being turned with assistance. Findings: A review of the Face Sheet for Resident 1 indicated the resident was originally admitted to the facility on 1/26/12, and was readmitted on 7/1/14, with diagnoses that included but not limited to gastrostomy (is a surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube is used for feeding or drainage), chronic airway obstruction (a lung disease that makes it hard to breathe) and lumbar disc displacement (disc has fallen out of its alignment in the backbone/spine). During an observation with the licensed vocational nurse (LVN) on 7/16/14, at 2:41 p.m., Resident 1 was lying in bed with her eyes closed and her mouth open. Her breaths were slow and deep. The resident had a laceration on the entire length of her left eyebrow. The LVN was asked what happened to the resident. The LVN stated the resident had a recent accident in the shower. A review of the comprehensive Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 2/5/14, indicated care area triggers (CATs/guide for the interdisciplinary team for care plan development) for falls. The problem area focused on impaired balance during transfers and the care plan consideration, indicated to proceed with care plan monitoring of safety needs and provide a safe, hazard free environment, to provide supervision/assistance as needed for safety.A further review of the recent MDS, dated 5/5/14, (MDS prior to fall on 6/27/14), indicated the resident sometimes understood others, was sometimes understood by others and had severe cognitive impairment (never or rarely made decisions). In addition, the resident had no impairment to her extremities, but, required total physical help for activities of daily living, such as, bed mobility, transfer between surfaces, eating and bathing. The MDS also indicated, the resident was unable to walk and required staff assistance to stabilize during the transfer from bed to chair or to the wheelchair. A review of Resident 1's restorative nursing weekly progress notes dated 6/24/14, indicated the resident was not able to balance herself when sitting. During an interview with the certified nursing assistant (CNA 1), on 7/16/14, at 3:02 p.m., about the accident on 6/27/14, CNA 1 stated Resident 1 was sitting in the shower chair rocking her upper body more than usual. The CNA further added the resident had the tendency to rock, but on the day of the accident, the resident was rocking more than usual. The CNA stated she told the resident twice in English to relax and stop rocking. As Resident 1 was rocking, she threw herself forward and due to the resident having lathered soap on her body and the CNA having soap on her hands, the resident went forward and landed face first on the floor. The CNA further stated she was unable to hold on to the resident because her hands were slippery and the shower chair slid from behind the resident, with the wheels locked in position.On 7/16/14 at 4:36 p.m., an inspection of the east shower room, the location of the accident on 6/27/14, was conducted in the presence of the director of staff development (DSD). Seven shower chairs were inspected and two were observed with the arm and seat mesh excessively stretched, rough, damaged and torn. One of the two damaged shower chairs was used during the resident's shower on the day of the accident. During an interview and observation with the director of maintenance on 7/17/14 at 9:27 p.m., the maintenance supervisor acknowledged the mesh of the shower chairs were excessively stretched, rough, damaged and torn. He further stated the chairs were being destroyed and replaced with new shower chairs on 7/17/14 and replaced with new shower chairs with a safety bar across the front of the chair and a safety belt. According, to the maintenance supervisor, there was no documentation of the maintenance of the shower chairs. Also, the old shower chair used for Resident 1 did not have seatbelts. During a subsequent interview with the CNA on 7/17/14 at 7:50 a.m., when asked which shower chair was used for the resident on 6/27/14, she responded it was one of the "old" shower chairs. Furthermore, at 8:22 a.m., 8:24 a.m., and 8:25 a.m., CNA 1, 2 and 3 were asked how did they know whether to use a shower chair or the gurney when giving a resident a shower. CNA 1, 2 and 3 responded the charge nurse gives them instructions in regard to which chair or gurney (wheeled cot or stretcher) to use for the resident during a shower. During an interview with the charge nurse, LVN 1, on 7/17/14 at 8:27 a.m., when asked about the facility's policy or procedure on how to assess whether to use a shower chair or gurney, she responded that a resident who is not able to sit in a wheelchair independently, and have contractures (permanent shortening of a muscle that causes a deformity) or a gastrostomy (G-tube/medical device used to provide nutrition to residents who cannot obtain nutrition by mouth or are unable to swallow safely) should use a gurney. She further stated for Resident 1, a chair was used even though the family did not like the resident to be up in a wheelchair and had requested the staff to not put the resident in a wheelchair. LVN 1 further added the family refused having the resident to sit in a wheelchair because the resident becomes short of breath when sitting. In addition, LVN reviewed the clinical record and was unable to find documentation or a care plan noting the family's request.During an interview with the director of nursing on 7/21/14 at 3:15 p.m., she reviewed the clinical record and was unable to find documentation or care plans addressing the family's request to not get the resident out of bed onto a chair, the rocking behavior of the resident while on a shower chair and reviewing the restorative nursing weekly progress notes indicating the resident was not able to balance herself while sitting, to provide the resident with the appropriate plan of care and care interventions of balance and safety. This deficient practice resulted in an actual fall on 6/27/14 at 10:45 a.m., where Resident 1 sustained a laceration (deep cut) to the forehead measuring 1.5 centimeters (cm) in width by 5 cm in length which required an evaluation in the local emergency room and seven stitches to close the laceration after a fall in the shower. In addition, the resident sustained an abrasion (superficial damage to the skin) to the tip of the nose and to the left lateral knee.A review of the acute hospital left knee radiology report dated 6/28/14, indicated the resident had a diagnosis of pain and soft tissue swelling to the knee. In addition, a radiology report of the spine with a clinical diagnosis of back pain showed a new compression (collapse of spinal bones) of the T4 vertebra possibly due to recent trauma. During an interview with the resident's family member, on 8/5/14, at 10:18 a.m., she stated the resident has been in the facility for about three years. When the resident was first admitted the resident was able to sit in the wheelchair for about 10 minutes, and then she would start to complain she felt tired and was not comfortable sitting in the wheelchair . Since the middle of last year, June 2013, the primary responsible party (RP) of Resident 1 requested the resident not sit in a wheelchair unless the RP party was present or the resident was asked if she was fine sitting in a wheelchair . The family member further stated Resident 1 was not able to sit in a wheelchair due to her lack of strength to her neck and upper body. When asked how the resident is doing after the accident, she stated the resident complains of pain, especially when she coughs she needs to hold her chest. In addition, prior to the accident the resident was able to turn with assistance, however, after the accident the resident is unable to turn with assistance without complaining of pain. The family member is concerned about possible skin impairment due to the resident not being able to turn while in bed. A review of the Pain Management flow sheet, since the resident readmission post falls, on 7/1/14, indicated the resident was administered Tylenol #3 (medication made of two pain-relieving medications) on: 7/1/14 at 6:30 p.m. for generalized pain with intensity of a 6 out of 10 (10 being the worst pain), 7/2/14 at 5 p.m. for generalized pain with intensity of a 6 out of 10, 7/4/14 at 10:30 p.m. for generalized pain with intensity of a 6 out of 10, 7/7/14 at 6:30 p.m. for generalized pain with intensity of a 6 out of 10, 7/9/14 at 6:30 p.m. for generalized pain with intensity of a 6 out of 10. During a further review of the Daily Licensed Nurses Note dated 7/4/14 during the 3 p.m. to 11 p.m. shift, indicated the resident was yelling and via a translator the resident was found to have generalized body pain of 6 out of 10. A review of the Pain Management flow sheet for 6/1/14 to 6/27/14, prior to the accident, indicated the resident did not complain of pain.The facility failed to ensure one of three residents (Resident 1) who had a history of falls, was provided care to prevent further falls based on the resident's identified care needs by: 1. Getting Resident 1 up in a shower chair against the wishes of the resident's family 2. Not providing Resident 1 an assistive device while in the shower chair 3. Not utilizing a gurney in accordance with the facility?s policy for Resident 1 who continuously rocked back and forth and had poor sitting balance. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result.
950000079	INLAND VALLEY CARE AND REHABILITATION CENTER	950011183	B	17-Dec-14	ZOVU11	4227	Inland Valley Care and Rehabilitation Center1418.91. (a) A long ?term health care facility shall report all incidents of alleged abuse or suspected abuse of a patient of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class ?B? violation. The Department received a complaint on December 11, 2013, indicating a patient (Patient A) alleged two weeks ago she was struck on the shoulder by a facility?s employee. Patient A reported the abuse to the social worker, indicating she felt unsafe. According to Patient A nothing was done by the facility to make her feel safe. Based on interview and record review, the facility failed to: 1. Report the abuse allegation to the Department of Health 2. To follow its policy and procedure in reporting an abuse allegation These failures resulted in Patient A not feeling safe and signing out against medical advance (AMA). On December 20, 2013, at 2:15 p.m., an unannounced complaint investigation was conducted to investigate the alleged abuse of Patient A, that a man dressed in all white came into her room, was trying to choke her and then hit her on the shoulder.A review of Patient A?s Admission Record indicated the patient was admitted to the facility on October 7, 2013, from home. The admission diagnosis was hypertension (high blood pressure). A review of a Licensed Nurses Note (LNN), dated November 12, 2013, and timed at 8:45 a.m., indicated the patient was upset and fearful because a man dressed in white came into her room the night prior and awaken her from sleep, and then offered to take her to the bathroom. The LNN also indicated, Patient A?s story changed stating she was standing next to her bed, when she was about to go to bed, but was not sure what time it was. The patient told the nurse she did not tell anyone about the incident, except for a certified nurse assistant (CNA). A review of a ?Body Skin Assessment? record, dated November 12, 2013, (no time written) for Patient A indicated, the patient?s skin was clear with no bruises present.A review of Patient A?s Minimum Data Set (MDS), an assessment and care screening tool, dated October 14, 2013, indicated, the patient?s mood was assessed as feeling depressed, down or hopeless. The patient required extensive assistance with bed mobility, dressing, toilet use and personal hygiene, transferring and walking in the room and corridors. A review of a care plan dated October 17, 2013, indicated Patient A had episodes of fabricating stories, by saying ?she?s not fed? and being fearful of having male staff assisting with personal hygiene. The facility?s approach to the plan was to not assign male staff for personal hygiene, and allow female staff to provide for the patient?s care needs. On December 20, 2013, at 3 p.m., another interview was conducted, the ADON indicated, he was informed about the patient reporting the incident and he asked the patient to describe the person. According to the ADON, the patient stated she did not recognize the person and could not name the person. A review of the facility?s undated ?Abuse Prohibition ? Reporting Response policy? indicated the facility?s investigation will continue as needed over the next 24-48 hours. The policy also indicated to telephone or fax an investigation to the Department of Health immediately, but not to exceed 24 hours. On December 20, 2013 at 3:55 p.m., subsequent interviews were conducted with the facility?s ADON and DON, collectively. They indicated an allegation of abuse should be reported to the Department of Health within 24 hours. On November 18, 2014, at 2 p.m., an interview with the assistant director of nurses (ADON ) stated, the police was notified and came to investigate the allegation, but the Department of Health was not notified. The facility failed to: 1. Report the abuse allegation to the Department 2. To follow its policy and procedure in reporting abuse allegation The above violation, of not reporting the abuse allegation of Patient A caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to patients.
950000079	INLAND VALLEY CARE AND REHABILITATION CENTER	950012946	B	3-Feb-17	CEGV11	5299	483.13(b), 483.13(c)(1)(i) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. On December 26, 2013, at 2:15 p.m., an unannounced visit was made to the facility to investigate an entity reported allegation that licensed vocational nurse (LVN) 1 verbally abused Resident 1. Based on interview and record review, the facility failed to ensure that Residents 1 was free from verbal abuse by LVN 1. This resulted in mental and emotional harm to Resident 1, who expressed that she was shocked, and felt mad by what LVN 1 said. A review of the Admission Record of Resident 1 indicated the resident was originally admitted to the facility on XXXXXXX 2009, and was readmitted on XXXXXXX 2012, with diagnoses that included sepsis (life-threatening condition that arises when the body's response to infection injures its own tissues and organs), hypoxemia (low level of oxygen in the blood), acute respiratory failure, and dependence on a respirator (an apparatus used to induce artificial respiration) status. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated October 2, 2016, indicated Resident 1 was able to complete the brief mental status interview, understood others and able to make self-understood and was totally dependent on the staff for most activities of daily living. A review of the facility's investigative report dated December 19, 2013, indicated on December 19, 2013, at 7 p.m., the director of staff development (DSD) received a text from Respiratory Therapist (RT) 1 informing her that during Thanksgiving week, RT 1 observed LVN 1 cursing at Resident 1 about putting her call light on. RT 1 stated that while he was attending to Resident 1's ventilator, LVN 1 entered the resident's room and stated "Do not f__ing (expletive word) start with me, I'm too busy and left the room." A review of LVN 1's written statement dated December 20, 2013, indicated that she was discussing a patient with RT 1 and there was a possibility that Resident 1 thought that the discussion was about her. Resident 1 probably thought that foul language was used. LVN 1 wrote that she never used foul language with her patients and that she respects and loves her patients. During an interview on December 26, 2013, at 2:40 p.m., Resident 1 stated sometime in November during 11 p.m. to 7 a.m. shift, she used the call light to ask for a blanket. Her certified nursing assistant (CNA) was busy so she called for LVN 1. LVN 1 came and brought her a blanket. After sometime, she called again because her t-bar [tracheostomy (an opening surgically created through the neck into the trachea or windpipe to allow direct access to the breathing tube) bar] came off, so LVN 1 came and fixed it. After that, she called again because her roommate needed help. Resident 1 stated she had to call LVN 1 another time because she needed to be suctioned (removal of accumulated substances from the resident's breathing tube) and was having a hard time breathing. LVN 1 told her she will call RT 1. According to Resident 1, she was still waiting for a staff to come, so she pressed the call light again. RT 1 walked in the room without turning off the call light and started suctioning her. While RT 1 was suctioning her, LVN 1 came in the room and stated "I am on my f__ing break (expletive word)" then left the room. RT 1 asked her, "Is she talking to you like that?" During the same interview with the resident, when asked how this made her feel, Resident 1 stated she was shocked and felt mad and hurt about it. Resident 1 stated that it still upset her when she thinks about it. During an interview on July 13, 2014, at 9:50 a.m., the DSD stated that there was no documentation that LVN 1 was suspended after the incident. The DSD stated that LVN 1 did not return to work despite many undocumented phone calls. According to the DSD, when LVN 1 returned to work on December 30, 2013, she was served a termination notice effective immediately and LVN 1 submitted a resignation letter at the same time. A review of the facility's policy and procedure titled "Abuse Prohibition" revised on September 2006 indicated each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, misappropriation of their property and be identified upon admission as a "Resident at Risk." Every resident at Inland Valley Care and Rehabilitation Center (IVCRC) will be treated with respect and dignity at all times. Staff will refrain from all actions that could be considered "abuse, mistreatment, and/or neglect." Verbal abuse is defined as any use of oral, written or gestured language that will fully include disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of a resident's age, ability to comprehend or mental and/or physical disability. The facility?s failure to ensure that Resident 1 was free from verbal abuse by LVN 1 had a direct relationship to the health, safety, or security of the resident.
950000079	INLAND VALLEY CARE AND REHABILITATION CENTER	950012947	B	3-Feb-17	CEGV11	3977	F223 483.13(b), 483.13(c)(1)(i) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. On December 26, 2013, at 2:15 p.m., an unannounced visit was made to the facility to investigate an entity reported allegation of verbal abuse. Based on interview and record review, the facility failed to ensure that Resident 2 was free from verbal abuse by Licensed Vocational Nurse (LVN) 1. Resident 2 felt bothered and upset when LVN 1 called her a big cry baby. A review of the Admission Record of Resident 2 indicated the resident was originally admitted to the facility on XXXXXXX, 2013, and was readmitted on XXXXXXX, 2013, with diagnoses that included pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid), pressure ulcer, sepsis (the presence of bacteria, other infectious organisms, or toxins created by infectious organisms in the bloodstream with spread throughout the body), acute respiratory failure, and dependence on respirator (an apparatus used to induce artificial respiration) status. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated November 20, 2013, indicated the resident was able to complete the brief mental status interview, understood others and able to make self-understood and was totally dependent on the staff for most activities of daily living. A review of RT 1?s undated written statement indicated on December 19, 2013, at 6 p.m., RT 2 informed him that Resident 2 claimed that LVN 1 had verbally abused her. According to the statement, RT 1 asked Resident 2 about her allegation of verbal abuse. Resident 2 confirmed it and added that this was not the first time LVN 1 had called her a big cry baby. A review of RT 2?s written statement dated December 22, 2013, indicated on December 19, 2013, during 7 a.m. to 3 p.m. shift, Resident 2 complained to RT 2 that her eyes were burning, so RT 2 got her a wash cloth to wipe her eyes. At that time, Resident 2 stated that LVN 1 had spoken harshly to her the night before when Resident 2 had complained about her eyes burning. The written statement indicated that Resident 2 said LVN 1 told her to ?stop crying like a big baby? and that she told LVN 1 she was not crying; her eyes were just burning. During an interview on December 26, 2013, at 3 p.m., Resident 2 stated sometime before Christmas during 11 p.m. to 7 a.m. shift, she called for LVN 1 because her eyes were burning. Resident 2 stated LVN 1 came in, did not even ask what was wrong with her and just said "Why are you crying for?" "Don't be such a big baby." According to Resident 2, this bothered and upset her because no one deserves to be talked to that way. A review of the facility's policy and procedure titled "Abuse Prohibition" revised on September 2006 indicated each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, misappropriation of their property and be identified upon admission as a "Resident at Risk." Every resident at Inland Valley Care and Rehabilitation Center (IVCRC) will be treated with respect and dignity at all times. Staff will refrain from all actions that could be considered "abuse, mistreatment, and/or neglect." Verbal abuse is defined as any use of oral, written or gestured language that will fully include disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of a resident's age, ability to comprehend or mental and/or physical disability. The facility?s failure to ensure that Resident 2 was free from verbal abuse by LVN 1 had a direct relationship to the health safety and security of the resident.
960001836	IDEAL HOME CARE	960008888	B	09-Jan-12	ZSGE12	8891	Class B Citation 4502. Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and Laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the legislature that persons with developmental disabilities shall have rights, including, but not limited to, the following: b) A right to dignity, privacy, and humane care. To the maximum extentpossible, treatment, services and supports shall be provided in natural community settings. On November 19, 2011, at 6:00 a.m., an unannounced visit was made to the facility to conduct a reconsideration survey.Based on observation, interview and record review, the facility's staff failed to:1. Ensure privacy during treatment and care of personal needs for Clients 1, 2 and 3. Client 2?s body was exposed to Client 4. Client 3 and 1 were exposed to all who walked past their rooms.2. Ensure humane care and dignity to Clients 3 and 1 while providing morning care in a cold room without covering the client. a. A review of Client 2's health record indicated the client was admitted to the facility on June 4, 2007 with diagnoses including severe mental retardation. Client 2 was observed non-verbal, and communicated via gestures and sound (with limited verbal skills that are sometimes imitative and repetitive). The client was wheelchair bound and dependent upon staff in meeting her needs with activities of daily living. On November 19, 2011 at 6:35 a.m., during observations, Client 4 was walking down the hall and direct care staff (Staff A) instructed the client to go back to her room. Staff A followed the Client 4 into the room where Client 2 was observed lying in bed. Client 4 sat on her bed. (Client 2 and 4's beds were side by side with approximately 4 feet in between the beds). Staff A then stated she needed to check Client 2 then pulled the blankets off Client 2 to check the client?s incontinent pad (adult diaper). Staff A then obtained clothes and supplies to clean the client. Staff A took Client 2's incontinent pad off and cleaned the client's perineal area then took off the client's blouse exposing her breasts. Client 4, who remained in the room, covered her head with her blanket. Staff A was not observed to provide Client 2 with privacy during care and Client 4 had full view of Client 2's body while care was provided. On November 20, 2011 at 3:05 p.m., during an interview, Staff A stated she instructed Client 4 to go back into her room while she provided care to Client 2 because Client 4 goes into the kitchen and ?prepare bread?. She stated she could not leave Client 4 alone. She further stated Client 4 usually covers her head with the blankets while she cares for Client 2.b. A record review of Client 3's health record indicated the client was admitted to the facility on March 10, 2000 with diagnoses including profound mental retardation and the client was blind. Client 3 was observed to be non-verbal, and communicated via sound and single words such as "No." The client was ambulatory and dependent on staff in meeting his needs with activities of daily living. A review of Client 1's health record indicated the client was admitted to the facility on November 9, 2000 with diagnoses that included mild mental retardation (developmentally functions at one half to two thirds of chronological age, is slow in all areas, but can acquire practical and vocational skills), cerebral palsy (a group of disorders that effect a person's ability to move and maintain balance and posture related to the brains ability to control the body) and right side paralysis (inability to move the right side of the body). Client 1 was dependent on staff for activities of daily living care (dressing, grooming and feeding). A record review of the client's regional center quarterly report dated February 1, 2011 indicated, the client was verbal and able to advocate most of his needs. On November 20, 2011 at 7 a.m., during observations, Staff A escorted Client 3 from the bathroom to the foot of his bed, where he held onto the footboard of the bed for support. Client 1 who was Client 3?s room-mate was observed lying in bed. Staff A then proceeded to wet a towel with water from the bathroom sink and wiped Client 3's face and arms. Client 3 grunted loudly as she wiped him. At that time the surveyor checked the wet towel and it was cold to touch. Staff A was observed not to allow the water to warm before removing the towel from the running water to apply to the client's skin. Staff A then returned to the bathroom sink, obtained a towel with warm water and continued wiping the client. The door to the bedroom was observed opened while Staff A wiped and dried the client's upper body exposing his chest to all who walked past his room. After applying the client's upper body clothing, Staff A removed the client's pajama bottoms and underwear (his diaper had been removed in the bathroom) exposing his nude body to Client 1 and to all who walked past his room while she wet the towel again. Staff A returned and wiped the client?s legs, groin area and feet then dried and dressed the client?s lower body. Client 1 remained in bed and Client 3 was escorted into the living room. Staff A was not observed to provide Client 3 with privacy during care. At 7:15 a.m., during observations, in Client 1 and 3's cold room, the only heater vent was observed in the room with still cob webs across it which indicated there was no heat blowing into the room to disrupt the cob webs. During an interview at the same time Staff G was asked to check the wall vent for heat. Staff G put her hand to the vent and confirmed no heat was coming through the vent to warm the room.At 7:25 a.m., on the same day during observations, the bedroom door remained open as Client 1's morning care was initiated. Staff A and G removed the client's clothing exposing him to all who walked past his room.The client was rolled over onto his left side revealing a urine saturated incontinence bed pad, pajama pant, underwear, diaper and approximately 70% of the bed was saturated with urine. Staff A wiped the client off with a wet towel only then used a no-rinse wash on the client's genitalia area. Staff A did not use soap to clean the urine soaked client. The remainder of the client's body was wiped with water. Staff G assisted Staff A with positioning and drying the client.At 7:35 a.m., during observations, Client 1?s genitalia remained exposed. The administrator/ qualified mental retardation professional (QMRP) entered the room, looked at the vent, raised his hand near the vent checking for heat, then exited the room and stated, ?I am going to give him a little privacy,? then closed the client's bedroom door. At 7:45 a.m., during observations, the bedroom emergency exit door to the home exterior had a gap between the door and the door frame which allowed an exchange of air in and out of the bedroom. It was a cold, rainy day outside and the bedroom was cold inside.At 3:05 p.m., during an interview, when asked about Client 1 not receiving privacy, Staff A stated the door was open because Staff G went out of the room to get something. She further stated she did not notice the door being opened. When Staff A was informed that she was observed to go in and out of the room without closing the door, Staff A responded Staff G was going in and out of the room. At 3:10 p.m., during an interview, when asked about Client 1 not receiving privacy, Staff G stated she did not realize the door was open. Staff G stated when she entered the bedroom to help Staff A, the door was open. She stated Staff A repeatedly went in and out of the open door, never closing the door behind her. Staff G stated the facility policy was to provide privacy to the client's by closing the door and if there are two in the room, one of the client's should leave the room because there were no privacy curtains available in the facility.The facility's undated policy and procedure titled, Provision of Privacy, indicated, visual privacy for each client shall be provided in client's rooms, tub, shower, and toilet rooms. The policy further states," Doors shall be closed as appropriate and privacy screens will be used when roommates may be present in bedrooms." Failure to ensure privacy during treatment and care of personal needs for Clients 1, 2 and 3 and ensure humane care and dignity to Clients 3 and 1 while providing morning care likely caused significant humiliation, indignity, anxiety, or other emotional trauma to the clients.
920000078	IMPERIAL CARE CENTER	920013201	AA	14-Sep-17	KBI011	12568	CFR 483.25 Quality of Care Each resident must receive and the facility must provide the necessary 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. 483.25 (h) Accident Hazards/Supervision/Devices The facility must ensure that (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 11/12/15, at 2 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1 falling near his bed and hitting his head, causing a subdural hematoma (a pool of blood between the brain and its outermost covering), and resulting in death. Resident 1 was assessed as a high fall risk upon entering the facility and had a history of falls. A plan of care was developed to implement a fall risk program, but the fall risk program failed to adequately address Resident 1?s fall risks, specifically getting out of bed unattended. The plan of care failed to include a bed alarm or other alarms to alert staff that Resident 1 was out of bed and would need assistance. Based on interview and record review, the Department determined that the facility failed to provide its residents with the necessary 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, and failed to ensure that the resident?s environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent falls and injuries, including but not limited to the following: 1. Failure to ensure Resident 1, who was assessed as a high fall risk due to confusion and poor safety awareness, was assisted with transfers and was supervised while walking as indicated in the comprehensive assessment and plan of care. 2. Failure to implement the facility?s policies and procedure on Fall Reduction by not re-evaluating the plan of care after the second fall and by not developing a new comprehensive plan of care to meet Resident 1?s specific needs to prevent recurrence of falls. 3. Failure to evaluate effectiveness of interventions in order to develop new and more effective interventions to prevent falls and minimize injuries. As a result, on 9/6/15, while Resident 1 was walking in his room unassisted, he sustained a fall with a head injury, developed a subdural hematoma (a pool of blood between the brain and its outermost covering), and subsequently died on 9/19/15. A review of the closed clinical record indicated Resident 1 was admitted to the facility on 4/1/15, with diagnoses including Alzheimer's disease (progressive disease that destroys memory and other important mental functions), dementia (a progressive decline in memory and at least one other cognitive area, such as attention, orientation, judgement, abstract thinking and personality), and psychosis (an abnormal condition of the mind described as involving loss of contact with reality). A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated 6/27/15, indicated Resident 1 had severely impaired cognitive skills for daily decision-making, required one-person physical assistance with transfers, and required supervision when walking in his room and in the hallway. A review of the fall risk assessments dated 4/2/15, 5/15/15, 7/30/15, 8/11/15, and 9/6/15, indicated Resident 1 was at high risk for falls. The nurses? notes indicated on 5/15/15, six weeks after admission, Resident 1 sustained a fall with no injury. A review of the investigative report of the fall indicated on 5/15/15, at 7:45 p.m., Resident 1 fell in the hallway. The measures to prevent recurrence included continued monitoring of the resident, assisting to activities under supervision, and continued physical/ occupational therapy (PT/OT) treatment. The post fall assessment indicated Resident 1 had impaired strength, balance, and safety awareness. A Fall Reduction care plan developed the same day of the fall, 5/15/15, indicated the fall was related to decreased strength/endurance, poor safety awareness/judgement, unsteady gait, not using the call light, history of falls, balance deficit, and cognitive impairment. The interventions included frequent visual monitoring, room close to the nurse's station for close monitoring, call light in reach, PT/OT (physical/occupational therapy) assessment and training, non-skid shoes, interdisciplinary team meeting for falls, restraint assessment, night light, and Falling Star Program. The Fall Reduction care plan did not include a bed / chair alarm for unassisted transfers. A Post-Fall Assessment and Follow-Up dated 5/18/15 indicated Resident 1 did not know how to use the call light, no restraints were in use at the time of the fall, and a restraint reassessment was not required. However, the fall reduction care plan indicated restraint reassessment as an intervention. According to the nurses? notes, Resident 1 had another fall on 8/11/15, resulting in a cut to the left third finger that required six sutures. The investigative report for this fall indicated on 8/11/15, at 11:50 p.m., Resident 1 was found lying on the floor in the hallway outside his room. The measures to prevent fall recurrence were the same as the previous investigative report dated 5/15/15. Another Fall Reduction care plan was developed with the same interventions as the plan of care dated 5/15/15. The care plan was not revised to develop new and more effective interventions to prevent recurrence of falls and to minimize injuries. An interdisciplinary team (IDT) note, dated 8/11/15, indicated Resident 1 required minimal assistance with transfers and ambulation and recommended respecting the right of the resident to be independent and to remind him to request assistance/use call light. The IDT did not assess what prompted the resident to get out of bed/or chair to ensure the resident?s needs were met. The IDT did not make recommendations to use alternative measures or safety devices such as applying bed/chair alarms to alert the staff when Resident 1 attempted unassisted transfers, engaging the resident in evening activities, or providing evening exercise program, as the falls occurred after dark. According to the nurses? notes, Resident 1 had a third fall on 9/6/15, at 8:30 p.m., in his room. The investigative report dated 9/6/15, indicated Resident 1 was found lying on the floor by the footboard of the bed and the window. Resident 1 was unresponsive, bleeding from a laceration on the left side of his head, the eyes were closed, and the respirations were rapid and heavy. First aids were administered and emergency rescue (911) was called. Resident 1 was transported to general acute care hospital 1 (GACH 1). According to a fall investigation Interview Record dated 9/6/15, certified nursing assistant 1 (CNA 1) stated at 8:30 p.m., while passing nourishment, she heard a sound, checked all the rooms until she found Resident 1 lying face down on the floor between his bed and the bathroom and in front of the window. The facility's undated policy and procedure titled, "Fall Reduction (General)," indicated under Policy, ?It is the policy of this facility to reassess all residents with falls every time they occur.? Under the part titled, ?Procedure? section 4, ?A comprehensive care plan shall be developed to meet resident's specific needs.? Under section 12, ?Residents with repeated falls, with or without injury, must have restraint assessment, fall risk assessment, physical therapy reassessment, new care plan entry to reduce fall risk and IDT meeting to discuss measures to reduce fall risk with family notifications.? The facility's undated policy and procedure titled, "Fall Reduction (Ambulatory)," under ?Policy? indicated ?(a) a comprehensive care plan would be developed to meet resident's specific needs.? Under ?Procedure,? section 8, ?(o) once fall risk had been established, IDT shall discuss the resident's status and implement a fall risk program that includes alarms, safety devices (like lap buddy), self-release soft belt, non-skid floor strips, floor mats, low bed etc.? On 11/12/15, at 3 p.m., during an interview, licensed vocational nurse 1 (LVN 1) stated on the evening of Resident 1's last fall (9/6/15), at 8:30 p.m., she was passing medications when CNA 1 called her to Resident 1's room. Upon arrival, LVN 1 found Resident 1 lying on the floor at the foot of his bed, with his head closest to the window. Resident 1 was given oxygen, 911 was called, and was transported to GACH 1. On 12/18/15, at 3 p.m., during an interview, Physical Therapist 1 (PT 1) stated Resident 1 was really confused, and even though she spoke the resident?s primary language, he could not follow instructions. PT 1 stated she tried to instruct the resident on using a walker, but he could not follow cues and did not know what to do with the walker. The PT stated they used a gait belt, and guided him to move his leg and to sit. On 12/18/15, at 2:30 p.m., during an interview, Resident 1's roommate (Resident 2) stated the night of Resident 1's fall in the room; Resident 1 got out of bed and went over to Resident 2's bedside. Resident 2 told Resident 1 to go away; Resident 1 slowly walked back toward his bed placing hand over hand on the footboard of Resident 2's bed. When Resident 1 reached the end of the footboard and had nothing to hold onto, he fell and struck his head. A review of the GACH 1 admitting history and physical exam (H&P) dated 9/8/15, indicated Resident 1 had a CT scan (series of X-ray images using a computer to show cross-sectional views) which revealed a subdural hematoma (a pool of blood between the brain and its outermost covering). Resident 1 was transferred to GACH 2 for further intervention and the plan was for a craniotomy (surgical removal of part of the skull to expose the brain) and evacuation of the blood. GACH 2 Discharge Summary Notes dated 10/5/15, indicated the hospital course included craniotomy, Resident 1 failed to improve postoperatively, developed seizures, and remained lethargic. It was decided to proceed with do not resuscitate (DNR) status and comfort care only. The discharge summary notes indicated Resident 1 was transferred to the medical floor, where he expired. The Death Pronouncement from the GACH indicated the cause of death was cardiopulmonary arrest (a sudden stop in effective blood circulation due to the failure of the heart to contract) due to acute subdural hematoma. The Certificate of Death indicated as immediate cause of death as acute cardiovascular accident. The facility failed to ensure its residents must receive and the facility must provide the necessary 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, and failed to ensure that the resident?s environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent falls and injuries, including: 1. Failure to ensure Resident 1, who was assessed as high fall risk due to confusion and poor safety awareness, was assisted with transfers and was supervised while walking as indicated in the comprehensive assessment and plan of care. 2. Failure to implement its policies and procedure on Fall Reduction by not re-evaluating the plan of care and by not developing a new comprehensive plan of care to meet Resident 1?s specific needs to prevent recurrence of falls. 3. Failure to evaluate effectiveness of interventions in order to develop new and more effective interventions to prevent falls and minimize injuries. As a result, on 9/6/15, while Resident 1 was walking in his room unassisted, he sustained a fall with a head injury, developed a subdural hematoma (a pool of blood between the brain and its outermost covering), and subsequently died on 9/19/15. The above violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and were a direct proximate cause of Resident 1?s death.
060001481	INDEPENDENT OPTIONS, INC. SHERWOOD HOUSE	060013522	A	28-Sep-17	6QMX11	17664	W127 - 483.420(a)(5) The facility must ensure that clients are not subjected to physical, verbal, sexual, or psychological abuse or punishment. On 8/14/17 at 0730 hours, an unannounced visit was made to the facility for a FUNDAMENTAL RECERTIFICATION SURVEY. The facility is a licensed Intermediate Care Facility for Developmentally Disabled/Nursing (ICF/DD-N) for six clients. At the time of the fundamental recertification survey, the facility had a census of six clients (Clients 1, 2, 3, 4, 5, and 6). One client (Client 3) was admitted to the facility on 8/14/17. Client 1, a 25 year old man, had a diagnosis of seizure disorder (sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioral manifestations). Client 1 had an intelligence quotient (IQ) of 92 (average range of intelligence) and did not have intellectual disability. Client 1 could speak in full sentences and his speech was readily understood. Client 1 was six feet, three inches tall, weighed 234 pounds, and ambulatory; however, due to the severity of his seizures, he used a self-propelled manual wheelchair most of the time. Client 1 had behaviors of physical aggression manifested by hitting, kicking, poking, and flicking his fingers at others. Review of the Annual Progress Report from the Behaviorist dated 4/28/17, showed in part, because the Client 1 had previously lived with his mother and a friend, he was accustomed to regular interpersonal interactions and banter (playful and teasing remarks). Due to the Client 1's limited ability to socialize/carry on conversations with the majority of the clients at the facility, it was very important for the facility staff to regularly engage with Client 1 to ensure he did not become under-stimulated. Client 2 had diagnoses including severe intellectual disability (an individual with an IQ of 20 to 35) and cerebral palsy (a disorder of movement, muscle tone or posture that is caused by an insult to the immature, developing brain, most often before birth). Client 2 was blind, deaf, nonverbal, and unable to defend himself from potential harm. The client was able to ambulate with Direct Care Staff (DCS) assistance for guidance. Client 4 had diagnoses including profound intellectual disability (an individual with an IQ of less than 20) and spastic tetraparesis (spastic refers to the muscle stiffness which accompanies the condition and tetraparesis is a neurological condition in which all four limbs are weak or paralyzed). Client 4 was confined to a manual wheelchair for mobility which was propelled by facility staff. Client 4 was nonverbal and unable to use her arms or legs to protect herself from potential harm. Client 5 had diagnoses including profound intellectual disability and cerebral palsy. Client 5 was verbal, able to use of his arms; however, he was confined to the manual wheelchair for mobility which he was able to self-propel. Client 5 had limited ability to protect himself from potential harm. Client 6 had diagnoses including mild intellectual disability (an individual with an IQ of 50 to 69), cerebral palsy, and paraplegia (complete paralysis of the lower half of the body, including both legs). Client 6 was verbal and had limited use of his left arm but full use of his right arm. Both of his legs were flaccid (limp) and had no muscle activity. The client was confined to the manual wheelchair for mobility with his knees hyperextended (bent backward) and his legs sticking straight out in front of him while he was seated in his wheelchair. Client 6's wheelchair was propelled by the facility staff. Client 6 had limited ability to protect himself from potential harm. Client A had diagnoses including profound intellectual disability and severe spastic quadriplegia (spastic refers to the muscle stiffness which accompanies the condition and spastic quadriplegia is the most serious and disabling form of spastic cerebral palsy because it affects the entire body). Client A was legally blind, nonverbal, and confined to the manual wheelchair which she was unable to self-propel. Client A was unable to protect herself from potential harm. On 8/14/17 at 0930 hours, an interview and concurrent review of the facility's General Event Reports (GERs) was conducted with the RN. The following was identified: - The GER dated 12/6/16, showed Client 5 was watching the television when Client 1 threw a pen at Client 5. Client 5 sustained a scratch on the top of his head. - The GER dated 6/8/17, showed Client 2 fell into the rose bush as a result of Client 1 pushing him over. Client 2 sustained minor scratches on the back of both thighs and on both calves. The Registered Nurse (RN) was asked why Client 1 was physically abusive to other clients. The RN stated Client 1 liked to see people getting hurt. The RN stated Client 1 was given a 30 day notice to move out of the facility after the incident on 6/8/17. On 8/14/17 at 1300 hours, an interview and concurrent clinical record review was conducted with the Program Director at Client 1's day program. The Program Director stated Client 1 had been kicked out from his previous day program due to being physically aggressive. Client 1 had continued hitting other clients since he was admitted to this day program on 3/1/17. In addition, the Program Director stated she was informed by the facility Client 1 had thrown items at people, laughed, and thought it was funny. The Program Director stated the day program monitored Client 1's physically aggressive behaviors at the day program. Review of the day program's documents showed Client 1's behaviors as follows: For May 2017, 25 episodes of physical aggression. For June 2017, 6 episodes of physical aggression. For July 2017, 9 episodes of physical aggression. The Program Director stated she had completed the Special Incident Reports (SIRs) on three occasions and provided the SIRs for review. Review of the SIRs showed the following: - On 6/1/17 at around 1430 hours, Client 1 was in the bus with other clients. Client 1 noticed Client C was looking at him. Client 1 put his hands inside his pants, pulled out his penis, and rubbed his penis in front of Client C. - On 7/13/17 at 1410 hours, Client 1 had hit Client C on the back of her head three times and asked Client C if it hurt. - On 7/14/17 at 1345 hours, Client 1 was wheeling himself through one of the rooms, then he abruptly kicked Client D without provocation. The Program Director stated she had asked Client 1 why he was physically aggressive towards other clients, but Client 1 just stared at her. The Program Director stated she had requested to meet with the facility staff to get direction on how to deal with Client 1's behaviors, but for the meantime, Client 1 would be separated five feet away from other clients. The Program Director further stated Client 1 was on a two clients to one staff ratio while in a group at the day program. Review of the GERs, SIRs, Clinician Reports, Programmatic Reports, and Human Rights Committee (HRC) meeting minutes showed the documentation on Client 1's physical and sexual abusive behaviors towards Clients 2, 4, 5, 6, A, B, C, and D and staff: Client 1 had a total of 136 episodes of physically abusive behaviors from October 2016 to August 2017 as follows: * In October 2016, Client 1 had seven episodes of hitting, three episodes of kicking, two episodes of flicking, and three episodes of poking which included the following: - Client 1 swatted DCS 10 on the face three times on 10/14/16. - Client 1 hit Client 6's feet multiple times on 10/18/16. - Client 1 hit a staff on 10/19/16. - Client 1 poked Client 6's feet and DCS 9 repeatedly on 10/31/16. * In November 2016, Client 1 had 12 episodes of hitting, two episodes of kicking, one episode of flicking, and three episodes of poking which included the following: - Client 1 hit Client 5 and kicked his peers at day program on 11/2/16. - Client 1 flicked Client 6's feet and poked a staff in the arm repeatedly on 11/3/16. - Client 1 kicked Client 4's wheelchair on 11/6/16. - Client 1 hit Client 6's feet on 11/7/16. - Client 1 hit Client 6 on 11/9/16. - Client 1 hit Client 6's chair repeatedly and tickled Client 6's feet on 11/12/16. - Client 1 poked Client A's face on 11/13/16. * In December 2016, Client 1 had one episode of hitting, one episode of kicking, one episode of flicking, and two episodes of poking which included the following: - Client 1 threw a pen and hit Client 5 on the head causing a scrape to Client 5's head on 12/6/16. - Client 1 flicked Client 6 repeatedly and the staff on 12/9/16. - Client 1 poked the staff on 12/10/17. - Client 1 kicked Client 5's wheelchair on 12/23/17. * In January 2017, Client 1 had three episodes of hitting, three episodes of kicking, one episode of flicking, and three episodes of poking which included the following: - Client 1 kicked Client 2, hit Client 6, and poked the staff with a straw full of milk on 1/6/17. - Client 1 threw water at another client on 1/11/17. - Client 1 hit and poked the staff repeatedly on 1/13/17. * In February 2017, Client 1 had six episode of hitting, three episodes of flicking, and five episodes of poking which included the following: - Client 1 slapped Client 5 on the face two times on 2/13/17. - Client 1 threw a pencil at the staff on 2/19/17. - Client 1 poked the staff on 2/21/17. - Client 1 hit DCS 9 on the stomach and poked her repeatedly on 2/28/17. * In March 2017, Client 1 had one episode of hitting and five episodes of poking which included the following: - Client 1 hit Client 4 on the forehead, poked LVN 1's stomach three times and another staff on 3/30/17. * In April 2017, Client 1 had two episodes of hitting and six episodes of poking which included the following: - Client 1 poked Client 5 on 4/26/17. - Client 1 hit Client B in the face and another staff on the back on 4/26/17. - Client 1 pulled the staff's hair on 4/28/17. - Client 1 pulled DCS 3's hair on 4/28/17. * In May 2017, Client 1 had 18 episodes of hitting, five episodes of kicking, and six episodes of poking which included the following: - Client 1 hit DCS 9 and stepped on DCS 3's foot on 5/3/17. - Client 1 hit Client 6 with his clothes protector and poked Client 6 on 5/6/17. - Client 1 hit Client 6, DCS 3, and another staff in the head on 5/7/17. - Client 1 hit Client 6's wheelchair on 5/13/16. - Client 1 hit Client 6's feet with a spoon on 5/14/17. - Client 1 smashed Client 5's hand on 5/15/17. - Client 1 hit Client 5 on the head on 5/16/17. - Client 1 poked DCS 3 on 5/20/17. - Client 1 hit DCS 3 on 5/24/17. - Client 1 threw a book at Client 5 and hit DCS 3 on 5/27/17. - Client 1 hit a staff on the back on 5/28/17. - Client 1 poked Client 6's feet and kicked Client 5's dog on 5/30/17. - Client 1 poked Client 6 with a pen and threatened to hit Client 6 with his tablet; and kicked Client 5's dog on 5/31/17. * In June 2017, Client 1 had 14 episodes of hitting, four episodes of kicking, two episodes of flicking, and four episodes of poking which included the following: - Client 1 exposed his penis and started rubbing his penis in front of Client C while on the bus on 6/1/17. - Client 1 pushed Client 2 into the rose bushes, which resulted in Client 2 sustaining scratches on the back of both thighs and calves on 6/8/17. - Client 1 threw a dog toy at Client 6 and poked DCS 3 on 6/9/17. - Client 1 kicked Client 5, poked the staff, and hit Client 5's dog three times on 6/11/17. - Client 1 flapped paper on Clients 5 and 6's faces on 6/23/17. - Client 1 hit Clients 2, 5, and 6 and DCS 8; kicked Client 5's wheelchair; and threw his helmet at Client 6 on 6/24/17 * In July 2017, Client 1 had two episodes of hitting, four episodes of kicking, one episode of flicking, and two episodes of poking which included the following: - Client 1 hit Client C on the back of her head three times on 7/13/17. - Client 1 kicked the staff three times on 7/14/17. - Client 1 kicked Client D in the leg on 7/14/17. - Client 1 hit the DCS with the wheelchair seatbelt and poked another DCS on 7/22/17. - Client 1 hit Client 6 with his shirt on 7/23/17. - Client 1 hit DCS 3 on 7/25/17. * In August 2017, Client 1 had kicked Client 5's wheelchair on 8/14/17. On 8/14/17 at 1515 hours, Client 1 was observed lying in bed in his bedroom which was shared with Client 2. An interview was conducted with Client 1. Client 1 was asked if he could get out of bed independently. Client 1 stated he was able to out of his bed independently. When Client 1 was asked if he had ever hurt other clients in the facility, Client 1 stated he had poked Client 5 in the face with his finger, pulled Client 5's ear, and stepped on Client 5's toe. Client 1 further stated he had kicked Client 2 in the feet multiple times, hit Client 2 in the arm once, and pushed Client 2 into the rose bushes. Client 1 verified he knew the rose bushes had thorns and the thorns could hurt Client 2. Client 1 also admitted that he had pulled DCS 9's hair. When Client 1 was asked why he had hurt the above mentioned clients, he replied "I don't know." Client 1 verified he had hit Client C at the day program but denied hitting Clients 4, 6, and A. On 8/14/17 at 1550 hours, an interview was conducted with the Qualified Intellectual Disabilities Professional (QIDP) and RN. The QIDP stated Client 1 liked to be the class clown and picked on Client 5. When the QIDP was asked what Client 1 did to pick on Client 5, the QIDP stated he poked Client 5. The QIDP stated Client 1 had behaviors of non-participation, intentionally soiling himself, making false allegations, and physical aggression manifested by hitting, kicking, flicking, and poking. The QIDP further stated Client 1 also had tripped people. The QIDP stated Client 1 and his brothers were jokesters and laughed about Client 1's physically aggressive behaviors. The QIDP stated Client 1 was given a 30-day notice to move out of the facility on 5/31/17, because of increased behaviors. The QIDP was asked if she had completed the investigation for the incident occurred on 6/8/17, when Client 2 fell into the rose bush as a result of Client 1 pushing him over. The QIDP stated she asked everyone about the incident but did not document her investigation. The QIDP was asked if the GERs were completed for these incidents related to Client 1's physically aggressive towards other clients. The QIDP replied no. The RN stated Client 1's behaviors were recorded on the behavior sheets; however, they did not complete the GER unless there was an injury. The QIDP was asked what she had done to protect other clients from further abuse by Client 1 in addition to giving the 30-day notice to Client 1. The QIDP stated she had kept Client 1 an arm length distance away from other clients. The QIDP stated Client 1 targeted Client 5. The QIDP further stated on one occasion, Client 1 had poured milk on Licensed Vocational Nurse (LVN) 1's pants. On 8/14/17 at 1600 hours, an interview was conducted with DCS 7. DCS 7 stated Client 1 usually wanted attention; therefore, he would poke others to get their attention. DCS 7 further stated he had witnessed Client 1 poking and hitting Clients 5 and 6. During an interview with the QIDP and RN on 8/14/17 at 1620 hours, the RN and QIDP were asked if Client 1's behavior of intentional hitting, kicking, pinching, flicking, and poking were reported to the California Department of Public Health, Licensing and Certification Program (CDPH, L&C Program). The RN and QIDP verified none of the incidents had been reported to the CDPH, L&C Program. On 8/14/17 at 1630 hours, an interview was conducted with DCS 9. DCS 9 stated she had witnessed Client 1 kicking Client 5 on the foot two weeks ago. DCS 9 further stated about five months ago, during dinner, she had witnessed Client 1 kicking Client 5's leg underneath the dining room table. DCS 9 was asked if Client 1 was capable of getting out of bed independently. DCS 9 stated Client 1 was able to get up out of bed and ambulate. On 8/15/17 at 0740 hours, an interview was conducted with Client 5. Client 5 was asked if he was scared of Client 1. Client 5 stated, "Yeah." On 8/15/17 at 0940 hours, an interview was conducted with Client 6. When Client 6 was asked if he was scared of Client 1, he stated he scared when Client 1 clapped the hands loudly next to him. He stated he was scared that Client 1 was going to hit him when Client 1 came near him. On 8/15/17 at 1210 hours, the QIDP was informed of the above findings. The facility failed to ensure Clients 2, 4, 5, 6, A, B, C, and D, LVN 1, and DCS 3, 8, 9, and 10 were not subjected to physical abuse and/or indecent exposure (conduct undertaken in a non-private or a publicly viewable location, which is deemed indecent in nature, such as nudity, masturbation or sexual intercourse in public view) from Client 1. As a result, Clients 2, 4, 5, 6, A, B, C, and D, LVN 1, and DCS 3, 8, 9, and 10 were subjected to hitting, kicking, physical aggression, and indecent exposure by Client 1 from October 2016 to August 2017. In addition, this also resulted in Clients 5 and 6 being anxious and fearful. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.
060001076	INDEPENDENT OPTIONS, INC. CHRISTOPHER HOUSE	060013695	B	18-Dec-17	6C5111	24858	W127 - 483.420(a)(5) The facility must ensure the rights of all clients. Therefore, the facility must ensure clients are not subjected to physical, verbal, sexual or psychological abuse or punishment. On 10/13/17, a complaint was received by the California Department of Public Health, Licensing and Certification Program (CDPH, L&C) regarding Client 2 had a bite mark on his forearm. An unannounced visit at the facility was conducted on 10/21/17. Review of the State Operations Manual-Appendix J dated 9/9/16, showed the following: - "Abuse" referred to the willful infliction of injury, unreasonable confinement, intimidation or punishment with the resulting physical harm, pain or personal anguish. - "Physical abuse" referred to any action intended to cause physical harm or pain, trauma or bodily harm (e.g., hitting, slapping, punching, kicking, pinching, etc.). Review of the facility's P&P (Policy and Procedure) titled Prevention of Abuse, Neglect, and Mistreatment dated 5/17 showed the following: - In the event an individual receiving facility services has been accused of or has engaged in abuse, the Administrator will make any changes necessary to prevent a similar occurrence from being repeated, including possible additions or changes in behavior plans, environmental changes, and/or increase staffing. - The Administrator or other management personnel will immediately initiate an investigation of any alleged incident of abuse, neglect, or mistreatment. - In cases when client to client abuse has been witnessed a report will be completed by the management staff which will include the action taken to prevent/protect/respond and report. An investigation will be conducted for all injuries which meet the CMS (Centers for Medicare and Medicaid Services) definition of injuries of unknown source. - If another client's intentional action resulted in abuse or mistreatment, the Administrator will implement temporary changes/interventions in environmental conditions until an IDT (Interdisciplinary Team) solution can be obtained. The Administrator will ensure any additional needed training is provided to staff to protect individuals. Review of the facility's undated P&P titled Management of Individual Inappropriate Behavior showed the following: - Interventions to manage inappropriate behavior will be employed with sufficient safeguards and supervision to ensure that the safety, welfare, and civil and human rights of individuals are adequately protected. - Individuals are to be encouraged to display appropriate and adaptive behaviors using positive reinforcement techniques. An unannounced visit was conducted at the facility on 10/20/17. The facility had a census of six clients (Clients 1, 2, 3, 4, 5, and 6). Clinical record reviews for Clients 1, 2, 3, 5, and 6 were initiated on 10/20/17, and showed the following: - Client 1 was admitted to the facility on 6/2/1992, with diagnoses including severe intellectual disability (an individual with an IQ score of 20 to 35), autistic disorder (a neurodevelopmental disorder characterized by impaired social interaction, non-verbal communication, and restricted and repetitive behavior), and attention deficit disorder (a chronic condition including attention difficulty, hyperactivity, and impulsiveness). Review of Client 1's Face Sheet showed under the Behavior section, Client 1 had hit and bit others, and also scratched others which left the red marks when he did this. Client 1's physically aggressive behaviors towards others had not required anything beyond the first aid. Client 1 also displayed SIB (self-injurious behavior) as hitting his head on the walls and windows. - Client 2 was admitted to the facility on 4/7/92, with diagnoses including moderate intellectual disability (an individual with an IQ score of 36 to 49) and autistic disorder. - Client 3 was admitted to the facility on 11/23/98, with diagnoses including moderate intellectual disability. - Client 5 was admitted to the facility on 2/11/13, with diagnoses including autistic disorder. - Client 6 was admitted to the facility on 9/13/94, with diagnoses including moderate intellectual disability. 1.a. Review of Client 1's Psychiatrist's Progress Notes showed the following: - On 6/12/17, Client 1's "behaviors continue." The client "tried to break a window last week." The client was "grumpy" in the morning and "go off when littlest thing does not go his way." - On 7/17/17, Client 1 was impulsive, acting out, and hitting a peer. The client displayed the assaultive and inappropriate behaviors with labile (unstable) and irritable moods. - On 8/7/17, Client 1 banged his head on the wall at times and bit his peer twice. The client continued displaying the assaultive, uncooperative, and inappropriate behaviors with labile and irritable moods. - On 9/11/17, Client 1 was aggressive, attacked others at the facility and day program, and banged his head. The client displayed the assaultive, uncooperative, and inappropriate behaviors with labile and irritable moods. Review of Client 1's Monthly Health Care Reports showed the following: - On 4/10/17, Client 1 attempted to put his head through a brick wall, which resulted in a deep abrasion (scraped skin). - On 10/10/17, Client 1 had the increase of self-abuse and explosive behaviors. Review of Client 1's General Event Reports from 12/16 to 9/17 showed the following 11 incidents: - On 12/20/16, Client 1 suddenly came out of his room and started exhibiting the aggressive behaviors toward staff. Client 1 slapped Client 2. When the staff redirected Client 1 to go back to his room, Client 1 started to slam his head against the nightstand and walls causing an abrasion to his scalp that required the first aid. - On 1/28/17, the staff discovered the bruise and cut on Client 1's left bicep (upper arm) and "backside." The RN documented on 1/30/17 (two days after), the staff reported the client had the behavior on 1/28/17, when "he flailed around and fell to the ground - On 3/24/17, Client 1 attempted to attack Client 5 during the birthday dinner causing multiple scrapes across Client 1's body and abrasion to his forehead. - On 6/11/17, Client 1 yelled and slammed his hands on the furniture and window blinds causing scratches to his left hand. - On 7/15/17, Client 1 hit the bedroom door causing a cut on his right wrist. - On 7/20/17, Client 1 hit his head against the bathroom wall causing a scrape on his forehead. - On 7/29/17, Client 1 hit another client (Client 2) after that client had finished using the bathroom. Client 1 then started to bang his hand against the bathroom mirror causing a cut to Client 1's left wrist. - On 8/5/17, Client 1 became agitated, hit the bathroom window, banged his head against the wall causing the abrasion to his forehead and reopening the healing abrasion. - On 8/16/17, Client 1 banged his head against the bathroom wall causing an abrasion to his forehead. - On 8/28/17, the staff noted the bruises on Client 1's right eye, left elbow, and chest with undetermined cause. The RN documented the client's injuries included the mild discoloration of the right upper eyelid, superficial abrasion on the left elbow, and redness to the right upper chest. The client had the behaviors at the facility on 8/26/17 (two days earlier), in which he tried to hit a staff. - On 9/8/17, the staff noted the scratches on Client 1's face. The RN documented the client had the episode of becoming angry and scratched his head while at another facility. Further review of the General Event Reports showed no documented evidence of the investigations related to the incidents that occurred on 1/28, 3/24, and 7/29/17. Review of Client 1's Clinician Reports from January to September 2017 showed the following: a. Under the physical aggression section showed 14 documented incidents related to Client 1's physically aggressive and abusive behaviors towards other clients as follows: - On 1/28/17, Client 1 hit another client (unnamed), then tried to break the computer, and rip his shirt off. - On 2/4/17, Client 1 had the aggression toward Client 5. - On 2/17/17, Client 1 tried to hit another client (unnamed). - On 2/25/17, Client 1 had the aggressive episode toward Client 5. - On 3/19/17, Client 1 displayed the aggression toward Client 5. - On 3/22/17, Client 1 displayed the aggression during the grocery shopping. - On 7/16/17, Client 1 was upset and hit another client (unnamed). - On 7/29/17, Client 1 hit another client's (unnamed) arm and started hitting the mirror in the restroom. - On 8/6/17, Client 1 bit another client (unnamed). - On 8/20/17, Client 1 was agitated and "smacked another client (unnamed) on the arm." - On 8/25/17, Client 1 attempted to hit another client (unnamed) and yelled out, to hit and bite (another client's name). - On 8/26/17, Client 1 attempted to hit another client (unnamed). - On 9/15/17, Client 1 bit another client (unnamed). - On 9/30/17, Client 1 woke up in a bad mood and attempted to attack another client (unnamed). Client 1 hit the van causing a minor indentation on the van. b. Under the SIB monitoring section showed some of the above incidents and additional incidents related to Client 1's self-injurious behaviors as follows: - On 7/15/17, Client 1 woke up, was agitated, and hit the bedroom door with his right hand causing a cut on his right wrist. - On 7/20/17, Client 1 was agitated and hit his head against the bathroom wall. c. Under the property destruction section showed six documented incidents, in which Client 1 exhibited the aggression manifested by destroying properties as follows: - On 2/9/17, Client 1 chased Client 5 to his room and dented the door with a punch. - On 6/11/17, Client 1 got upset and broke the blinds in his room. - On 7/15/17, Client 1 woke up agitated and hit another client's bedroom door causing a small hole on the door. - On 7/29/17, Client 1 was upset with another client and hit the mirror in the restroom. - On 8/16/17, when the staff asked Client 1 to take a shower, the client got upset and broke a shampoo bottle. - On 9/9/17, Client 1 woke up agitated and attempted to break the computer. Review of Client 1's HRC (Human Rights Committee) Minutes showed the following: - On 2/15/17, Client 1's physical aggression had an average of 16.66 episodes a month (a decrease from 6 episodes) and SIB had an average of two episodes a month (an increase from 1 episode) for the three-month period from November 2016 to January 2017. - On 5/17/17, Client 1's property destruction behavior had an average of 0.66 episode a month (a decrease from 1.66 episodes) for the three-month period from February to April 2017. - On 8/16/17, Client 1's SIB had an average of 1.33 episodes a month (an increase from zero episode) and property destruction behavior had an average of one episode a month (an increase from 0.66 episode) for the three-month period from May to July 2017. * Further review of the clinical record showed no documented evidence of the preventative measures to address Client 1's above ongoing SIB and physically aggressive behaviors toward others to prevent the reoccurrence of the incidents and protect other clients from Client 1's aggressive behaviors until 9/20/17, when the one to one staff plan was implemented; and 9/26/17, when Client 1's ISP (Individual Service Plan) was updated. On 10/20/17 at 0650 hours, during an interview, DCS 1 stated Client 1 had the behaviors of physical aggression. Sometimes, Client 1 yelled out (to hit Client 2), then walked toward Client 2 and started hitting or biting Client 2. DCS 1 stated when Client 1 was upset or did not receive what he wanted, he would seek for Client 2 and attempt to hit Client 2. DCS 1 stated Client 2 "was an angel," would let Client 1 hit and bite, and would not defend himself against Client 1. When asked how the staff would prevent Client 1's physical aggression toward other clients, DCS 1 stated the staff sometimes was unable to stop Client 1's physical aggressions toward other clients because Client 1's mood could quickly change. The staff would try to keep Client 1 away from other clients. On 10/20/17 at 0820 hours, during an interview, Job Coach 1 (from Client 1's Day Program) stated Client 1 had been exhibiting the aggressive behaviors toward himself and others more frequently for the past four months. She stated he would hit his head and hit and bite other clients. She stated there was one particular client at the Day Program whom Client 1 always directed his aggression to. On 10/20/17 at 0945 hours, during an interview with the QIDP (Qualified Intellectual Disabilities Professional) and RN (Registered Nurse) regarding the incidents documented on the General Event Reports, the QIDP stated she was not aware the client had the behavioral incident on 1/28/17, when Client 1 fell to the ground. When asked about the 3/24/17 incident when Client 1 attacked Client 5, the QIDP stated she did not know how the incident occurred and was unable to provide documented evidence of the investigation for the incident. The RN confirmed there was no documented evidence to show Client 5 was assessed after the incident had occurred. When asked about the 7/29/17 incident when Client 1 had hit Client 2 for the details of the investigation, such as how Client 1 was able to hit Client 2 when the staff was present, how the staff redirected the client's agitation or frustration, and what interventions were provided to Clients 1 and 2 at that time, the QIDP was unable to provide such information. On 10/20/17 at 1300 hours, during another interview with the QIDP, she confirmed Client 1 had not met his objectives to reduce his physical aggression, SIB, and property destruction for the past 10 months (from 12/16 through 9/17). On 10/20/17 at 1200 and 1440 hours, during the concurrent interviews with the QIDP, RN, and RD (Regional Director), the RN stated Client 1 could become agitated and aggressive toward others with no warning signs. When asked what other measures the facility had implemented to protect the other clients from Client 1's physical aggression and protect Client 1 from his self-injurious behaviors since 12/16, the QIDP stated the behavioral specialist recommended the new program plan starting on 9/20/17 (10 months after the last ISP update while Client 1's aggressive behaviors were continued), with the one to one staff to provide supervision for Client 1. The QIDP confirmed there was no documented evidence to show Client 1's ISP was revised to address the ongoing physical aggression toward others from 12/16 to 9/17 (a 10-month period). When asked what other measures were put in place to specifically address Client 1's continuing hitting and causing injuries to his head, the QIDP confirmed there was no documented evidence to show such measures were in place. When asked what other measures were put in place to address the staff's inability to intervene before Client 1 hit or bit others and injured himself, the RD confirmed there was no documented evidence to show such measures were in place and implemented. In addition, the RD confirmed there were no investigations conducted for the incidents documented in the Clinician Reports on 1/28, 8/20, 8/26, and 9/30/17, in which Client 1 had hit or bitten unidentified clients. There were no investigations conducted for the incidents that occurred on 2/17 and 8/25/17, in which Client 1 had attempted to hit the unidentified clients. The RN stated she did not know who Client 1 had slapped on 1/28/17. The QIDP stated she was not aware of the 1/28/17 incident and did not know who Client 1 slapped that day. The RD confirmed there was no investigation conducted for the 1/28/17 incident. 1.b. Review of Client 2's General Event Reports from 4/17 through 9/17 showed the following: - On 8/6/17, while Client 2 was washing dishes, another client bit Client 2's arm. - On 9/15/17, when Client 2 was leaving the bathroom, another client bit Client 2's right arm. - On 9/29/17, when Client 2 returned from the Day Program, he stated "my arm hurts." The staff noted the red marks on the client's left arm with undetermined cause. On 10/20/17 at 0637 hours, an observation of Client 2 was conducted. The client was ambulatory and interacted with staff. Client 2 had the quarter-sized pinkish discoloration with presence of a scab on the left forearm and pinkish discoloration with darker red marks on the right forearm. When asked what happened to his forearms, the client kept repeating the phrase that Client 1 bit him multiple times. When asked how often Client 1 bit him, Client 2 stated Client 1 bit him but was unable to say how often. When asked if the discolored areas hurt, Client 2 stated yes. On 10/20/17 at 0645 hours, during an interview, DCS 2 stated she was informed that Client 1 had previously bit Client 2. On 10/20/17 at 0940 hours, during an interview, the QIDP confirmed Client 1 was the one who had bitten Client 2's arm on 8/6 and 9/15/17. 2. Review of the facility's In-service Education Record provided by the Behavioral Specialist dated 9/20/17, showed the following: - Staff assigned to Client 1 would be "responsible to ensure that he is an arm-length away from the other consumers at all time." - One to one staff's main priority is to ensure Client 1 does not aggress towards others, and to prevent SIB and property destruction in the facility during the morning and evening shifts. - Night shift staff would leave Client 1's bedroom door open during the night and have a visual-check every 10 to 15 minutes to ensure the safety and well-being of every consumer in the home. On 10/20/17 at 0915 hours, during an interview, the QIDP stated the plan was to increase the staffing by having three staff for the morning (0600 to 1000 hours) and evening (1400 to 2200 hours) shifts, which included the one to one staff assigned to Client 1 after the 9/20/17 in-service. However, review of the facility's Monthly Employee Schedule from 9/21 to 10/30/17, showed the facility failed to schedule three DCSs for the morning and evening shifts as follows: - On 9/24 and 10/1/17, there were no third DCS scheduled to work in the morning from 0600 to 1000 hours (4-hour period) and evening shifts from 1800 to 2200 hours (4-hour period). - On 9/21, 9/25, 9/26, 9/27, 9/28, 9/29, 10/2, 10/3, 10/4, 10/5, 10/9, 10/16, and 10/21/17, only two DCSs were scheduled to work in the morning instead of three DCSs. - On 10/7/17, only two DCSs were scheduled to work in the evening shift instead of three DCSs. - On 10/8/17, only two DCSs were scheduled to work in the evening from 1800 to 2200 hours instead of three DCSs. - On 9/22, 9/23, 9/30, and 10/14/17, only two DCSs were scheduled to work in the morning and evening shifts instead of three DCSs for each shift. On 10/20/17 at 0935 hours, during an interview, the QIDP verified the inconsistencies of staffing to provide the one to one staff for Client 1. The QIDP stated she was unable to find additional DCS to sufficiently staff on the various days to ensure the implementation of the plan for Client 1 to be supervised by the one to one DCS to ensure safety for Client 1 and others. 3. Further review of the facility's document and Client 1's clinical record showed after the implementation of one to one staff, Client 1 continued to have self-injurious and physically abusive towards other behaviors. Review of Client 1's Clinician Reports for September and October 2017 showed the following: - On 9/27/17, Client 1 smacked the front door. - On 9/30/17, Client 1 woke up in a bad mood and attempted to attack another client. Client 1 hit the van causing a minor indentation on the van. - On 10/14/17, Client 1 woke up, was agitated, and hit his head against the wall causing a scrape on his forehead. - On 10/16/17, while walking to the doctor's office, Client 1 became frustrated, knelt down to the ground, and hit his head on the ground. Review of Client 1's General Event Reports for September and October 2017 showed documentation of the above incidents on 10/14 and 10/16/17. In addition, another incident was documented by the RN showing on 9/30/17, after returning from the morning walk, Client 1 hit his head against the black board in the living room causing a cut to his head. The RN documented the client had the scrapes on the left side of his face. Client 1's Psychiatrist's Progress Notes dated 10/6/17, showed Client 1 had daily SIB. The client directly banged his head on the sidewalk, had aggression toward others, and needed one to one staff coverage. The client had the assaultive and inappropriate behaviors with labile and irritable moods. However, there was no documented evidence of other preventative measures to address the ineffectiveness of the implemented plan as Client 1 continued to have the aggressive behaviors toward himself and others. On 10/20/17 at 0658 hours, during an interview, DCS 3 stated Client 1 now had the one to one staff assigned to him during the morning (0600 to 1000 hours) and evening (1400 to 2200 hours) shifts, except for the night (2200 to 0600 hours) shifts. DCS 3 stated the one to one staff was responsible to supervise Client 1 and keep the client at the safe distance from other clients to ensure safety for other clients. On 10/20/17 at 1440 hours, during concurrent interviews with the QIDP, RN, and RD, the QIDP stated the staff was to supervise Client 1 closely and keep him at least an arm-length from the other clients to ensure the safety of the other clients. When asked why Client 1 was still able to hit or bite other clients and staff if Client 1 was to be supervised closely and kept at an arm-length distance from others, the QIDP stated the staff should have prevented Client 1 to get close to the other clients. The QIDP confirmed the one to one staff assigned to Client 1 was not always available for the morning and evening shifts. When asked what other measures were put in place to address the staff's inability to intervene before Client 1 hit or bit others, and injured himself, the RD confirmed there was no documented evidence to show such measures were in place and implemented. 4. On 10/20/17 at 0715 hours, an observation was conducted of the clients' bedrooms with DCS 1. Client 2 had his own room, and Clients 1 and 3 shared a bedroom together. DCS 1 stated Client 1 had previously attempted to hit his roommate (Client 3), but the attempts to hit Client 3 were less frequent in comparison with the attempts to hit Client 2. DCS 1 stated Client 3 sometimes could be hyperactive and would pace around the house, which could potentially annoy and anger Client 1 causing Client 1 attempting to hit Client 3 when Client 3 walked by Client 1. At 0740 hours, during an interview and observation, DCS 3 confirmed she was assigned to the one to one duty for Client 1 this morning. However, at 0751 hours, Client 1 was observed putting the money in his backpack by the entrance door when Client 6 returned from the morning walk. Client 6 was observed to be in close proximity to Client 1 when Client 6 walked past Client 1 by the front door. At this time, DCS 3 (the one to one staff) was observed sitting on the couch by the entrance to the kitchen away from Client 1. The facility failed to ensure four clients residing in the facility (Clients 2, 3, 5, and 6) were not subjected to physical abuse from Client 1 and failed to protect Client 1 from SIB as evidenced by: 1. The facility failed to investigate incidents related to Client 1's aggressive behaviors toward others and ensure the preventative measures were in place to address Client 1's ongoing aggressive behaviors towards self and others. 2. The facility failed to ensure three DCSs were consistently scheduled to include the one to one staff for the morning and evening shifts for safety of the clients as per the facility's Behavior Specialist's recommendations. 3. The facility failed to ensure other preventative measures were in place when the implemented plan was ineffective as Client 1 continued to be physically aggressive towards himself and others. 4. The facility failed to ensure the one to one staff provided appropriate care by being in the close proximate distance with Client 1 to prevent the client from hurting himself and others. This failure had a direct and immediate relationship to the health, safety, and security of the clients.
220001020	Idylwood Care Center	070013494	B	13-Sep-17	YPHU11	10267	F281 483.21(b)(3)(i) SERVICES PROVIDED MEET PROFESSIONAL STANDARDS (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. The facility failed to follow the physician orders to administer laxatives (substances designed to loosen stools and increase bowel movements) and to notify the physician when Resident 1 did not have a bowel movement for six consecutive days. These failures resulted in Resident 1 having a megacolon (abnormal dilation of the large intestine) without volvulus (a condition in which the bowel twists on itself, causing obstruction to the flow of material through the bowel) and having to undergo a sigmoid colectomy (an operation to remove part of the left side of the large intestine), end colostomy (a surgical procedure in which the end of the large intestine is brought through the abdominal wall to form an opening called a stoma from which stool drains into a bag or pouch attached to the abdomen), and fecal disimpaction (manually removal of feces). Review of Resident 1's admission record indicated Resident 1 was admitted on 3/11/16 with diagnoses including dementia (a chronic or persistent disorder of the mental processes marked by memory disorders, personality changes, and impaired reasoning), chronic kidney disease, schizoaffective disorder (a chronic mental health condition characterized primarily by hallucinations or delusions, mania and depression) and depressive disorder (a mental disorder characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities). Review of the Minimum Data Set (MDS, an assessment tool), dated 7/25/17, indicated Resident 1 did not ambulate (move from place to place), and he was always incontinent of urine and bowel. Review of Resident 1's physician orders, dated 8/2017, indicated Resident 1 had orders dated 3/11/16 for mirtazapine (a medication used to treat depression) 15 milligrams (mg, a metric unit of mass) at bedtime, clozapine (a medication used to treat schizoaffective disorder) 100 mg at bedtime, dated 9/27/16, olanzapine (a medication used to treat schizoaffective disorder) 10 mg at bedtime, dated 5/1/17, and olanzapine 2.5 mg every day, dated 6/22/17. Resident 1 also had orders for monitoring side effects of these three medications, such as constipation, dated 3/11/16. Review of Resident 1's care plan, dated 3/30/17, indicated Resident 1 had the potential/risk for constipation due to dementia, limited physical mobility, and use of psychotropic medications (medication capable of affecting the mind, emotions, and behavior). During an interview with the registered dietitian (RD) on 8/24/17 at 2 p.m., she stated Resident 1 had poor bowel movement, so she recommended adding fiber blend (a dietary supplement that helps with the regularity of bowel movements) and Hyfiber (a medical food that provides the nutrients for the dietary management of constipation, hard stools, and irregularity) to his diet for bowel regularity. Review of Resident 1's physicians orders, dated 8/2017, indicated Resident 1 had an order for fiber blend, 2 ounces (oz, a unit of weight), three times a day, dated 7/10/16, and Hyfiber, 1 oz, three times a day, dated 7/26/17. Resident 1 also had and order for Milk of Magnesia (MOM, a medication used to treat constipation) 30 milliliters (ml, a metric unit of volume) every 24 hours as needed for constipation; Dulcolax suppository (a medication used to treat constipation), 10 mg as needed if MOM was ineffective, and Fleet Enema (a medication used to relieve constipation), 7-19 grams (g, a metric unit of mass)/118 ml every 24 hours as needed if the Dulcolax suppository was ineffective. Review of Resident 1's Transfer Discharge Notice, dated 8/14/17, indicated Resident 1 was sent to the hospital for difficulty breathing at 3:46 p.m. Review of Resident 1's Emergency Department (ED) Provider Notes, dated 8/14/17, at 4:13 p.m., indicated Resident 1 had a markedly distended abdomen. Resident 1's computed tomography (CT, the use of computer-processed combinations of many X-ray measurements taken from different angles to produce cross-sectional images of specific areas, allowing the user to see inside the object without cutting) of the abdomen and pelvis, indicated Resident 1 had diffuse colonic distention without volvulus and with prominent fecal retention in the distal colon and rectum. The ED physician recommended and the resident was sent to surgery on 8/14/17 for severe dilation and bowel ischemia (a restriction in blood supply to tissues in the bowels) due to chronic constipation. Review of Resident 1's Full Operative Report, created on 8/15/17 at 7:29 a.m., indicated Resident 1 went through an exploratory laparotomy (a surgical operation where the abdomen is opened and the abdominal organs examined for injury or disease), sigmoid colectomy with end colostomy and fecal disimpaction. According to the Full Operative Report, "The most remarkable finding was a massively distended left colon...with the colon packed completely full of stool." The facility policy and procedure titled, "Bowel Care, Managing constipation", revision dated 9/1/13, indicated, "Residents/clients are assisted to prevent and relieve bowel constipation or impaction. Upon written order from the physician, the following protocol shall be followed to provide adequate elimination of the bowels for residents/clients who require assistance... Licensed nurses monitor resident/client bowel movements daily with assistance of certified nursing assistants. Bowel care protocol will be indicated for those who have not had a bowel movement in the past three days as follows (per physician order): A. The licensed nurse will administer 30 ml of MOM per physician order (recommend evening shift). B. If no results from MOM by the end of the subsequent shift (i.e., night shift), the licensed nurse will administer a Dulcolax suppository per physician order. C. If no results from a suppository by subsequent shift (i.e., morning shift), the licensed nurse will give resident a Fleet Enema per physician order. If no results from Fleet Enema by the end of the same shift, the licensed nurse will check for a possible fecal impaction. If the current bowel care orders are not sufficient to maintain regular evacuation of the bowels, contact the physician to discuss further interventions that may be needed ..." Review of Resident 1's Bowel Elimination Report for 7/2017 and 8/2017 indicated from 7/31/17 to 8/14/17, within those 15 days, there were 10 days Resident 1 did not have a bowel movement. In addition, Resident 1 did not have a bowel movement for six consecutive days from 7/31/17 to 8/5/17. Review of Resident 1's Medication Administration Record (MAR) for 8/2017 indicated from 7/31/17 to 8/5/17, MOM was given to Resident 1 on 8/3/17 at 6 p.m. by licensed vocational nurse A (LVN A) which was ineffective. The Dulcolax suppository was not given until 8/5/17 at 9:30 a.m. by a morning nurse, which was ineffective. MOM, rather than a Fleet Enema, was given on 8/5/17 at 6:57 p.m. by registered nurse B (RN B), and it was ineffective. During an interview with LVN A on 8/28/17 at 3:40 p.m., he stated he should have given Resident 1 MOM on 8/2/17 instead of 8/3/17 since Resident 1 did not have a bowel movement since 7/31/17. On 8/29/17 at 12:20 p.m., LVN A stated after he gave Resident 1 MOM on 8/3/17 which was ineffective, and if the subsequent shifts did not give Resident 1 a Dulcolax suppository, he should have given it to him on 8/4/17. LVN A stated he did not inform the physician about Resident 1's constipation. During an interview with LVN C on 8/29/17 at 11:50 p.m., she stated after LVN A gave Resident 1 MOM on 8/3/17 at 6 p.m. which was ineffective, she did not give Resident 1 the Dulcolax suppository because she did not know LVN A gave him MOM. LVN C stated she did not give Resident 1 the Dulcolax suppository on 8/4/17 either because she did not know the previous shifts did not give it to him. LVN C stated she did not check for a fecal compaction in Resident 1 and did not call the physician because she did not know Resident 1 was constipated. During an interview with LVN D on 8/29/17 at 11:05 a.m., she stated after LVN A gave Resident 1 MOM on 8/3/17 at 6 p.m., which was ineffective, and LVN C did not give him the Dulcolax suppository on the night shift, she should have followed up and given Resident 1 the Dulcolax suppository on 8/4/17. LVN D stated she did not check Resident 1's Bowel Elimination Report and did not call the physician. During an interview with RN B on 8/29/17 at 3:10 p.m., she stated after a morning nurse gave Resident 1 a Dulcolax suppository on 8/5/17 at 9:30 a.m. which was ineffective, she should have given Resident 1 a Fleet Enema instead of MOM. RN B stated she did not know Resident 1 did not have a bowel movement for six consecutive days, so she did not check fecal compaction for Resident 1 and did not notify the physician. During an interview with Resident 1's physician on 8/30/17 at 2:20 p.m., she stated she came to the facility to visit Resident 1 on 8/9/17, but she was not notified about Resident 1's constipation. Resident 1's physician stated the licensed nurses should have informed her about this issue, and if she knew she would have examined Resident 1 and ordered lab tests. During an interview with the director of nursing (DON) on 8/30/17 at 2:50 p.m., she reviewed Resident 1's MAR for 8/2017 and Bowel Elimination Report for 7/2017 and 8/2017, and she stated the licensed nurses did not follow the facility's policy on bowel management. The facility failed to follow the physician orders to administer laxatives and to notify the physician when Resident 1 did not have a bowel movement for six consecutive days. These failures resulted in Resident 1 having a megacolon without volvulus and having to undergo a sigmoid colectomy, end colostomy, and fecal disimpaction. This violation had direct relationship to the health, safety, or security of residents.