Table: ltc_citation_narratives_2012_2017_data_file , facility_name like O*

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
140000092	Orinda Care Center, LLC	020011532	B	10-Jun-15	IHM111	8398	F224- The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility violated the above regulations by failing to: 1. Provide anti-seizure medication for Resident 1 on 2/7/15 at 11:00 p.m. when he started having seizures which continued over the next hour and a half , 2. Inform the physician of a change in Resident 2's condition, delaying treatment. As a result of these failures, Resident 1's seizures were untreated for an hour and a half; and Resident 2 had a delay in getting treatment for a stroke. 1. Review of records showed Resident 1 was admitted on 2/7/15 at 2:30 p.m., after hospital treatment for seizure disorder, with diagnoses that included history of stroke and encephalopathy (brain dysfunction). The hospital faxed orders to the facility on 2/7/15 at 12:00 p.m. including an order for Kepra (anti-seizure medication).Resident 1 starting having a seizure on 2/7/15 at 11:00 p.m. On day of admission the facility did not have his anti-seizure medication (Kepra) available. Staff attempted to contact the Medical Director (MD1) and the Co-Medical Director (MD 2) for orders for another anti-seizure medication, but they did not respond, resulting in Resident 1 experiencing untreated seizure activity for over one and half hours which affected his oxygen saturation (O2) levels (initially O2 was 92% at the start of the seizure activity and dropped to 86 -88%. Normal O2 is 94-100%). Resident 1 had to be transferred back to the hospital by emergency ambulance for treatment of the seizures at 12:20 a.m. on 2/8/15.During an interview on 2/19/15 at 10:15 a.m., the Director of Nurses (DON) stated, "He (Resident 1) was admitted stable and began convulsing. The Medical Director (MD 1) and the Co-Medical Director (MD 2) were called but did not respond. The ordered medication to treat Resident 1's seizures was not in the emergency kit, but there were other anti-seizure meds in the kit. We needed an order from a physician to use them." Nurses' notes, dated 2/8/15 at 3:48 a.m., showed, "Unable to take vital signs due to seizure. Resident (1) started to have seizure at 2300 (11:00 p.m.) Oxygen saturation (measure of oxygen reaching the extremities) at that time was 92% on room air. Called and left message for MD 2, the attending. So I called 911 because resident had a seizure for 30 minutes and oxygen saturation was 86 to 88% (low). Resident was sent to hospital at 12:20 a.m." During a phone interview on 3/3/15 at 3:50 p.m., RN 1 stated, "I left messages for MD 2 and, after about fifteen minutes, I called the medical director (MD 1). The doctor on call for the medical director would not give his name, said he only took calls for the medical director's patients and hung up. Between 11:30 p.m. and 12:20 a.m., he (Resident 1) continued shaking and his oxygen saturation was dropping, so I sent him out." 2. Review of the medical record showed Resident 2 was admitted to the facility on 12/13/14 with diagnoses that included intracerebral hemorrhage (bleeding into the brain), Alzheimer's disease, and chronic kidney disease. There was a physician's order, dated 1/9/15, "Ativan (anti- anxiety medication) one milligram by mouth every eight hours as needed for inability to relax." Resident 2 had increasing confusion and required increasing amounts of anti-anxiety medication over a two day period and the facility did not inform the physician of the change in behavior, resulting in Resident 2's family calling 911 to send the resident to the hospital, where Resident 2 was diagnosed as having a stroke.During phone interview on 2/18/15 at 9:00 a.m., Resident 2's relative stated that the resident stopped talking and could not get out of bed. The DON was informed of this change, but nothing was done. The relative stated the family asked for the physician to visit on 1/28/15 and tried to contact the physician on 1/29/15, 1/30/15 and on 1/31/15 and asked the staff to call 911 due to the family's concern. When the physician could not be contacted, the family called 911 on 1/31/15 and Resident 2 was transferred to the hospital and admitted. The medication administration record for 1/15 showed that Ativan was given once on 1/9/15, once on 1/13/15, twice on 1/15/15, once on 1/17/15, 1/18/15, 1/19/15, and 1/20/15. It was given twice on 1/22/15, 1/23/15, and 1/24/15, once on 1/25/15, twice on 1/26/15, once on 1/27/15, twice on 1/28/15 and 1/29/15 and once on 1/30/15 and 1/31/15.The nurses' notes, dated 1/30/15 showed, "Resident noted with increased confusion. Called, texted, and left voice mail for (MD 2). Family made aware." A nurse's note, dated 1/31/15 at 2:41 p.m., showed, "Patient noted with increased confusion. Texted (MD 2) to report change and possibly get a urinalysis order (to rule out a urinary tract infection as the cause of the increased confusion). Waiting for response." A nurse's note, dated 1/31/15 at 10:41 p.m., showed, "Caregiver arrived at 6:40 p.m. stating the family was going to have patient sent out via ambulance transport because 'there was no way else to get her out of here.' At 7:05 p.m., emergency personnel arrived after 911 was called and they were informed the patient was having a stroke....Family spoke with paramedics and demanded they take patient to the hospital."During interview on 2/19/15 at 2:00 p.m., LVN 1 (licensed vocational nurse) stated, "On 1/31/15, I attempted to contact the doctor (MD 1) and notified the family of increasing confusion. The family was here. Resident 2 was confused but her vital signs were stable. I told her I had left a message for MD 2 because the relative thought Resident 2 was more confused, too. MD 2 didn't call back on my shift." During interview on 2/19/15 at 2:20 p.m., LVN 4 stated, "On 1/30/15, I attempted to contact the doctor (MD 2) and notified the family of the increased confusion. The relative was here and I told her that vital signs were stable. I told her I left a message for the doctor ( MD 2), because she also thought Resident 2 was more confused. MD 2 did not call back on my shift." Review of the emergency department physician's evaluation, dated 1/31/15, showed, "Chief complaint: Worsening confusion. History of present illness: This is a female known to have Alzheimer dementia who at baseline is confused, but normally is alert and able to answer questions. However, in the last several days, the patient has been yelling and more confused, speaking gibberish, not following commands. She would usually be given Ativan and this would result in the patient calming down and being able to sleep through the night...Assessment and Plan: 1. Encephalopathy (a brain dysfunction), likely secondary to a subacute infarct (An area of tissue which undergoes necrosis (death) due to cessation of blood supply, a stroke) involving the left parietal occipital, posterior temporal and lobes. Perhaps cardioembolitic (caused by a blood clot). Admitted...2. Lactic acidosis, unclear etiology (origin). (Lactic acid is formed in muscles due to the breakdown of glycogen, a starch. With muscle contraction glycogen breaks down into lactic acid, causing fatigue.) Urinary tract infection versus colonization. Will await urine culture." During phone interview on 3/4/15 at 10:30 a.m., DON stated, "MD 2 does not have anyone on-call for him. A physician should be available." Review of the facility's contract with MD 2, showed "The agreement for Professional Services, dated 8/1/14 and is entered between (MD 2). The Physician shall perform the professional services normally incident to the position of Co-Medical Director... The scope of duties shall include, but not be limited to: 3.1.3 Coordinating medical care in the facility; 3.1.4 Overseeing that all necessary medical services provided to residents are adequate and appropriate; 3.1.7 Providing 'on-call' availability and responding at all times to medical, regulatory, or other emergencies in the facility." Therefore the facility failed to: 1. Provide anti-seizure medication for Resident 1 on 2/7/15 at 11:00 p.m. when he started having seizures which continued over the next hour and a half , 2. Inform the physician of a change in Resident 2's condition, delaying treatment. These violations had a direct or immediate relationship to the health, safety, or security of patient.
030000530	Oak Ridge Healthcare Center	030010437	B	06-Feb-14	AI0S11	3466	Health & Safety Code - 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. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 1/19/11 at 1:20 p.m. an unannounced visit was made to the facility to investigate complaint CA00255338. The allegations included bruising of unknown origin on the left hand, ring finger of Patient A and theft of a ring from the left, hand ring finger of Patient A.The Department determined the facility failed to report this alleged abuse to the Department within 24 hours as required. Patient A was admitted to the facility on 10/15/10 for therapy, dementia and Parkinsonism. A Minimum Data Set (MDS - a standardized assessment tool) dated 11/22/10 indicated Patient A had short term and long term memory deficits.On 1/11/11, the Department received a complaint reporting that a family member of Patient A informed the complainant of an allegation of abuse. According to a family member, on 11/26/10 Patient A was taken to the bathroom where their wedding ring was removed from a finger and there were bruises on the left ring finger. In a follow up interview with the complainant on 9/12/13, they confirmed the written allegations and stated that during conversations with the Administrator on 12/11/10 and 12/12/10, the complainant told the Administrator the ring may have been stolen. The complainant instructed the Administrator to report this as suspected abuse, but the Administrator refused. Bureau of Medi-Cal Fraud and Elder Abuse (BMFEA) reports were reviewed. On 1/24/11 at 1:30 p.m., a family member of Patient A stated to an Agent of BMFEA that on 11/26/10 Patient A said that someone had taken Patient A to the bathroom at the facility, placed the left hand in the sink and put water and soap on the hand and forcefully removed the wedding band off the finger on the left hand. The Agent wrote that on 11/29/10 and 11/30/10 the [family member] stated they had met with the facility's Admissions/Community Relations Director, Social Service Director and Administrator telling them of the theft allegations. Health and Safety Code Section 1418.91 reads in pertinent part: For purposes of this section, "abuse" shall mean any of the conduct described in subdivisions (a) and (b) of Section 15610.07 of the Welfare and Institutions Code." Welfare and Institutions Code Section 15610.07 reads in pertinent part: "Abuse of an elder or a dependent adult" means...Physical abuse...financial abuse...or other treatment with resulting physical harm or pain or mental suffering.The Administrator was interviewed on 1/19/11 at 2:30 p.m. The Administrator stated that, "[Patient A's family member] came in and [Patient A] told them that someone took [Patient A's] ring." The Administrator stated that he did not believe the ring was stolen, so he did not report it. The Resident sustained bruising of unknown origin on the left hand ring finger and allegations that the Resident's wedding ring was forcibly removed from the left hand ring finger that was not reported to the Department.Therefore the Department determined the facility failed to report this alleged abuse to the Department within 24 hours as required. This violation had a direct or immediate relationship to the health, safety or security of long-term care facility patients or residents.
040000058	Oakhurst Healthcare & Wellness Centre	040010032	B	25-Jul-13	DPHX11	21936	483.65 Infection ControlThe facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. 483.65 (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such and isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. 483.65 (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. 483.65 (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.The facility failed to implement and maintain a safe and sanitary environment to prevent transmission of resident infections when facility processes were not implemented for: 1) Hand hygiene for staff prior to and following resident care for residents on isolation and those who were not. 2) Effective staff education and training based upon professional standards of practice. 3) Environmental cleaning when staff did not consistently follow recommended guidelines. 4) Handling and processing of contaminated linens by laundry staff. 5) Staff sick leave and visitor guidelines when no evidence policies were established. This failure exposed residents and staff to infectious disease resulting in resident illness and harm to 7 residents (Residents 1, 2, 3, 4, 5, 6 & 7) and one staff member who was diagnosed with Clostridium difficile (C. difficile) [a contagious gastrointestinal bacteria resulting in diarrhea and severe gastrointestinal illness].1. On 4/26/13 at 1:45 p.m., during initial tour and concurrent interview, the Director of Nursing (DON) stated, "The staff wash hands in the resident's rooms."On 4/26/13 at 2:15 p.m., during a concurrent observation and interview at the nurses' station, Registered Nurse (RN) 1 was observed leaning over a medication cart, dressed in casual street attire (blue jeans and a T shirt). RN 1 stated, "This is casual Friday in case you are wondering...We wash our hands in the utility room." On 4/26/13 at 2:16 p.m., during an observation, the utility room was observed locked, requiring key entry. The door key was observed on the wall adjacent to the utility room. No observations were made of staff washing hands in the utility room. On 4/26/13 at 2:17 p.m., during an observation, "Gel-San" (an alcohol based hand sanitizer) hand wipes and pump solution were noted on medication and treatment carts, and on the nurses' station countertop. No gloves were observed on any carts.On 4/26/13 at 2:18 p.m., during an initial tour, Occupational Therapist, (OT) stated residents were being asked to use alcohol based sanitizer on their hands before entering the therapy room. On 4/26/13 at 3:00 p.m., during an interview, the Director of Staff Development (DSD) was asked how residents were being protected from healthcare associated infections and stated, "We keep hand sanitizer and gloves in all the rooms." On 4/26/13 at 3:02 p.m., during an interview regarding components of the facility infection control program, the DON stated, "I can't speak to that, you'd have to ask the DSD." On 4/26/13 at 3:05 p.m., during an interview regarding facility methods of monitoring for staff compliance with hand washing, the DSD paused and stated, "I can't really answer that." On 5/4/13 at 3:05 p.m., during an observation of Resident 4's care at the bedside, RN 2 used hand sanitizer prior to entering Resident 4's room. RN 2 donned (put on) exam gloves and a disposable yellow gown. RN 2 assisted Certified Nursing Assistant (CNA 1) with skin care for Resident 4. RN 2 then pulled out a second pair of exam gloves which she placed over the dirty pair of exam gloves on both hands. RN 2 removed the cap from Resident 4's Gastrostomy Tube (GT) (a tube inserted through the skin into the stomach to feed or deliver medications) and placed the cap on top of the bag holding the enteral feeding.On 5/4/13 at 3:15 p.m., RN 2 stated she had donned a second set of gloves over her first pair in order not to get bowel movement (BM) on the feeding tube. When asked what she might have done differently to maintain a sanitary environment for Resident 4, she stated she should have removed the first set of gloves, washed her hands, and put on a clean set of gloves prior to handling his GT. When asked if she had attended an in-service training in the area of infection control this week she stated she had, but, "They just didn't get into details like that. They just talked about hand washing, gowning and gloving in isolation."On 5/10/13 at 11:30 a.m., during an interview, the Housekeeping and Laundry Coordinator (HLC) stated, "I have seen nurses and CNAs glove up (on entering a resident room), take the gloves off (after resident care), and leave the room and not wash hands. The only place I have seen staff washing their hands is in the break room."The facility policy and procedure titled, "Infection Control, Policy for Antibiotic Resistant Microorganisms (MDRO)," undated, indicated under A. Standard Precautions including Contact Precautions, "1. Hand washing-before and after resident contact, and after removing gloves is the single most effective infection control measure known to reduce the potential for transmission of microorganisms, including...MDRO..."Review of "Clinical Practice Guidelines for Clostridium difficile Infection (CDI) in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America," Infection Control and Epidemiology, May 2010, indicated on p. 432, under Measures for Healthcare Workers, Patients, and Visitors, " 14. Emphasize compliance with the practice of hand hygiene...p. 441 indicated "Hand hygiene is considered to be the one of the cornerstones of prevention of... C. difficile.... in its spore form, is also known to be highly resistant to killing by alcohol.....healthcare workers who decontaminate their hands with alcohol-based products....could potentially increase the risk of transferring this organism to patients under their care." 2. On 4/26/13 at 2:25 p.m., during an interview, the Director of Staff Development (DSD) stated, "I do the [infection control] inservice with the staff and with housekeeping." On 4/26/13 at 4:20 p.m., during an interview, the DSD stated she had recently provided infection control training to facility staff on 4/23/13. Training documents received indicated infection control reference information was taken from http://en.wikipedia.org downloaded on 9/13/12 and 3/8/13, a general information internet website, not recognized as a standard resource for professional infection control practice. Review of facility documents titled, "Inservice Training Minutes," indicated the DSD provided infection control inservice on the following dates: 8/1/12, 8/30/12, 9/2/12, 9/14/12, 10/18/12, 11/28/12, 1/9/13, 1/31/13, 2/26/13, and 3/11/13. No documented evidence of evaluations, observations of staff performance, or return demonstrations was provided. On 4/26/13 at 2:25 p.m., during an interview, the Director of Nursing (DON) stated, "We have three residents (Residents 1, 2 and 3) who are positive for Clostridium difficile (C. difficile) [a contagious gastrointestinal bacteria resulting in diarrhea and severe gastrointestinal illness]. The DON stated she was waiting on test results for Resident 5. On 4/26/13 at 3:00 p.m., during an interview, the Director of Staff Development (DSD) confirmed she was also the Infection Control Coordinator for the facility. The DSD stated Resident 1, 2 and 3 were diagnosed with C. difficile infection, and Resident 4 was a confirmed Methicillin Resistant Staphylococcus aureus (MRSA) infection (communicable bacteria passed to other residents by direct and indirect contact).On 5/4/13 at 3:05 p.m., during an observation of Resident 4's care at the bedside, RN 2 used hand sanitizer prior to entering Resident 4's room. RN 2 donned (put on) exam gloves and a disposable yellow gown. RN 2 assisted Certified Nursing Assistant (CNA) 1 with skin care for Resident 4. RN 2 then pulled out a second pair of exam gloves which she placed over the dirty pair of exam gloves on both hands. RN 2 removed the cap from Resident 4's Gastrostomy Tube (GT) (a tube inserted through the skin into the stomach to feed or deliver medications) and placed the cap on top of the bag holding the enteral feeding.On 5/4/13 at 3:15 p.m., RN 2 stated she had donned a second set of gloves over her first pair in order not to get bowel movement (BM) on the feeding tube. When asked what she might have done differently to maintain a sanitary environment for Resident 4, she stated she should have removed the first set of gloves, washed her hands, and put on a clean set of gloves prior to handling his GT. When asked if she had attended an in-service training in the area of infection control this week she stated she had, but, "They just didn't get into details like that. They just talked about hand washing, gowning and gloving in isolation."On 5/10/13 at 11:30 a.m., during an interview, the Housekeeping and Laundry Coordinator (HLC) stated, "I have seen nurses and CNAs glove up (on entering a resident room), take the gloves off (after resident care), and leave the room and not wash hands. The only place I have seen staff washing their hands is in the break room."Review of "Clinical Practice Guidelines for Clostridium difficile Infection (CDI) in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America," Infection Control and Epidemiology, May 2010, indicated on p. 432, under Measures for Healthcare Workers, Patients, and Visitors, " 14. Emphasize compliance with the practice of hand hygiene...p. 441 indicated "Hand hygiene is considered to be the one of the cornerstones of prevention of... C. difficile.... in its spore form, is also known to be highly resistant to killing by alcohol.....healthcare workers who decontaminate their hands with alcohol-based products....could potentially increase the risk of transferring this organism to patients under their care."3a. On 4/26/13 at 2:18 p.m., during an initial tour, the Occupational Therapist, (OT) stated "We wipe our equipment down first thing (in the morning) and then at the end of the day....each staff person is responsible for wiping down therapy mats after resident use."On 4/26/13 at 3:10 p.m., during an observation and concurrent interview, Housekeeper 1 (H1) was observed at the entry to a resident room with a cleaning cart. She produced a spray bottle from her cleaning cart and admitted she was unable to read measurement markings, stating, "I just put bleach to that line [pointing to the bottom rim of the bottle, approximately 2 ounce mark] and fill the rest with water." The spray bottle measurement indicated it was a 32 ounce spray container. H1 stated "For the floor (a 4 gallon container) I use two of these (producing a bleach container cap, approximately 1.5 Tablespoons - less than a 1:10 ratio) and then fill it with water. We use 10:1 ratio (10 parts water to 1 part bleach), that's what they said." Review of Centers for Disease Control and Prevention "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008" indicated under 5. Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities, "17. In units with high rates of ...Clostridium difficile infection or in an outbreak setting, use dilute solutions of 5.25%-6.15% sodium hypochlorite (e.g., 1:10 dilution of household bleach) for routine environmental cleaning." According to this ratio (1:10 dilution), a 4 gallon container of water would have required 6.64 cups of bleach to obtain a 1:10 ratio; (instead of the 1.5 Tablespoons used). On 4/26/13 at 3:40 p.m., during an interview regarding deep cleaning of the facility (as a result of C. difficile infections), the Director of Nursing (DON) was unable to state the date or time of a scheduled cleaning. On 4/27/13 at 3:45, during an interview, the DON and Interim Administrator (IA) were unable to state who was responsible for cleaning medical equipment used by multiple residents. The IA stated, "I'll need to call our maintenance supervisor to find that out." On 4/30/13 at 12:15 p.m., during an observation and concurrent interview, H1 was observed mopping the floor of Isolation Room 25. H1 stated she was mopping the floor with a bleach solution. H1 stated someone else had mixed the bleach water for her, and was unable to verify it was the correct concentration.On 4/30/13 at 1:15 p.m., during an interview, the IA was unable to provide a cleaning schedule for resident equipment, stating, "My maintenance supervisor cleans them every Friday with bleach. We don't have a schedule or a log."The facility policy and procedure titled, Infection Control, Policy for Antibiotic Resistant Microorganism (MDRO), undated, indicated under C. Environmental and Equipment Protection, "1. Disinfection of soiled surfaces and equipment daily or more frequently by the designated staff member should be done in order to prevent the spread of ...MDRO and other pathogenic microorganisms." On 5/10/13 at 11:00 a.m., during an interview, the Housekeeping and Laundry Coordinator (HLC) stated she had no documentation of observations, return demonstrations or other measures for validating staff competence in correctly mixing 1:10 (1 part bleach to 10 parts water) bleach solutions. The HLC stated housekeeping staff do not routinely clean patient equipment. The HLC stated housekeeping staff were not routinely informed of resident status and care changes requiring isolation or contact precautions. The HLC stated, "Usually I would hear about it by word of mouth from CNA staff...days have gone by before I knew someone had C. diff or MRSA."On 5/10/13 at 11:45 a.m., during an interview, the HLC stated, "Some days I cannot finish my assignment because of interruptions and I get redirected to clean for (resident) room changes. There are a lot of room changes."Review of the facility documents titled, "Daily Census Report," (a report of daily resident admissions, discharges and bed changes), from January 2013 through April 2013, tracking room changes for residents with C. diff infections indicated:Resident 1's room locations: 19B, 25A, 27B, 16B, 25B, 21B. Resident 2's room locations: 25B, 31C, 1B, 21B, 21C. Resident 3's room locations: 10A, 25B. Resident 5's room locations: 16A, 21A, 22A. Resident 6's room locations: 17A, 25A. Resident 7's room locations: 10A. "Making Health Care Safer, Stopping C. difficile Infections," Vital Signs, March 2012, Centers for Disease Control and Prevention, indicated, "Make sure cleaning staff follows CDC recommendations, using an EPA-approved, spore-killing disinfectant in rooms where C. difficile patients are treated." 3b. On 5/2/13 at 1 p.m., during an observation of Resident 3 and 6's room (both positive for C. difficile), Room 25 had 8 - 10 inches of water, half an inch deep on the floor surrounding the base of the toilet bowl in the bathroom. Brown flecks were observed floating in the water on the floor, on the toilet seat, and in the toilet bowl. Resident 3 stated, "The toilet ran over in there about 10:30 this morning, the Maintenance Supervisor (MS) fixed it, but it hasn't been cleaned up yet. They told us they couldn't fix it until we were done eating."4. On 4/26/13 at 1:45 p.m., during an initial tour of the facility laundry room, two open piles of resident laundry were observed lying on the floor adjacent to the washing machine.On 4/26/13 at 1:46 p.m., during an interview, the Director of Nursing (DON) stated, "I need to take care of that," and directed laundry staff to move the laundry to a covered laundry cart. On 5/10/13 at 11:40 a.m., during an interview, the Housekeeping and Laundry Coordinator (HLC) stated there were no special handling procedures for resident laundry, including those on contact precautions, "We don't do that. We were told it wasn't necessary...we don't get consistent information and direction on how to handle laundry.'' On 5/15/13 at 4:30 p.m., during an interview, the Medical Director (MD) could not state the facility laundry procedures were in place for residents on contact precautions. The facility policy and procedure titled, "Infection Control," undated, indicated under Section D. Linens, "Contaminated linens should be handled appropriately whether their source was an isolation room or a non-isolation room. All linen should be handled as if it were highly infectious." 5. On 4/26/13 at 1:30 p.m., during entry to the facility, no visitor instruction or guidance was posted at the entrance to the facility. Three to four visitors were observed talking with residents seated adjacent to the nurse's station. On 4/26/13 at 5:45 p.m., during an interview, the Director of Staff Development (DSD) stated one staff person had been off work for several weeks, with a confirmed C. difficile infection. On 4/30/13 at 4:00 p.m., during an interview, the Interim Administrator (IA) was unable to produce a sick leave policy for facility staff, stating, "I'll have to look for it." The IA produced a new employee handbook, stating the policy was included in the handbook. On 5/2/13 at 1:45 p.m., during a subsequent interview, the Administrator Consultant (AC) confirmed the handbook information was the only facility policy regarding staff illness. Review of the facility document titled, "[Facility] Handbook" dated 12/12, contained no direction to ill employees regarding not exposing residents of the facility to their illness.Review of SHEA/APIC Guideline for Infection Prevention and Control in the Long Term Care Facility (LTCF), July 2008, indicated, "Initial assessment of employees and education in infection control are also important, as is a reasonable sick leave policy. Ill employees may cause significant outbreaks in the LTC....LTCFs are required to prohibit employees with communicable diseases...from direct contact with residents ..." The facility policy and procedure titled, "Infection Control, Policy For ARM/MDRO" undated, indicated under I. "Visitors: Instruct visitors to wash their hands prior to resident contact, following contact with body fluids, before and after feeding the resident and following contact with other residents." Review of Centers for Disease Control and Prevention "Guideline for infection control in healthcare personnel, 1998, indicated under D. Elements of a Personnel Health Service for Infection Control, "Certain elements are necessary to attain the infection control goals of a personnel health service....(e) management of job-related illnesses and exposures to infectious diseases, including policies for work restrictions for infected or exposed personnel, (f) counseling services for personnel on infection risks related to employment or special conditions..." As a result of the above failures 6 residents (Residents 1, 2, 3, 5, 6, & 7) and one staff member contracted C difficile. On 4/26/13 at 5:45 p.m., during an interview, the DSD stated one facility staff person (HLC) had been absent from work for several weeks, with a confirmed C. difficile infection.On 5/10/13 at 11:00 a.m. during a telephone interview, HLC stated her date of onset for C difficile was on 3/30/13 and her culture was positive for C difficile on 4/17/13. Review of the administrative documents reported to Madera County Public Health Department titled, "Confidential Morbidity Report," dated 4/29/13,indicated the following dates of C. difficile symptom onset and dates of diagnosis: Resident 1: onset 3/29/13, diagnosis 4/1/13. Resident 2: onset 3/31/13, diagnosis 4/1/13. Resident 3: onset 4/18/13, diagnosis 4/19/13 (based on hospital records). Resident 5: onset 4/4/13, diagnosis 4/5/13. Resident 6: onset 4/24/13, diagnosis 4/26/13. Resident 7: onset 5/1/13, diagnosis 5/6/13. Review of clinical laboratory record documents titled, "Diagnostic Laboratories and Radiology," dated 4/23/13, 4/1/13, 4/26/13, and 5/6/13 for Resident 1, 2, 5, and 7 respectively, all indicated "Toxigenic C. Diff Positive... The 027/NAP1/BI strain has a high risk of sporulation and toxin production, and has been associated with epidemics of C. difficile infection." The lab record results identified all 4 residents were infected with the same strain of C difficile. The facility's failure to ensure: 1) Hand hygiene for staff prior to and following resident care for residents on isolation and those who were not. 2) Effective staff education and training based upon professional standards of practice. 3) Environmental cleaning when staff did not consistently follow recommended guidelines. 4) Handling and processing of contaminated linens by laundry staff. 5) Staff sick leave and visitor guidelines when no evidence policies were established; resulted in residents' and staff's exposure to infectious disease, which lead to illness and harm to 7 residents (Residents 1, 2, 3, 4, 5, 6 & 7), and one staff member who was diagnosed with Clostridium difficile (C. difficile). The above violation had a direct or immediate relationship to the residents' health, safety, or security, and therefore constitutes a Class 'B' Citation.
040000729	OUR HOUSE WESTGATE	040010307	B	10-Dec-13	73IZ11	7666	42 CFR 483.420 (d) (l) Staff Treatment of Clients The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. The facility failed to implement its policy to prohibit abuse of Client A when he was strapped into a "Lift Walker" (a medical apparatus that lifts clients to a standing position, harness supporting body weight, allowing client to move feet) and forced to walk because Client A did not do what Direct Care Staff (DCS) 10 demanded. Client A's clinical record contained documentation that he was admitted to the facility in 1995. Client A's Comprehensive Functional Assessment (CFA) dated September 2, 2013 indicated Client A had a diagnosis that included Rosai-Dorfman (histiocytic disorder which involves the over production of a type of white blood cell). The CFA described Client A as non-ambulatory, used a wheelchair, a lift walker (used as a walker, gait trainer and a transfer assist device designed to improve strength, balance and coordination). Client A needed assistance in transferring, could answer yes and no questions, and understood changes in his environment. On 9/5/13 the facility received a report that Direct Care Staff (DCS) 1 had witnessed DCS 10 use the lift walker on Client A as a means of punishment. DCS 1 reported on 9/3/13 she arrived for her 4 p.m. to 6 p.m. shift to see that DCS 10, who was not assigned to Client A, was assisting Client A in his lift walker exercise. DCS 1 was assigned to Client A and was supposed to do the lift walker exercises. DCS 1 observed the lift walker being used incorrectly. DCS 1 reported she told DCS 10 that Client A was uncomfortable, sweating, and had done enough. DCS 10 replied "No he needs to do it again, he has to learn to stop scratching." Client A's clinical record titled "Registered Nurse (RN) Quarterly Summary" dated 7/11/13; indicated Client A had a skin condition (histiocytosis) which caused chronic itching. A review of the "Registered Nurse Quarterly Summary" dated 7/11/13, indicated Client A had limited lower extremity strength with hip and knee contractures. His lower extremity contractures caused difficulties with ambulation. Client A used a lift walker to maintain mobility and strength. A review of the "Mobility - Lift Walker" dated 10/30/11, indicated the teaching method in using the lift walker was to tell Client A it's time to use the walker, but "do not force him" and to "verbally encourage and praise him the whole time."On 9/6/13 at 11:20 a.m., DCS 1was interviewed. DCS 1 stated that on 9/3/13, she had been the DCS assigned to walk Client A in lift walker that afternoon. DCS 1 stated when she arrived to the facility, DCS 10 was just finishing the lift walker exercise with Client A. DCS 1 stated Client A looked uncomfortable, tired, and sweaty; and she told DCS 10 said that was enough walking. DCS 10 replied, "No make him (Client A) do it again he needs to learn to stop scratching." Client A told DCS 1 "I don't want to" and tried to call DCS 1 by name (to object to more walking). DCS 10 insisted Client A walk around again (from the family room around to the living room through the hall back to the family room, making a circle).DCS 1 stated the lift walker had a chest strap that was used to help position Client A while walking. DCS 1 stated that DCS10 had Client A walk around again although Client A was very tired, sweating and objected to walking. She stated that after the additional walk, Client A's legs were giving out and he had difficulty supporting his weight. Client A began to slip down in the walker, which caused the chest strap to apply pressure directly to Client A's armpits. DCS 1 stated that was really uncomfortable for Client A. DCS 1 stated DCS 10 had no reason to be involved with Client A, since DCS 10's only job was to watch and take care of Client B. DCS 1 stated that she did not know why she did not report this incident right away to administrative staff. On 9/6/13 at 12:30 p.m., DCS 5 was interviewed. She stated (could not remember the days or times), that DCS 10 had used the lift walker to threaten Client A when he (Client A) didn't do what she wanted, usually on the p.m. shifts. DCS 5 said she heard DCS 10 tell Client A, "If you don't finish your dinner I'm going to put you in that walker." DCS 5 (not sure of the date) said a month ago in the afternoon she and DCS 1 arrived at the facility to find that DCS 10 had already put Client A in the walker. DCS 5 stated Client A looked really tired and sweaty. DCS 5 stated DCS 1 was upset because Client A was her client and she was supposed to manage Client A's exercises not DCS 10. DCS 5 stated that DCS 10 was supposed to be working with Client B only. DCS 10 told them the reason she put Client A in the lift walker was because he wouldn't stop scratching. DCS 5 stated she did not know why she did not report these incidents. DCS 5 stated she was afraid and didn't know what to do. On 9/6/13 at 2:05 p.m., DCS 8 was interviewed. She stated that DCS 10 put Client A in the lift walker because Client A was out of shape and wouldn't stop scratching. DCS 8 stated that Client A would fight DCS 10 because Client A did not like the lift walker. DCS 8 stated she did not remember the dates that DCS 10 had put Client A in the lift walker, but she recalled DCS 10 had done this a couple of times within the last two weeks. DCS 8 stated she did not report these issues because she was not sure it was abuse. She stated she was not sure what a mandated reporter was or what the mandated reporter was supposed to do. On 9/6/13 at 2:40 p.m., during an interview, DCS 9 stated she had heard DCS 10 threaten to put Client A in the walker to punish him when he would not eat. DCS 9 stated DCS 10 had done that a couple of times but she was not sure of exact dates. DCS 9 stated she was not sure why she did not report the incidents. On 9/16/13 at 4:35 p.m., the Administrator/Registered Nurse stated during an interview, she was made aware of these allegations of abuse on 9/4/13 at approximately 3:40 p.m., at which point she placed DCS 10 on administrative leave. DCS 10 was not available for interview when attempts were made to reach her on 9/17/13 at 2:30 p.m. and on 9/24/13 at 12:55 p.m. A review of the Histiocytosis Association's Rosai-Dorfman Disease website at http://www.histio.org/page.aspx?pid=399 indicated the following symptoms: Shortness of breath, joint pain, difficulty swallowing or speaking, headaches, decreased sensation and paralysis. The site also contained information that "Many adults with RD experience severe and sometimes overwhelming pain associated with this disease." The facility's policy on Abuse Reporting, dated 10/2010, contained documentation that employees of the facility were mandatory reporters of incidents of physical, sexual or mental abuse of clients within their care. Circumstances mandating report of suspected abuse included direct observation of abuse and a complaint of abuse stated by the client. The facility failed to prohibit abuse of Client A when he was repeatedly witnessed to be placed in the lift walker by DCS 10, against his will and made to walk to the point of exhaustion as a form of punishment. Although these incidents were witnessed by four DCS (DCS 1, 5, 8 and 9), none of these staff members reported the incidents to administrative staff to prevent recurrences. Client A was forced to endure repeated physical and emotional abuse as a result of DCS 10's actions. The above violation had a direct or immediate relationship to the client's health, safety, or security, and therefore constitutes a Class 'B' Citation.
040000729	OUR HOUSE WESTGATE	040010308	B	10-Dec-13	73IZ11	7084	42 CFR 483-420 (d) (l) Staff Treatment of Clients The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. The following reflects the findings of the California Department of Public Health during the investigation of Entity Reported Incident: CA00368648. The facility failed to prohibit abuse of Client B when he was subjected to multiple incidents of abuse that included the following: slapped, isolated to his room, had his hair pulled, yelled at, and sexually abused by a Direct Care Staff (DCS) 10.A review of Client B's clinical record indicated Client B was admitted to the facility in 8/1992. Client B's Comprehensive Functional Assessment (CFA) dated September 2, 2013. Client B was unable to communicate verbally. To communicate, he screamed, grunted, moaned and used physical movements. Client B was unable to follow simple verbal directions, basic gestures or facial expressions. When he had periods of increased hyperactivity he could become aggressive by hitting, pulling hair, pinching, and pushing. His aggression was typically directed at staff members. Client B was assigned one staff to be with him at all times to help manage his behaviors.On 9/6/13 at 11:40 a.m., DCS 2 stated during an interview that she had seen (could not remember dates or times) DCS 10 being rough with Client B, "pushing him (Client B)." DCS 2 stated she did not tell anyone of the incident, and stated she did not know she was a mandated reporter. On 9/6/13 at 12:15 p.m., DCS 5 stated during an interview that she had seen DCS 10 "jerk [Client B] around by the shirt." DCS 5 stated she did not know why she did not report what she witnessed. DCS 5 stated she was afraid and did not know what to do. On 9/6/13 at 1:30 p.m., DCS 6 stated during an interview that on 9/2/13, Client B had hold of DCS 10's hair. When Client B let go, DCS 10 in retaliation pulled Client B's hair. Client B made a little scream indicating he did not like having his hair pulled. At dinner the same day, DCS 6 stated DCS 10 came over to where Client B was sitting at the table and backed up into Client B with her "butt" and started "to shake it at him (Client B)." DCS 6 stated like a "lap dance" (a dance maneuver that is intended to arouse the other person by moving the pelvic area back and forth over the other person's private area). DCS 10 said "he (Client B) likes it." DCS 6 stated during shower time after dinner, DCS 10 said to DCS 6 that if Client B was "a little more normal" she (DCS 10) "would do him" ("do him" is a slang phrase meaning to have sexual intercourse). After showers (the same day), DCS 6 stated Client B slapped DCS 10. In return, DCS 10 became angry, "went after Client B" and slapped him in the chest. DCS 6 stated, later that night DCS 10 took Client B's favorite toy, (a stuffed monkey with long dangly arms and legs), and placed it between her legs next to her pelvic bone and told Client B to "come and get the monkey." DCS 6 stated she should have reported these incidents earlier to prevent further abuse. She stated she should not have let her (DCS 10) get away with the abuse. On 9/6/13 at 1:45 p.m., DCS 7 stated during an interview that a month ago (not sure of date), she (DCS 7) observed Client B slap DCS 10 in the face. DCS 10 told Client B if he slapped her (DCS 10) again DCS 10 would slap him back. Client B slapped DCS 10 again. DCS 10 put her hand on Client B's cheek and did little slaps and asked Client B "how do you like that?" Client B pulled his head away. DCS 7 stated later the same day she was coming down the hall towards Client B's bedroom when Client B pulled open the door about 12 inches." When DCS 7 looked in she saw that DCS 10 had her feet on one door and her head on the other door of Client B's bedroom talking on her cell phone. Client B could not get out of his room. DCS 7 stated she tried to push the door open because Client B was trying to get out. She stated DCS 10 did not move and continued to block the bedroom doors preventing Client B from leaving his bedroom. DCS 7 stated she should have reported what she saw but she was afraid of DCS 10. On 9/6/13 at 2:05 p.m., DCS 8 stated during an interview that she and DCS 10 had worked a lot of shifts together. DCS 8 stated Client B pulled DCS 10's hair (did not remember the date) and DCS 10 "tugged" on Client B's hair to show him what it felt like. DCS 8 confirmed DCS 10 kept Client B in his room "sometimes." DCS 8 stated DCS 10 could "be rough with" Client B. She recalled that not long ago (she was not sure of the date), DCS 10 was sitting on the arm of the sofa and Client B was lying on the bean bag chair adjacent to the sofa. She stated that "somehow [DCS 10] fell into Client B's lap." DCS 8 stated she did not know what a mandated reporter was or supposed to do.On 9/6/13 at 2:40 p.m., DCS 9 stated during an interview that DCS 10 "yells at him (Client B)." DCS 9 stated she should have reported it, but did not know why she did not. DCS 10 was not available for interview when attempts were made to reach her on 9/17/13 at 2:30 p.m. and on 9/24/13 at 12:55 p.m. On 9/16/13 at 4:35 p.m., the Administrator/Registered Nurse stated during an interview, she was made aware of these allegations of abuse on 9/4/13 at approximately 3:40 p.m., at which point she placed DCS 10 on administrative leave. The administrative document titled "Mandatory Reporter Policy" dated November 23, 2010, indicated "...abuse and neglect...this includes physical, verbal, mental, emotional...threats or intimidation of clients...an incident of abuse or neglect of a developmentally disabled person is a felony...I promise to protect the individuals who live at this facility at all times." The undated administrative document titled "Behavior Management" indicated employees should provide a safe and secure environment to promote trusting relationships. Provide a relaxing and pleasant environment. It contained information that threats and isolation were inappropriate behavior management techniques. The DDA (Developmental Disability Assistant) Role was to protect all clients during behavior episodes and to ensure there were no client's rights violations. The undated administrative document titled "Crisis Intervention Strategies for Adults with Developmental Disabilities," contained a goal to "Provide staff will [sic] necessary skills to apply positive approaches to deal with aggression and/or physical violence that will elicit positive behavior from clients."The facility failed to implement the abuse policy when Client B was subjected to multiple forms of abuse such as being slapped, had his hair pulled, blocked from leaving his room, and sexually abused by DCS 10 with multiple staff members' knowledge (DCS 2, 5, 6, 7, 8, and 9) and no staff reported these incidents to prevent continued abuse of Client B.The above violation jointly, separately or in any combination had an immediate direct relationship to the client's health, safety and well- being and therefore constitutes a Class "B" Citation.
030000079	Oakdale Nursing and Rehabilitation Center	040010996	B	15-Sep-14	045D11	7225	CLASS B CITATION - QUALITY OF CARE F323: CFR 483.25(h) Accidents The facility must ensure that: (1) The resident environment remains as free from accident hazards as possible, and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 7/9/14 at 2:30 p.m. an investigation was conducted on an anonymous Complaint #CA00404815 regarding resident Quality of Care. The facility failed to provide an environment free from accidents when Certified Nursing Assistant (CNA)1 and CNA 2 attempted to transfer Resident 1 (Res 1) using a bed sheet. Res 1 slipped from the bed sheet onto the floor and sustained lacerations (an open and torn skin wound) to the scalp, face, eyes and forearms. This failure resulted in an avoidable injury to Res 1 and a hospital Emergency Department visit for treatment and services.Review of the clinical record indicated Res 1 was admitted to the facility on 1/30/02. Res 1's date of birth was 3/31/1913. She had admitting diagnoses of Alzheimer's disease, general osteoarthrosis (a condition of chronic arthritis, usually mechanical, with pain in joints but without inflammation) and dysphagia (difficulty in swallowing). Res 1's weight on 4/22/14 was 61 pounds (lbs.). The Minimum Data Set (MDS - a standardized tool used to access nursing home residents) indicated she was unable to verbally communicate, unable to move on command due to involuntary, uncontrolled movements of her lower extremities, and was totally dependent on staff for her care. Res 1 was unable to independently change positions.On 7/9/14 at 3:10 p.m., during an interview, Certified Nursing Assistant (CNA) 1 stated on 7/7/14 at 4:45 p.m., she and CNA 2 attempted to transfer Res 1 from the bed to the specialized reclining chair next to the bed. CNA 1 stated they decided to use a twin bed sheet for the transfer. CNA 1 stated that in the process of transferring, Res 1 slipped from the twin bed sheet onto the floor, striking her face, head and arms on the floor. CNA 1 described how the transfer was done. CNA 1 and CNA 2 were holding opposite ends of Res 1's twin bed sheet. CNA 1 stated "[Res 1] started twisting and sliding off the sheet to the right of the bed." The reclining chair was placed against the bed on the right side. CNA 1 stated they were standing on the right side of the bed, with CNA 1 at the head of the bed and CNA 2 at the foot of the bed. CNA 1 stated Res 1 began falling out of the bed sheet between the reclining chair and the side of the bed. CNA 1 stated because they could not prevent the fall they tried to assist the resident to the floor. In trying to assist Res 1 to the floor, Res 1 struck her face, scalp, eyes and arms on the floor.During this interview, CNA 1 stated the reason why they (CNA 1 and CNA 2) decided to use the twin bed sheet to transfer was because Res 1 had a history of bruising between the thighs when the mechanical lift was used to transfer. When asked whether or not training was provided for techniques in transferring with the twin bed sheet CNA 1 stated "No". When asked whether or not the licensed nursing staff knew transfers were being done with the twin bed sheet, CNA stated "Yes". CNA 1 stated she was not aware of a facility policy and procedure for transferring with a twin bed sheet. CNA 1 stated that transferring Res 1 with a twin bed sheet was "routine" and she could not remember how long the practice had been going on.Review of Res 1's Emergency Physician Record dated 7/7/14 indicated Res 1 sustained eight lacerations located in the following areas: above the right eyebrow, right cheek, left frontal area above the left eye, left eyebrow, the left frontal scalp, the right chin area, the left forearm above the elbow, and the right arm below the elbow. The Emergency Physician Record indicated steri-strips (thin adhesive strip which can be used to close small wounds instead of sutures) were used to treat the lacerations.On 7/10/14 at 4:25 p.m., during an interview, LN 1 stated on 7/7/14 at 4:45 p.m., she heard a loud yell "STAT"..."(immediate help needed) coming from Res 1's room. LN 1 stated she ran into the room and observed Res 1 on the floor with her head at the foot of the bed. LN 1 stated the reclining chair was against the wall at the foot of the bed. LN 1 stated she saw bleeding coming from the back of Res 1's scalp, right chin area, both lower arms, and inside of the mouth. Res 1's eyes were open and she was grinding her teeth. LN 1 notified Res 1's physician and received a verbal order to transfer Res 1 to the hospital emergency room. LN 1 stated this was not the first time Res 1 was transferred using a twin bed sheet. LN 1 could not say how long the practice of transferring Res 1 with a bed sheet had been going on.On 7/14/14 at 1:45 p.m., during an interview, LN 2 (Resource Nurse - for support and charge duties) stated the facility had no policy and procedure for transferring with bed sheets. LN 2 stated she was aware that Res 1 was being transferred from the bed to the bed side specialized reclining chair by a twin bed sheet. LN 2 stated there was no specialized training provided to CNA's to guide on the technique to transfer with bed sheets. During this interview, LN 2 spoke directly with the Director of Nurses (who was out of the facility) and confirmed the facility did not have a policy and procedure on transferring with bed sheets.Review of annual competency 2014 Checklist for CNA's indicated there was no training for sheet transfers.On 7/14/14 at 3:10 p.m., during an interview, CNA 2 confirmed CNA 1's history of attempting to transfer Res 1 from the bed to the specialized reclining chair. CNA 2 stated Res 1 fell on the floor and ended up with her head at the foot of the bed. When asked how Res 1's head ended up at the foot of the bed, CNA 2 stated "it happened so fast, I can't remember everything ... she was going down and all we could do was assist her."The facility policy and procedure titled "Resident Lift Team", dated 01/14, indicated "Nursing personnel will not lift non-weight bearing [unable to bear weight on legs] residents, except in an emergency situation or if resident is unable to tolerate or be safely lifted using a mechanical device during the shifts for which the Lift Team is scheduled. When the Lift Team is not scheduled, available nursing staff will use a mechanical lift for all non-weight bearing transfers or other approved lifting techniques as determined by the IDT team." On 8/28/14 at 12:30 p.m., during an interview, LN 2 was asked if there was any nursing assessment or discussion regarding the use of sheet transfers for Residents. LN 2 stated "no". The facility failed to provide an environment free from accidents when CNA 1 and CNA 2 attempted to transfer Resident 1 using a bed sheet without appropriate training. Therefore, the facility failed to provide proper training in the transfer of residents using a twin bed sheet and failed to develop and implement a policy and procedure to guide in the technique of transferring and prevention of injury while using a bed sheet.This violation compromised Resident 1's safety resulting in multiple lacerations and Resident harm, and constitutes a class "B" Citation.
040000058	Oakhurst Healthcare & Wellness Centre	040012581	B	16-Sep-16	77UF11	16165	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 facility failed to identify Resident 1's need to have the individualized assessment, care plan, and care planned interventions to minimize the risk for injury based on his pattern of behaviors and diagnosis of neuropathy (a disease affecting one or more nerves, causing numbness, lack of sensation or weakness). These failures resulted in Resident 1's development of avoidable foot injuries including abraded areas to the toes of his right foot, formation of a diabetic neuropathic foot ulcer (a type of wound formation seen in individuals with diabetes) (disorder that affects blood sugar levels) and right foot cellulitis (skin infection) requiring hospitalization, antibiotics and wound care. On 7/29/16, 8/3/16, 8/9/16 and 8/12/16, unannounced visits were made to the facility to investigate Complaint CA00496994 regarding Quality of Care/Treatment. Resident 1's clinical record indicated he was admitted to the facility on 7/20/15 with diagnoses including diabetes, chronic kidney disease stage 4 (kidney failure), peripheral vascular disease (PVD)(narrowing and hardening of the arteries, causing decreased blood flow which can injure nerves and other tissues), and hypertension (high blood pressure). Resident 1's clinical record titled, "History and Physical Examination" dated 7/26/15, indicated a diagnosis of neuropathy. The facility document titled, Minimum Data Set (MDS) assessment, (an assessment used for screening, clinical and functional status and needs for nursing home residents)" dated 5/2/16, indicated Resident 1 had moderately impaired cognitive function (pertaining to long and short term memory deficits). Resident 1 required supervision for bed mobility and transfers. The MDS assessment indicated Resident 1 required assistance for mobility in the wheelchair including limited (guided) assistance to extensive (weight bearing support) from facility staff. The MDS assessment indicated Resident 1 required extensive assistance with personal hygiene. On 7/29/16 at 1 p.m., during an observation and concurrent interview, Resident 1 propelled himself in his wheelchair by using his legs and bare feet. There were no foot rests on Resident 1's wheelchair. Resident 1 had long thick toe nails which extended outward past the top of all five toes of his right foot. Resident 1 had no toes on his left foot due to previous amputation. Resident 1 had four abraded, freshly bleeding areas to the 2nd, and 3rd, 4th and 5th toes on his right foot. Resident 1 stated he had bad eye sight and poor sensation in the foot which affected his ability to see and to feel the abrasions on the top of the right foot. Resident 1 stated he had been a resident in the facility close to one year and had been a diabetic for almost all of his life. Resident 1 stated he had "neuropathy" to both feet. Resident 1 stated he preferred not to wear shoes. On 7/29/16 at 1:35 p.m., during an interview, Certified Nursing Assistant (CNA) 1 stated Resident 1 occasionally became confused requiring re-direction, cues and reminders from staff. CNA 1 stated Resident 1 had the ability to propel himself in his wheelchair by using his legs and feet and did not like to wear shoes. CNA 1 stated Resident 1 received a shower on 7/29/16 around 10:30 a.m., by CNA 2, who discovered the abrasion on Resident 1's foot and informed a licensed nurse (LN), and the LN responsible for performing the treatments ordered for residents. CNA 1 did not provide a response when asked if Resident 1's abrasion to the top of his foot was new or old. CNA 1 did not provide a response when asked if she routinely removed residents' socks to inspect their skin. CNA 1 stated Resident 1 liked going outside and sitting in the sun in his wheelchair, barefoot, on the cement patio. On 7/29/16 at 2 p.m., during an interview, the facility's Social Service Director (SSD) stated she was responsible for tracking podiatry services of the residents in the facility. The SSD stated Resident 1 was on a list she used for her tracking. The SSD stated Resident 1 was not eligible for podiatry services due to a lack of payment for these services by his insurance provider. The SSD stated Resident 1 had not been seen by the Podiatrist (doctor specializing in treatment of the feet) during his service visit to the facility on 5/31/16. The SSD stated she was unsure if Resident 1 had ever received services from the Podiatrist. The SSD stated she had previously spoken to the Podiatrist about providing services to those residents with non-eligible insurance. The SSD stated the facility was required to provide podiatry services as ordered and the facility was responsible for the payment of those services given to residents with non-eligible insurance. Resident 1's clinical record titled, "Physician's Orders" dated 7/20/15, indicated "Podiatry care for mycotic (fungus infected), keratotic (overgrown), and hypertrophic (large) nails." Resident 1's clinical record titled, "Podiatric Evaluation and Treatment" dated 5/31/16, indicated under assessments, "No Elig [not eligible]." On 7/29/16 at 2:20 p.m., during an interview and concurrent record review, the SSD stated Resident 1's physician orders for podiatry services had not been followed. Resident 1's care plan titled, "Diabetes" dated 7/22/15, indicated "...Approach Plan...Podiatry Services as needed." On 7/29/16 at 2:50 p.m., during an observation of Resident 1's foot abrasions and foot ulcer, Licensed Nurse (LN) 2 measured the abraded areas determining length by width by depth on Resident 1's toes and ball of the right foot. Measurements were as follows: The second toe's abraded area measured 4.3 centimeters (cm)-(dry unit of measurement) by 1.8 cm. The third toe's abraded area measured 3 cm by 1.3 cm. The fourth toe's abraded area measured 3.4 cm by 1.9 cm. The fifth toe's abraded area measured 2.2 cm by 1.3 cm. Resident 1's area of eschar (a dry dark scab or falling away of dead skin, caused from injury to the skin) found on the ball of the right foot (below the toes), measured 4 cm by 5.7 cm; the area was dry, black, thick, and leathery with surrounding boggy (soft) edges that were lifting without drainage. There was mild redness throughout the edges of the eschar and throughout the abraded areas of the toes. On 7/29/16 at 3 p.m., during an interview with LN 2, LN 2 stated she was informed by CNA 2 of Resident 1's foot wounds. LN 2 stated Resident 1 had abraded areas to the top of his toes and eschar on the bottom of his right foot. LN 2 stated she did not know how Resident 1 obtained the abrasion to the top of his toes or the eschar formation to the bottom of his foot. LN 2 stated Resident 1 preferred not to wear shoes, and had no foot rest on his wheelchair. On 8/3/16 at 3:05 p.m., during a joint interview with the Director of Nursing (DON) and the Quality Assurance Nurse (QAN), the DON stated Resident 1 had diagnoses that included diabetes, and neuropathy. The DON stated Resident 1 did not have a care plan to reflect Resident 1's diagnosis of neuropathy and there were no interventions identified for the risk of foot injury due to neuropathy. The QAN stated Resident 1 had a risk of injuring his lower extremities because of the lack of sensation to his feet. The DON stated Resident 1 did not like to wear shoes and stated there was no care plan that addressed Resident 1's risk for injury from going barefoot. The DON stated the CNA's were supposed to do head to toe skin checks every shower day but didn't think this was being done. The DON stated Resident 1 should have had a skin assessment done by a LN on 7/25/16 and the assessment should have been documented in a weekly progress note. The DON stated there was no skin assessment or weekly progress note for 7/25/16 in Resident 1's clinical record. The DON stated she did not know how Resident 1 sustained the abrasions and ulcer to his right foot. The DON stated she had observed Resident 1 sitting barefoot on the outside cemented patio in his wheelchair a few days before his hospitalization on 7/29/16. The DON stated she asked Resident 1 to return indoors when she saw him sitting outside. The DON stated when Resident 1 returned indoors she did not inspect his feet for injury after being outside with contact to the hot cement while barefoot. On 8/3/16 at 4 p.m., during an interview, the DON stated Resident 1's foot abrasions and ulcer may have been prevented if the proper interventions had been implemented by the facility staff. The DON stated interventions should have included to keep Resident 1 indoors, ensure the CNA's performed daily skin checks, ensure licensed nurses performed their skin assessments during the completion of the weekly progress notes and ensure Resident 1 wore shoes to protect his feet. The DON was unable to produce documentation the CNA's had completed skin checks for Resident 1. The DON stated she could not say if the CNA's were providing the residents with routine foot hygiene. On 8/3/16 at 4:20 p.m., during an interview, the Physician Wound Specialist (PWS) stated on 8/3/16 was the first time he saw and treated Resident 1's foot wounds. The PWS stated the abrasions to Resident 1's toes were injuries typically seen from having the foot dragged under the wheelchair while being propelled. On 8/4/16 at 10:55 a.m., during a telephone interview, CNA 3 stated she was assigned to care for Resident 1 during the night shift. CNA 3 stated she had never inspected Resident 1's feet. CNA 3 stated she did not typically do this for any of her residents. On 8/4/16 at 11:30 a.m., during a telephone interview, CNA 4 stated she was familiar with Resident 1 and cared for Resident 1 during the evening shift. CNA 4 stated Resident 1 had times of refusing to shower or change clothes. CNA 4 stated if Resident 1 refused to shower she would provide him with a bed bath washing his chest and back, not his feet. CNA 4 stated she did not check Resident 1's feet and had not removed his socks to check his feet when she cared for Resident 1. CNA 4 stated CNA's were not allowed to provide any type of foot or nail care to Resident 1 because of the diagnosis of diabetes. CNA 4 stated Resident 1 did not wear shoes and enjoyed going outside to sit on the cement patio in the sunshine. CNA 4 stated Resident 1 sat outside on the cement patio almost every day and sometimes wore socks, but no shoes. On 8/4/16 at 3 p.m., during a telephone interview, CNA 2 stated she was the CNA who had identified the wound during Resident 1's shower on 7/29/16. CNA 2 stated she was assigned to complete all the daily showers for the residents in the facility and the last time she had seen Resident 1's feet was during his shower on 7/2/16. On 8/4/16 at 5:20 p.m., during a telephone interview, LN 3 stated Resident 1 had episodes of refusing care from the CNA's. LN 3 stated Resident 1 would refuse to shower or change his clothes, sometimes for two to three days. LN 3 stated Resident 1 enjoyed being outside, sitting in the sun on the cement patio during extreme heat. LN 3 stated she understood Resident 1 had diabetes and neuropathy. LN 3 stated she did not make an assertive effort to talk to Resident 1 about the potential complications of his diagnoses and the risks associated with non-compliance to his foot care. LN 3 stated she did not refer Resident 1's noncompliance to the interdisciplinary team (the healthcare team that makes care planning decisions) and had not given Resident 1 an option to accept or decline the use of a foot rest, which would have prevented the resident from propelling the wheelchair with his bare feet. Resident 1's clinical document from the acute care hospital titled, "Discharge Summary" dated 8/2/16, indicated Resident 1 was admitted to the acute care hospital on 7/30/16 with a diagnosis of "right foot cellulitis" and was discharged back to the skilled nursing facility on 8/2/16 after treatment with antibiotics for his right foot infection. Resident 1's clinical document from the acute care hospital titled, "Patient Education" dated 8/2/16, indicated, "Diabetes and foot care. Diabetes may cause you to have a poor blood supply (circulation) to your legs and feet...you may not notice minor injuries to your feet that could lead to serious problems or infections...do not go barefoot. Bare feet are easily injured; check your feet daily for blisters, cuts and redness...wear shoes all the time..." Resident 1's clinical record titled, "Facility acquired...Ulcer Investigation Tool" dated 8/4/16, indicated, "Root cause identified for pressure ulcer development: Diabetic Neuropathy; no sensation of pain, prefers not to wear shoes, noncompliance to diabetic diet, unable to check his own feet, PVD, refusal of showers..." Review of professional reference, "Nerve Damage, Diabetic Neuropathies, 2013", indicated"...Foot Exams. Experts recommend...People diagnosed with peripheral neuropathy need more frequent foot exams. A comprehensive foot exam assesses the skin, muscle, bones, circulation and sensation of the feet...Foot Care. People with neuropathy need to take special care of their feet. Loss of sensation in the feet mean that sores or injuries may not be noticed and may become ulcerated or infected...Careful foot care involves cleaning the feet daily...inspecting the feet and toes every day for cuts, blisters, redness, swelling, calluses, or other problems. Using a mirror-handheld or placed on the floor-may be helpful in checking the bottoms of the feet, or another person can help check the feet...filing corns and calluses gently with a pumice stone after a bath or shower...cutting toenails to the shape of the toes...always wearing shoes or slippers to protect feet from injuries. Wearing thick, soft, seamless socks can prevent skin irritation...wearing shoes that fit well and allow the toes to move. New shoes can be broken in gradually by first wearing them for only an hour at a time...People who need help taking care of their feet should consider making an appointment to see a foot doctor, also called a podiatrist." Review of American Diabetes Association article titled, "Foot Care" dated 10/10/14, indicated, "Prevention:...Because people with diabetes are more prone to foot problems, a foot care specialist may be on your health care team...Caring for Your Feet: Check your feet every day...Wear shoes and socks at all times...Never walk barefoot...Protect your feet from hot and cold...Wear shoes at the beach or on hot pavement...You can burn your feet without realizing it..." The facility policy and procedure titled, "Care Planning" dated 3/1/2014, indicated, "To ensure that a comprehensive Care Plan is developed for each resident. It is the policy of this Facility to provide person-centered, comprehensive...care that reflects best practice standards for meeting health, safety...behavioral and environmental needs of residents in order to obtain or maintain the highest physical, mental and psychosocial wellbeing...a Care Plan may be initiated upon identification of a change of condition or any new needs..." The facility failed to maintain Resident 1's highest physical, mental and psychosocial wellbeing as indicated in their policy and procedure for care planning; that reflect best practice standards aimed at meeting health, safety, behavioral and environmental needs. The facility failed to ensure Resident 1 remained free from developing complications and minimize the risk for injury based on his pattern of behaviors and diagnosis of neuropathy. These failures resulted in Resident 1's development of avoidable foot injuries including abraded areas to the toes of his right foot, formation of a diabetic neuropathic foot ulcer and right foot cellulitis requiring hospitalization, antibiotics and wound care. The above violation had an immediate direct relationship to Resident 1's health, safety and wellbeing and therefore constitutes a Class "B" Citation.
050000058	OXNARD MANOR HEALTHCARE CENTER	050010993	B	02-Jan-15	49VU11	2469	HSC 1418.91(a)(b) - Failure to Report (a) A long-term 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.(b) A failure to comply with the requirements of this section shall be a class "B" violation.The Department determined the facility was in violation of the above statute by it's failure to report to the Department an allegation of suspected sexual abuse involving Resident A to Resident B immediately or within 24 hours.Resident A was admitted to the facility with diagnoses including epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), Anxiety (uneasiness, apprehension), and Cerebral palsy (a condition marked by impaired muscle coordination).The facility's assessment dated 5/12/14 indicated Resident A had no memory problems and was independent in his ability to walk around the facility. On 7/6/14 Resident A called Resident B (a female resident) into his room, grabbed Resident B's hand, and placed it under the sheets to touch Resident A's genitalia. On 7/6/14 the facility sent a fax communication "Sexually Inappropriate Behavior-Alleged" to a physician, requesting for a psychological evaluation for Resident A due to the alleged sexual abuse. The facility's "Resident Grievance/Complaint Investigation Report" indicated on 7/6/14 Resident B's daughter reported to the facility Resident A "grabbed resident's (Resident B) hand and put it under the sheets to hold his (Resident A) private part (genitalia)."During an interview on 8/8/14 at 11:35 a.m., the daughter of Resident B stated "my mother told me about [Resident A] grabbing her hand and making her touch his private area, it was really weird because my mom never talks about those things; so it really worried me."A physician's progress note dated 7/7/14 at 11:15 a.m. indicated the facility called in a psychologist to interview Residents A and B regarding the allegation of sexual abuse. During an interview on 8/7/14, at 5:55 p.m., the facility administrator (ADM) stated that the facility had not reported to the Department (CDPH, L & C) the alleged sexual abuse between Residents A and B. This placed Resident B at further risk of abuse.The violation of this regulation had a direct relationship to the health, safety, or security of residents.
050000058	OXNARD MANOR HEALTHCARE CENTER	050011623	B	29-Jul-16	ZZY411	7723	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. The Department determined, the facility failed to protect Resident 1 from emotional and physical abuse. Resident 1 requested of the facility that certified nursing assistant (CNA 1) not be her caregiver. However, CNA 1 provided care to Resident 1 without supervision. As a result, Resident 1 suffered emotional distress and bruising to her wrist and arms. Review of Resident 1's chart on 6/30/15 revealed, a 76 year old female, re-admitted to the facility on 5/14/15, with diagnoses including kidney disease requiring renal dialysis (process of removing waste products from the blood) and thrombocytopenia (decreased blood cells that help blood clot and therefore causes bleeding and bruising after an injury). Review of a comprehensive assessment dated 4/23/15 revealed, Resident 1 was able to make herself understood and clearly understood others. Resident was cognitively intact (mentally aware) and required extensive assistance of one staff for bed mobility, transfer, and personal hygiene. Review of a plan of care dated 5/15/15 and 5/16/15, related to Resident 1's thrombocytopenia, and risk for injury secondary to osteoporosis (weak, brittle bones), indicated the resident was to be handled gently during care and while assisting to turn, transfer or walk. Review of licensed nurse note, dated 6/23/15 at 7 a.m., indicated, prior to leaving for dialysis at 5:30 a.m., Resident 1 complained CNA 1 attacked her. A call from the dialysis center's social worker (SW) informed the facility that upon arrival at the dialysis center, Resident 1 appeared shaken up and said she [Resident 1] was physically abused by a CNA who pinned her against the bed rail, was on top of her, and took the call light away when she [Resident 1] tried to call for help. At 11 a.m., Resident 1 returned from dialysis complaining of generalized body pain and had a "sad" affect. Review of licensed nurse note, dated 6/24/15 at 11:15 a.m., indicated Resident 1 was seen by a nurse practitioner for complaints of pain in her left wrist and mid-back. At 7 p.m., the nurse practitioner was contacted regarding Resident 1's continued complaints of pain. At 8:30 p.m., the facility documented, Resident 1 had multiple bruises to her upper extremities and left shoulder. At 9 p.m., Resident 1 was taken by ambulance to the emergency room for further evaluation. Review of a psychologist note, dated 6/24/15 at 11:40 a.m., revealed Resident 1 was seen by the psychologist because the resident reported being handled in a rough manner by a CNA who pushed her into the side rail and used inappropriate language, "have to turn over so I can clean your ass." The psychologist's note indicated Resident 1 was crying throughout the session and became increasingly distressed while relaying the events. During an interview on 7/7/15 at 11:30 a.m., utilizing CNA 4 as a Spanish speaking interpreter, Resident 1 indicated, two weeks ago, before dialysis, CNA 1 came into her room mad. CNA 1 told Resident 1 to turn over so she (CNA 1) could "clean her [Resident 1's] ass." Resident 1 indicated, CNA 1 was on top of her and caused Resident 1 to hit her right arm against the side rail causing bruises. Resident 1 stated, she used to like the door to her room closed at night, but after the incident with CNA 1, she's now afraid to have the door closed at night. During an interview on 6/30/15 at 9:15 a.m., the social worker (SW) confirmed, Resident 1 arrived at the dialysis center the morning of 6/23/15, "upset," "tearful," and "shaky." SW described Resident 1 as alert and oriented, with a good memory, and was calm and cooperative. Resident 1 told SW, on 6/23/15 a new night shift staff came to help her [Resident 1] get ready for dialysis and the staff pinned the resident to the bed and snatched the call button away telling the resident no one was going to help her. SW indicated, Resident 1 had visible red bruising on her left forearm and right hand. During an interview, on 6/30/15 at 5 p.m., CNA 1 indicated, she was not assigned to Resident 1, but was helping another CNA by getting the resident ready for dialysis. CNA 1 assisted Resident 1 to turn over and the resident started screaming and calling for the nurse. Resident 1 sat up on the edge of the bed and told CNA 1 bruised her arms. CNA 1 stated, "Before I touched the resident she said she didn't want to see me." During an interview on 6/30/15 at 5:15 p.m., the director of staff development (DSD) indicated, CNA 1 cared for Resident 1 once previously and the resident reported she didn't like CNA 1. Based on this, the DSD decided CNA 1 needed more training. The DSD stated, "CNA 1 was not supposed to be in the resident's room without additional staff." During an interview on 7/2/15 at 7 a.m., CNA 3 indicated, she was asked to help Resident 1 because the resident was "mad" with CNA 1. When CNA 3 entered the room, Resident 1's was mad and screaming to fire CNA 1. Resident 1 complained, CNA 1 pushed her [Resident 1] into the siderail. CNA 3 confirmed, Resident 1 had bruises and redness on both arms. During an interview on 7/2/15 at 7:30 a.m., CNA 2 indicated she was in another resident's room when told to go help with Resident 1. CNA 2 indicated when she entered Resident 1's room the resident was sitting on the edge of the bed and there were bruises on the resident's arms. During an interview, on 7/2/15 at 8:10 a.m., a licensed nurse (LN 1) indicated on the morning of 6/23/15, he was across the hall from Resident 1's room when he heard Resident 1 crying. The door to the resident's room was partially closed and he heard raised voices like the resident was having an argument in Spanish. When LN 1 entered the room, Resident 1 was sitting on the edge of the bed and CNA 1 was standing near the resident. CNA 1 told LN 1, Resident 1 didn't want her [CNA 1] taking care of the resident. LN 1 indicated, he could see Resident 1 was upset so he asked that CNAs 2 and 3 to assist with the resident and dismissed CNA 1 from the room. Resident 1 indicated CNA 1 grabbed her [Resident 1's] arms and was rough. LN 1 observed quarter size red spots on Resident 1's forearms during the pre-dialysis assessment. When shown a photograph, taken on 6/23/15, of Resident 1's right forearm, LN 1 confirmed the three bruises closest to the resident's right wrist corresponded with the location of the red spots he observed the morning of 6/23/15. During an interview, on 6/30/15 at 1:30 p.m., the director of nursing (DON) indicated Resident 1 was her own responsible party, was alert and oriented, and a good historian. According to the DON, CNA 1 was orienting with CNA 2. CNA 1 was directed to provide care only under the direct supervision of CNA 2. Resident 1 doesn't like to be touched, and gets agitated with new staff. When describing the incident CNA 1 said Resident 1 was verbally abusive and asked CNA 1 to leave. The DON confirmed Resident 1 did not have any bruises when the resident left the facility for dialysis on 6/23/15 but only new red spots. The facility was aware that Resident 1 gets agitated with new staff. Resident 1 requested the facility not to assign CNA 1 to be her direct care giver. The facility knew or should have known not to assign CNA 1 to be Resident 1's direct care giver, with or without supervision. Failure to implement Resident 1's request had resulted to Resident 1's emotional distress and physical harm. The violation of the regulation has caused or occurred under circumstances likely to cause, significant humiliation, indignity, anxiety, or other emotional trauma to the resident.
050000141	Ojai Valley Community Skilled Nursing Facility	050012340	A	8-Aug-16	EH4U11	5994	Title 42 of the Federal Code of Regulations, 483.25 (h) (1) and (2) Accidents (h) 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 determined the facility failed to provide an environment free of accident hazards, and failed to provide adequate supervision, and effective use of assistance devices to prevent injury for Resident 1. Resident 1 was identified to be at high risk for falls, with a history of removing the tab alarm (warning system attached to clothing with a clip used to alert staff) and getting out of bed unassisted. The bed pad alarm was not checked if it was operating properly, per facility policy. As a result, Resident 1 attempted an unassisted transfer from the bed and sustained a right knee fracture. Resident 1 was a 93 year old female, admitted to the facility on 11/30/15 for physical therapy due to previous fall and right ankle fracture. Review of the comprehensive assessment, dated 12/9/15, revealed Resident 1 had diagnoses to include dementia (progressive loss of memory and reasoning ability) and history of falls. Resident 1's cognition (mental awareness) was severely impaired, needed extensive assistance of staff for transfers and bed mobility, and was frequently incontinent of urine and bowel. Review of the fall risk assessment, dated 11/30/15, revealed Resident 1 was a high risk for fall due to falls prior to this admission and dementia, to name a few. Review of the plan of care initiated on 12/01/15 (before the fall on 2/22) indicated "Bed pad alarm when in bed" to alert staff when Resident 1 attempts to get out of bed unassisted. "Tab alarm in wheelchair" (W/C) to alert staff when Resident 1 attempts to get out of W/C unassisted. During an interview on 3/7/16 at 12:20 p.m., the director of nursing (DON) explained, on 2/22/16 around 7 a.m., Resident 1 got out of bed unassisted and had an unwitnessed fall. According to the DON, the tab alarm and bed pad alarm (weight activated pad that will alarm if body weight is removed from the pad, and no weight is detected) did not go off. Resident 1 was found in her room, on the floor next to her bed by facility staff. Review of the facility policy and procedure titled "Tab and Pad Device Use" dated 2/7/13, indicated, "...When certified nursing assistants CNA's [certified nursing assistants]are rounding at the beginning and end of their shifts [checking residents assigned], the devices will be checked to see if they are intact and functioning properly..." During an interview on 3/22/16 at 11:05 a.m., CNA 1 acknowledged, during her shift and before Resident 1's fall incident on 2/22/16, she did not check (at the beginning 10:45 p.m., nor prior to giving the day shift CNA report, around 7 a.m.) the bed pad alarm for proper functioning and connection, as was facility policy. CNA 1 acknowledged, she and the morning CNA (CNA 2) were in the hallway during the morning report. CNA 1 explained, Resident 1 was always "taking off her tab alarm." During an interview and concurrent observation with CNA 2, on 3/7/16, at 1:25 p.m., CNA 2 explained on the morning of 2/22/16, at approximately 7 a.m., when Resident 1 fell, CNA 2 heard Resident 1 screaming "help" from her room. At that time, CNA 1 (night CNA) and CNA 2 (day CNA) were exchanging report at the nursing station, approximately 10-15 feet away from Resident 1's room and not within line of sight of Resident 1's room. CNA 2 explained the facility practice was to give and receive report "inside resident's room." CNA 2 went to Resident 1's room and found Resident 1 on the floor. CNA 2 explained not hearing the tab alarm and bed pad alarm warning sounds prior to or after Resident 1 fell. CNA 2 confirmed the bed pad alarm was not connected between the green (battery) box and the cord connected to the pad alarm. CNA 2 further explained and demonstrated (on Resident 1's bed) that on the date of the fall, 2/22/16, Resident 1's bed pad alarm was on top of the mattress, a cable connecting the bed pad alarm to the battery box was "tucked" underneath the bed mattress, and a fitted sheet was on top covering the entire mattress. The battery box was hanging on the right side rail. The cable connecting the bed tab alarm to the green battery box was not connected. During an interview on 3/10/16 at 12:35 p.m., restorative nursing assistant (RNA) explained, Resident 1 constantly was trying to get up from the wheelchair and take off the tab alarm. RNA explained that the tab device clips would be off most of the time. During an interview on 3/7/16, at 2:49 p.m., license nurse (LN 3) explained on 2/22/16 at around 7 a.m., LN 3 responded to CNA 2's request for assistance in Resident 2's room. LN 3 reported not hearing any of the tab and pad devices alarming or sounding when she walked into the room. LN 3 stated, "Tab alarm on bed not connected to resident [Resident 1] because she takes them off all the time." During an interview on 3/22/16 at 11:17 a.m., LN 1 explained, on the night of 2/22/16, LN 1 did not check Resident 2's tab alarm and bed pad alarm to see if they were connected and functioning during her night shift. LN 1 indicated Resident 1 was always taking off her tab alarms. Review of Resident 1's X-ray of the right knee dated 2/22/16 revealed, fracture of the lateral tibial plateau (fracture at the top of the lower leg bone affecting the knee joint). The facility knew or should have known Resident 1 frequently removed her tab alarm and attempted to get out of the bed without assistance of staff. The facility failed to monitor the proper functioning of the bed pad alarm, per facility policy, as a safety precaution. As a result, Resident 1 sustained a fracture. These failures presented either imminent danger of death or serious harm to patients or substantial probability of death or serious physical harm to patients.
630011658	OakView Skilled Nursing	050012343	A	28-Jul-16	ZSD611	3740	Title 42 of the Federal Code of Regulations 483.25 (h)(1) and (2) 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 determined the facility failed to provide adequate supervision and assistive devices to prevent an injury related to Resident A falling. Resident A was assessed to be at a high risk of falls, and had a history of multiple falls prior to and during her stay in the facility. As a result, Resident A suffered a traumatic brain injury (subdural hematoma -swelling and bleeding of the brain) and is dependent on staff. Resident A was an 88 year old female, admitted to the facility with the diagnoses including dementia (progressive decline in memory and thinking skills), muscle weakness, abnormal gait, and history of falls. A comprehensive assessment dated 1/17/16, revealed Resident A was alert but forgetful, required assistance for bed mobility, transfers, ambulation and incontinent of urine. Review of the fall risk assessment dated, 1/10/16, 3/01/16, and 4/18/16 indicated, Resident A was identified as a high risk for falls due to balance problems, inability to ambulate, urine incontinence, use of multiple medications, and history of falls. Review of the nurses notes dated 1/12/16 to 5/6/16, indicated, Resident A was alert with "forgetfulness and confusion." The nurse's notes also indicated the resident fell on 1/14/16, 3/1/16 and again on 5/6/16. The 5/6/16 fall resulted in Resident A hitting her head and suffered a brain bleed, as a direct result of the fall. During a concurrent record review and interview on 6/2/16 beginning at 11:45 a.m., the Director of Nurses (DON) indicated the investigation surrounding Resident A's falls revealed, the 1/14/16 fall was from the bed to the floor. The fall precaution interventions were changed to include a tab alarm (safety device). Resident A's fall on 3/1/16 was also from the bed to the floor. The interdisciplinary notes (IDT) dated 4/14/16 indicated, no discussion occurred regarding Resident A's January and March falls nor was there an exploration of other alternative fall prevention measures. No further revisions or updates were noted in Resident A's plan of care. On 5/6/16, Resident A fell again from the bed to the floor, sustaining a head injury and was transported to the hospital. The facility was unable to produce evidence to indicate the tab alarm was in use during May 2016 fall incident. The DON confirmed that neither floor pads, bed alarms, personal alarms, nor any sensing devices were in place when the 5/6/16 fall occurred. Review of the facility's policy and procedure titled," Fall Intervention Policy and Procedure", dated 11/1/15, indicated, "The policy is to ensure a safe environment..." The steps necessary, following a fall, are to review and update causative factors related to the fall; nursing staff will determine interventions necessary, and initiate or update the plan of care to "Prevent reoccurrence of a fall or to minimize injury." During an interview on 6/16/16, at 10:45 a.m., the DON and Director of Staff Development (DSD) confirmed the facility did not follow the fall policy related to Resident A's fall incidents. The facility knew Resident A was a high risk for falls, but failed to revise the plan of care and failed to provide the appropriate assistive devices to prevent injury related to a fall. As a result, Resident A sustained a traumatic brain injury. These failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.
060001591	OLIVE STREET NORTH HOME	060013100	B	3-Apr-17	53PH11	4492	W331 - The facility must provide clients with nursing services in accordance with their needs. On 1/23/17, the facility reported an incident to the California Department of Public Health (CDPH) alleging Client 1's toe was slightly bruised and appeared to be swollen. The report showed Client 1 was brought to an urgent care center and had an x-ray of the right foot. The x-ray results showed Client 1's toe had a fracture. On 2/28/17 at 0730 hours, an unannounced visit was made to the facility to conduct a recertification survey and investigate the above Entity Reported Incident (ERI). Clinical record review for Client 1 was initiated on 2/28/17. Client 1 was a 72 year old woman with diagnoses including profound intellectual disability (person with an Intelligence Quotient score of less than 20). Client 1 was nonambulatory, mobile via staff propelled manual wheelchair, non-weight bearing, and dependent on facility staff for all transfers. Client 1 was nonverbal and completely dependent on facility staff for her health care needs. On 2/27/17 at 0908 hours, an interview was conducted with the Registered Nurse (RN). The RN stated a cut on Client 1's right first toe was discovered by the facility staff on 1/5/17, when the client returned from the day program. The RN stated she assessed the client and informed the physician on 1/5/17, and the physician ordered to transport the client to the urgent care center. The RN stated there was no one available that late on that day to transport the client to the urgent care center, so she was taken to the urgent care center on 1/6/17. When Client 1 was seen at the urgent care center on 1/6/17, an x-ray of her right foot was recommended and the client was transported to an acute care hospital to have the x-ray taken. The RN stated she requested the x-ray results of the right foot multiple times, but she did not receive the x-ray results until 1/19/17, 13 days later. The x-ray results showed the client had a fracture to the right first toe. During a later interview and concurrent clinical record review with the RN on 2/27/17 at 1500 hours, the RN was asked if she had documented any of her attempts to obtain the x-ray results prior to obtaining them on 1/19/17. The RN reviewed her notes and verified she had not. During an interview with Direct Care Staff (DCS) 1 on 2/28/17 at 1251 hours, DCS 1 stated she was working with DCS 2 on 1/3/17, when DCS 2 observed Client 1's foot bleeding. DCS 1 stated they noticed Client 1's foot was bleeding when she was sitting in her wheelchair in the living room after dinner and they informed the RN. DCS 1 presented documented evidence showing she informed the RN on 1/3/17 at 1758 hours, that Client 1 was bleeding from the interdigital space between her first and second toes on her right foot. Review of the Nurse's Notes failed to show the RN completed an assessment of Client 1's right foot on 1/3/17, after being informed of the injury. The RN did not assess the client until 1/5/17. Review of the right foot x-ray results dated 1/6/17, showed Client 1 had a fracture involving the base of the proximal first phalanx (largest bone in the toe). Documentation on the x-ray report showed the x-ray result was sent via fax to the facility on 1/19/17. Review of the Nurse's Notes dated 1/19/17, showed the primary care physician was notified of the x-ray result and the primary care physician ordered for an orthopedic (medical specialty concerned with correction of deformities or functional impairments of the skeletal system) consultation for evaluation. On 1/25/17, Client 1 was seen by the orthopedist (specialist in conditions and diseases of the bones, joints, and spine) with recommendations for the client to wear the clog shoes at all times and for follow up in four weeks. The facility failed to ensure the RN promptly assessed Client 1 when she was informed of the client's injury on 1/3/17. The RN did not assess the reported injury until 1/5/17, Client 1 was not taken to the urgent care center until 1/6/17, and the RN did not obtain the right foot x-ray results until 1/19/17. These failures resulted in Client 1 not being assessed by the RN for two days after the injury, no diagnostic test of the injury for three days, and did not receive treatment of the injury for 16 days. The above violations, either jointly, separately, or any combination had a direct or immediate relation to patient health, safety, or security.
070000868	O'CONNOR HOSPITAL D/P SNF	070009756	AA	05-Mar-13	I7KF11	8217	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 ensure the resident environment remained free of accident hazards for one of one sampled resident (1) when Resident 1's ventilator (a machine that provides breaths to the lungs via an artificial opening in the neck [tracheostomy]) was left in standby mode (machine remains on but delivery of air to resident and disconnect/safety alarms are suspended). Resident 1 was found unresponsive and lifesaving measures were initiated. The resident was transferred to the intensive care unit for a higher level of care. The resident expired soon after.Resident 1 was admitted to the facility on 8/14/12 with diagnoses including amyotrophic lateral sclerosis (ALS - a progressive disease that affects the brain's ability to initiate and control muscle movement, in later stages of ALS the muscles involved with breathing begin to deteriorate and the act of breathing is no longer automatic) and quadriplegia (paralysis of the arms and legs) and required mechanical ventilation (breathing by ventilator). Review of Resident 1's ventilator settings ordered by Physician 1 (PH 1) dated 8/14/12 indicated MODE ACVC (assist control/volume control) [ventilator provides a full breath for every breath attempted by the resident] at a Tidal Volume (size of each breath) of 450 milliliters per breath.On 2/19/13 at 10 a.m. review of Resident 1's minimum data set (MDS resident assessment and care screening form) dated 12/26/12 indicated Resident 1 had memory problems, and moderately impaired decision making capacity for tasks of daily life. The MDS further indicated Resident 1 was fully dependent on staff for bed mobility and activities of daily living.In an interview on 1/10/13 at 10 a.m., Respiratory Therapist 1 (RT 1) stated he provided care for Resident 1 since her admission to the facility and was familiar with the resident. RT 1 further stated although Resident 1 required mechanical ventilation she was able to breathe on her own for minutes at a time. On the morning of 12/26/12 at approximately 9:10 a.m. RT 1 performed tracheostomy care for Resident 1. Tracheostomy care per RT 1 included cleaning the tracheostomy site and changing the inner tracheostomy cannula. The tracheostomy device has an outer cannula to maintain the patency of the airway and an inner cannula that fits snugly inside the outer cannula that can be removed for cleaning and removal of accumulated secretions without disturbing the operative site.RT 1 further stated during the procedures the ventilator was changed to standby mode prior to disconnecting the resident from the ventilator. RT 1 stated he disconnected the resident from the ventilator for a couple of seconds during the procedure and then reconnected the resident to the ventilator. After the tracheostomy (trach) care was completed, RT 1 stated he deflated the tracheostomy cuff (a balloon around the distal end of the cannula which forms a seal between the tracheostomy tube and the trachea when the cuff is inflated) so Resident 1 could speak but the resident turned her head away and appeared to fall asleep. RT 1 further stated it was not unusual for Resident 1 to withdraw at times by turning away her head. RT 1 re-inflated the cuff and proceeded to the next resident.RT 1 also stated during the above interview he was called back into Resident 1's room by her primary nurse (LVN 1) at approximately 9:25 a.m. because the resident was non-responsive. RT 1 stated he attempted to stimulate the resident but was unsuccessful. Resident 1's pulses were difficult to palpate (unable to find a pulse) and therefore he initiated cardiopulmonary resuscitation (CPR) (an emergency procedure in which the heart and lungs are made to work manually). During the emergency event, RT 1 and LVN 1 noticed the ventilator was on standby mode (machine on, but not ventilating the resident). When asked, RT 1 stated he did not recall if he placed the machine back on ventilating mode after completing Resident 1's tracheostomy care. In an interview on 1/10/13 at 11 a.m., LVN 1 stated that on 12/26/12 at approximately 9:15 a.m. she went into Resident 1's room to give her medications. Once she arrived in the room she noticed Resident 1 was unresponsive and immediately called the charge nurse and RT 1 into the resident's room for assistance. Due to Resident 1's condition a code blue (medical emergency in which a team of medical personnel work to revive an individual in cardiac arrest) was called for Resident 1. LVN 1 stated she noticed Resident 1's ventilator was on standby mode.On 1/10/13 at 11:15 a.m. a review was conducted of LVN 1's note dated 12/26/12 at 9:30 a.m. LVN 1 documented she "went to resident room to give morning medications at 9:25 a.m. found resident unresponsive, no pulse noted called respiratory therapy for help, called charge for help, called code blue. "On 1/10/13 at 11:30 a.m. review of Resident 1's discharge summary note dated 12/28/12 by Physician 1 (PH 1) indicated the resident was transferred to the intensive care unit on 12/26/12 for respiratory and cardiac arrest. The note further indicated Resident 1 "had been stable in the subacute unit for several months...She had been doing well on her ventilator until today...Neurologically she is intact". The note further indicated the resident "had a respiratory arrest as the vent was not functioning for her and then went into cardiac arrest...when she was noticed, she was pulseless and a code blue was called." On 1/10/13 at 11:45 a.m., review of Resident 1's consultation report by Physician 2 (PH 2) dated 12/28/12 indicated on 12/26/12 "a trach change was completed but there were some complications with the ventilator after the trach change and the resident went into respiratory arrest." On 1/10/13 at 12 p.m. further review of Resident 1's medical record indicated the resident's condition worsened in the intensive care unit and Resident 1 passed away on 12/28/12 at 10:03 p.m. On 1/10/13 at 12:30 p.m. during a telephone interview with PH 1, he stated prior to the event on 12/26/12 Resident 1 was able to breathe on her own (without the ventilator assistance) for minutes at a time. PH 1 stated he could not say for certain if the cause of Resident 1's respiratory event was due to the ventilator being left on standby mode. PH 1 further stated Resident 1's cause of death was brain anoxia (brain does not receive adequate oxygen), secondary to acute respiratory failure (resident's lungs do not provide adequate ventilation to the body).On 2/19/13 at 7:14 a.m. via a fax, the risk manager indicated the facility did not have a policy and procedure regarding use of the standby mode for ventilators. According to the American Association for Respiratory Care Clinical Practice Guideline from the August 1992 issue of Respiratory Care (http://www.rcjournal.com/cpgs/mvsccpg.html), MV-SC1.0 Procedure: Patient Ventilator Check, MV-SC 2.0 Description: A patient-Ventilator system check is a documented evaluation of a mechanical ventilator and of the patient's response to mechanical ventilatory support. MV-SC 2.3 All data relevant to the patient-ventilator system check must be recorded...and include observations indicative of the ventilator's operation at the time of the check. Observations should include...2.3.1 observation that the ventilator is turned on and that the patient circuit is securely attached. 2.3.2.2 OVP [operational verification procedure] should be performed at the bedside just prior to connection to the patient after the patient circuit has been changed or disassembled for any reason. MV-SC 4.0 Indications: ...In addition, a check should be performed 4.3 following any change in ventilator settings. The facility's failure to ensure the resident environment remained free of accident hazards when Resident 1's ventilator was left in standby mode after tracheostomy care presented an imminent danger to the patient and was a direct proximate cause of the death of the patient.
110000084	Orchard Post Acute Care	110009258	A	12-Dec-13	WF6711	7398	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 to prevent accidents, for Resident 1 who was at risk for falling. This failure resulted in Resident 1 falling from the wheelchair twice (6/24/11 and 8/04/11), sustaining a hematoma to her forehead twice and a probable brain bleed identified 6/25/11 with the potential for serious disability and death.Resident 1 is a 79 year old female, admitted to the facility on 7/12/07, with diagnoses including altered level of consciousness and previous cerebral vascular accident (stroke).During an observation on 8/17/11 at 10:45 a.m., Resident 1 was sitting in the facility dining room in a Geri-chair (a large heavily padded wheelchair with a high back and a foot rest that can be elevated. It can not be self propelled.) A greenish discoloration was observed above Resident 1's left eyebrow, extending the length of the eyebrow and up into the hairline.Review of a Minimum Data Set (MDS/assessment tool) dated 6/8/11, indicated Resident 1 had short and long term memory problems, rarely understood others and was totally dependent upon staff for activities of daily living (ADLs: moving in bed, transferring surfaces, moving between locations, dressing, eating, personal hygiene and bathing). Fall risk assessments of 12/10 and 3/11 document fall risks of 14 and 12. The form indicated that 10 or above represents high risk of falls. A long term care plan titled, "Risk for Injury," dated 2/26/10, indicated Resident 1 was at risk for injury due to poor balance, limited mobility, and lack of awareness, and history of falling. Interventions identified on the care plan included call bell within reach and assist resident as necessary.Review of a document that was titled "Post Fall Investigation" revealed that Resident 1 experienced a fall on 6/24/11. During an interview on 8/30/11 at 12 noon, Certified Nursing Assistant (CNA) B stated he was caring for Resident 1 on 6/24/11. He stated he put Resident 1 in her wheelchair sometime before lunch and positioned her in the hall. He further stated someone had moved the resident; he went to the facility dining room where he found Resident 1 on the floor on her left side. A CNA on the other side of the dining room could not see Resident 1, but heard her, turned and saw her.Review of the "Post Fall Investigation", dated 6/24/11, contained documentation that the resident was leaning forward in wheel chair and the alarm was activated, as the patient hit the floor. The investigation also reflected that the resident tended to lean forward. A history and physical of 6/24/11, that was done post fall at the acute care hospital, documented abrasions and hematoma (a localized swelling filled with blood), with a current diagnosis of questionable hemorrhagic contusion (an area of injured tissue in which blood vessels have been ruptured) of the right frontal lobe of the brain. A care plan update, of 6/25/11, was completed due to a fall risk assessment score of 14 and history of mechanical fall. Interventions identified on the care plan included: call bell and personal items within reach; provide assistance with transfer and mobility and an alarm in wheel chair to alert staff if resident is attempting to get up. The care plan lacked interventions specific to Resident 1 leaning forward in her wheel chair and the subsequent risk for falling.During an interview and concurrent record review, on 8/18/11 at 4:50 p.m., Resident 1's physician stated Resident 1 suffered a hemorrhagic contusion of the right frontal lobe of her brain as a result of the 6/24/11 fall. Resident 1's physician stated, "Anytime someone hits their head they get some kind of damage," and Resident 1 should be watched closely. Resident 1 experienced a second fall on 8/4/11. The clinical record, reviewed on 8/17/11 at 10:30 a.m., contained a physician's progress note, dated 8/4/11, which indicated the physician was asked to see Resident 1 because she leaned forward and fell out of her wheel chair, which landed on top of her. The physician documented Resident 1 was crying, complaining of dizziness and had a "large" hematoma on her forehead.During an interview, on 8/18/11 at 11 a.m., CNA C stated that on 8/4/11 she heard the alarm beeping and ran into the dining room, where she found Resident 1 face down on the floor with her wheel chair on top of her. She also stated that Resident 1 "always" leaned forward in her chair. During interview and concurrent document review on 8/17/11 at 10:35 a.m., Licensed Nurse D stated he documented, Resident 1 had an area of swelling on her left forehead which measured 6 centimeters (cm), approximately 2 1/2 inches X 5 cm X 1 cm. on a "Skin Condition Record," dated 8/5/11. He stated a greenish discoloration surrounded the area of swelling.Continued review of the record included review of a "Post Fall Investigation," dated 8/4/11, which indicated Resident 1 was in her wheel chair and wearing a personal alarm when she fell the second time. The response to the question, "What have you learned?" was, "...Resident has tendency to lean forward..." The long term care plan titled, "Falls Care Plan," dated 6/28/11, was updated 8/5/11 with a new intervention, "Resident will be on Geri-chair today,". A facility document, "Fall Prevention Program," dated 8/17/07, indicated the purpose of the program was, "To improve or maintain the quality of life for facility residents by properly assessing their risk for falling, providing adequate interventions to minimize that risk and evaluating the effectiveness of those interventions." The plan included; on-going assessment, updating the care plan with "any" change in condition, identifying causative factors and "accelerating" the care plan with new interventions to prevent further falls. Review of the facility policy titled, "Falls - Clinical Protocol," dated 4/07, revealed it was the facility policy to; identify the cause of falls, identify "pertinent" interventions to try to prevent subsequent falls, and address risks of, "Serious consequences of falling." During an interview and concurrent record review on 8/18/11 at 10:40 a.m., the Medical Records Supervisor reviewed Resident 1's entire clinical record and stated the clinical record lacked documented evidence of a care plan specific to the potential for falls 2/26/10 - 6/28/11.During an interview on 8/30/11 at 2:50 p.m., the Director of Nursing (DON) stated Resident 1 fell twice (6/24/11 and 8/4/11) when seated in her wheel chair, unsupervised. The DON further stated facility staff did not provide supervision for Resident 1 when she fell from her wheel chair on 6/24/11 or 8/4/11. Therefore, the facility violated the regulation when facility staff failed to provide supervision to prevent accidents for Resident 1 (who was at high risk for falling). This failure resulted in Resident 1 falling from her wheelchair twice (6/24/11 and 8/4/11), sustaining a hematoma (twice) and a brain bleed, and the potential for death.These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.
110000084	Orchard Post Acute Care	110011788	B	10-Nov-15	N4GW11	5505	Health & Safety Code 1418.91(a) (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.Health & Safety Code 1418.91(b) (b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report an allegation of physical abuse to the Department of Public Health, State Licensing and Certification Agency immediately or within twenty-four hours. This failure resulted in the Department's inability to independently investigate the abuse allegation without delay, had the potential for Resident 10 and other residents to be exposed to further abuse and likely continued to cause fear and anxiety to residents who had heard about the incident and saw that the perpetrator was not removed from resident care immediately following the incident. The Department's Intake Information form, dated 10/6/15, indicated that the facility (Administrative Staff A) reported an allegation of visitor to resident abuse. The incident occurred on 10/3/15. During a review of the clinical record for Resident 10, the Face Sheet (admission record) indicated that Resident 10 was a 60 year old female, who was admitted to the facility on 10/18/13. The Minimum Data Set (MDS) (an assessment tool) Section I, dated 7/27/15, indicated multiple active diagnoses including quadriplegia, rheumatoid arthritis, and muscle weakness. Section C - Cognitive Patterns, Brief Interview for Mental Status (BIMS) indicated a summary score of 15/15 (15 denotes the resident was able to understand and is oriented to year, month and day). During an interview on 10/8/15, at 11:00 a.m., Resident 10 stated that while she was sitting in her wheel chair in her room, Visitor A entered her room, he kissed her on the right cheek with his lips and placed his hand down her shirt and touched her left breast. Resident 10 stated that this had happened last Saturday afternoon (10/3/15). The 10/3/15 incident was reported to CDPH and to Administrator A on 10/6/15. During an interview on 10/7/15 at 8:40 a.m., Licensed Staff G stated she became aware of the incident from Resident 10 at the end of her shift on Saturday (10/3/15). She stated Resident 10 told her about the incident with Visitor A. She stated she interviewed Resident 10 about the incident and at that time counseled Resident 10 she needed to report this to the administrator. She stated she did not report Resident 10's allegations to administration at the time she became aware of the incident on 10/3/15 and now knows she should have.During an interview on 10/8/15 at 12:05 p.m., Unlicensed Staff H stated she became aware of the incident from Resident 10 at the beginning of the evening shift shift on Saturday (10/3/15). She stated Resident 10 told her about the incident with Visitor A. She stated she did not report Resident 10's allegations to administration at the time she became aware of the incident on 10/3/15 and now knows she should have. The facility policy and procedure titled "Reporting Abuse to Facility Management," not dated, indicated "It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source, and theft...to facility management... Employees, facility consultants and/or attending physicians must report any suspected abuse or incident of abuse to the director of nursing service promptly. In the absence of the director of nursing service such reports may be made to the nurse supervisor on duty...The administrator and director of nursing services must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the administrator and director of nursing services must be called as home or must be paged and informed of such incident." The facility policy an procedure titled "Reporting Abuse to State Agencies and Other Entities/Individual," not dated, indicated "1. Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse... be reported, the facility administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility...2. Verbal/written notices to the above agencies will be made within 24 hours of the occurrence of such incident and such notice may be submitted via US mail..." The facility's follow-up investigation letter, dated 10/9/15, indicated the charge nurse (Licensed Staff G) was aware of the concerns of inappropriate behavior by Visitor A kissing Resident 10 on the cheek and touching of her breast.The Department's investigation identified that the facility failed to report an allegation of physical abuse to the Department of Public Health, State Licensing and Certification Agency in a timely manner. This resulted in the Department's inability to independently investigate the abuse allegation without delay. This practice had the potential for Resident 10 and other residents to be exposed to further abuse and likely continued to cause fear and anxiety to residents who had heard about the incident and saw that the perpetrator was not removed from resident care immediately following the incident.
230000221	Oroville Hospital Post-Acute Center	230008706	B	20-Nov-12	Y0YI11	15457	F 329 483.25(I) DRUG REGIMEN IS FREE FROM 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. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. The facility failed to ensure Patient 1 was free from unnecessary drugs when multiple psychotherapeutic (related to the treatment of mental and emotional disorders) medications, and Vicodin (an opiate-containing pain medication) were administered for behaviors identified by the facility as related to recurrent urinary tract infections (UTIs). Additionally, the facility failed to recognize, report, and address adverse side effects; repeated falls, recurrent UTIs, increased agitation and aggression, confusion, wandering and increased sedation, that Patient 1 demonstrated from the use of multiple psychotherapeutic medications. Patient 1 was admitted to the facility on 2/9/09 with diagnoses that included dementia (a brain disorder of behavior and intellectual function), Parkinson's disease (a brain disorder that includes progressive loss of control of movement and coordination), abnormal gait (walk), mental disorders of psychosis, depression, anxiety, mood disorder, and behavior, and a history of prostate cancer.On 8/17/11, 8/26/11, and 9/13/11, a review of Patient 1's clinical record indicated the following: The August 2011 Physician Order Sheet and Medication Administration Record (MAR) listed medications administered to Patient 1 that included: Effexor, an antidepressant medication; Ativan, an antianxiety medication; Risperdal, an antipsychotic medication; Divalproex Sodium Extended Release (ER), a mood stabilizer; and Vicodin, an opiate (narcotic) containing pain medication. The physician ordered injections of Haldol, an antipsychotic medication, on four occasions between 5/13/11 and 8/21/11 for acute agitation (striking out at staff and Patients). Patient 1 also received Seroquel, an antipsychotic medication, for combativeness. A physician discontinued the Seroquel on 10/19/10 as it, "was ineffective." According to Lexi-Comp ONLINE, a nationally recognized medication reference resource, Risperdal, Haldol and Seroquel, all had anticholinergic (a drug classification) adverse side effects including urinary retention/hesitancy (the bladder abnormally retains urine), urinary tract infection (UTI), sedation/drowsiness, increased falls/dizziness, confusion, anxiety/agitation, and akathasia (a pattern that included uncontrolled movements, restless over activity, and pacing).Vicodin also had adverse side effects that included urinary retention, and dysuria (difficult or painful urination).Additionally, Vicodin, Haldol, Ativan and Risperdal are central nervous system depressants, lending to sedation/drowsiness, increased falls/dizziness, and anxiety/agitation. An Incontinence (inability to control urine flow) Care Plan (CP) for Patient 1, started 7/21/10, and most recently reviewed 7/25/11, included his problems of "urine incontinence: daily with some control," and "bowel incontinence 2-3 times a week." To carry out the plan of care, staff was to, "assist with toileting, bedpan, urinal every two hours and as needed." An Elimination Care Plan, started 8/8/11, listed "chronic UTIs" as a problem, and instructed staff to check Patient 1 every two hours for stool and urine incontinence and to provide incontinence care as needed. IDT (Interdisciplinary Team) Notes, dated 3/24/11, documented, "...Patient also has a long standing history of chronic UTI's. He has a tendency to have aggressive behaviors, especially when he has a UTI...Patient was last treated for a UTI with antibiotic [medication that kills bacteria] therapy...on 3/13/11...Patient was involved in a Patient to Patient altercation on 3/24/11...order obtained for urinalysis [UA]." An IDT CP for Antidepressant Therapy for Patient 1 was first dated 10/7/10. An IDT CP for Antipsychotic Therapy was first dated 2/4/11. An IDT CP for Patient 1's Anti-anxiety therapy was first dated 2/4/11. Each of these care plans specified that the side effects of the related medications were to be monitored. During an interview on 8/17/11 at 2:10 pm, Staff H stated that Patient 1 had had at least one Patient-to-Patient altercation each shift; and that almost every shift, he strikes out at staff. She stated that when he had a roommate, he would crawl out of bed to get to the roommate and claw at him; and that, three weeks ago, when she was assigned "1 on 1" with Patient 1, he, "punched me in the mouth and busted my lip." From 3/2009 to 12/2010, the following was documented in Patient 1's health record: confusion, disorientation, persistent anger, verbal and physical abuse/aggression, repetitive anxious complaints, intruding on others, tearfulness, sleeping more, agitation, combativeness, striking out at staff, and pacing (via wheelchair). A physician added or changed Patient 1's psychotherapeutic medications and/or diagnoses on 18 occasions from 7/31/09 to 11/18/10, following staff reports of aggressive behaviors. Behavior data for the month of January 2011 showed that Patient 1 received 35 doses of Ativan in response to aggressive or agitated behavior. The behavior data indicated that there had been no side effects from his psychoactive medications. A Behavior Evaluation Review form, dated 2/4/11, documented the following for the month of 1/2011: 10 episodes of Patient 1 striking out at staff; 35 doses of "as needed" Ativan administered (a minimum of one dose per day) to Patient 1... Notify MD of potential non-verbal signs and symptoms of pain, Patient unable to communicate need. Possible routine pain medication would be beneficial to Patient." Twenty-four nursing note entries and IDT notes from 2/4/11 to 7/7/11, described Patient 1's behaviors as confusion, refusing vital sign checks (assessment of blood pressure, heart rate, respiration rate and temperature), indications of pain, agitated, spitting, yelling out, verbally aggressive to other patients, whining, crying, pounding on glass at nurses' station, verbally combative, argumentative, restless, anxious, crying for his daddy, kicking and striking out at staff, physical aggression with minor injuries to other patients, and that a visitor reported Patient 1 wandering outside the facility in his wheelchair. The facility did not correlate any of Patient 1's behaviors to the side effects of his medications. On 6/23/11, Patient 1 was involved in an altercation where he caused skin tear injuries to another patient. Facility team notes on 6/27/11 stated that his aggression had increased and that he had, "a history of becoming increasingly angry/abusive when he has a UTI." A physician progress note, dated 7/12/11, stated, "Dementia confused, disoriented...Aggressive behavior. Patient to Patient altercations. Combative. Frequent UTIs?...plan: increase Risperdal. Increase Depakote..." An IDT note, dated 8/1/11, documented that Patient 1 became agitated, attempted to hit staff, and grabbed staff...Patient has significant history of multiple UTIs...episodes have historically been related to UTI prevalence...IDT recognizes that aggressive/abnormal behaviors noted almost daily since 7/26/11...recommend...a broad spectrum antibiotic for pending UA results, as well as, consider prophylactic [preventative] antibiotic for chronic UTI's." Patient 1 suffered from at least ten UTIs (4/16/09, 2/9/10, 6/17/10, 11/18/10, 2/16/11, 3/3/11, 4/7/11, 5/16/11, 6/27/11, and 8/3/11). The facility's policy, Urinary Tract Infections, dated May 2002, stated that the, "Patients will receive appropriate treatment and services to prevent UTIs," and "The licensed nurse assesses for contributing factors, identifies risk factors for reoccurrence and establishes interventions to reduce risk of reoccurrence." There was no evidence of assessment or interventions by facility staff for the contributing factors. In Patient 1's health record, there was no documentation by staff, clinicians, administration, or a pharmacist, that recognized that Patient 1 was potentially suffering from any or all of the adverse side effects of the medications that he was given. Between 3/16/09 and 8/21/10, Patient 1 had increasingly abnormal laboratory results that indicated his prostate was becoming progressively larger. Per Taber's Cyclopedic Medical Dictionary, edition 15, and MayoClinic.com, the prostate (a gland that secretes fluid for semen) surrounds the neck of the urinary bladder and the urethra (urine outlet tube) in the male; and when the prostate enlarges, either with or without cancer, it results in urethral obstruction and urine retention. The urine retention often contributes to urinary tract infections. On 8/21/10, a clinician ordered Patient 1 to be referred to a urologist (a doctor who specializes in issues related to the urinary system and the prostate gland). During an interview on 8/24/11 at 11:42 am, Staff B stated that she had found no record of Patient 1 having a urology consult, and that she had called the urologist's office and was told Patient 1 had not been seen by the urologist. On 8/20/11, three days after this surveyor brought the issue of Patient 1's prostate to the facility's attention, a physician ordered Flomax (a medication to treat the symptoms of an enlarged prostate by relaxing muscle tissue in the neck of urinary bladder and in the prostate, thereby improving the flow of urine). On 8/24/11, a physician's progress note stated, "...This gentleman has [progressively increasing] aggression [with] current Rx [treatment]. Last night, he tried to strike the care taker, but additional Ativan...seem to help. It was in my plan to increase Risperdal tomorrow if any aggression. This behavior problem is probably a complication of chronic UTI and his Alzheimer dementia. Most likely cause of UTI [probable] bladder outlet obstruct, incomplete emptying of urinary bladder [urinary retention]." The physician discussed difficulty in catheterization (inserting thin plastic tubing) of the bladder to obtain residual urine from Patient 1 and stated, "Meantime, we are increasing Risperdal and Depakote (Divalproex), [and as needed injections of] Haldol. Rx [treat] UTI." Adverse effects of medications, a failure to investigate the cause of the UTIs, and the progressive enlargement of his prostate, potentially contributed to the recurrence of Patient 1's UTIs, and continuation of his agitated and aggressive behaviors. As stated on MayoClinic.com: Parkinson's disease is a progressive disorder of the nervous system that impairs movement.Those with Parkinson's disease may fall more easily; may be thrown off balance by just a small push or bump, or by reaching or leaning. As stated in Mosby's Drug Guide for Nurses (eighth edition) and/or Lexi-Comp's Handbook, Risperdal, Haldol, and Seroquel each had the adverse effects of causing the same symptoms that are common to Parkinson's disease, including impaired memory, confusion, and impaired urination. Patient 1's Parkinson's disease, multiple anticholinergic and sedating medications, potentially inhibited Patient 1's cognition, memory, and control of his movement and balance. Interdisciplinary team notes, post fall evaluation forms, and nurses notes indicated that Patient 1 had had at least ten falls (some with minor injuries such as swollen hand, bruises, and skin tears), additional unexplained injuries, an incident of wandering outside the facility, and repeated episodes of confusion, from 6/15/10 to 8/26/11.A CP for Fall Risk was noted as not being started until 8/8/11, despite falls dating back to 6/2010. Patient 1's MARs indicated that in June 2011 he received 12 doses of Vicodin and 37 doses of Ativan. In July 2011 he received two injections of Haldol 0.5 mg, 27 doses of Vicodin and 48 doses of Ativan. In August (through 8/26/11) he received 66 doses of Vicodin (routinely and as needed) and 35 doses of Ativan. On 8/26/11 at 10:55 am, Patient 1 was observed sleeping in his bed with Staff I in attendance. Staff I stated that she had awakened him, showered him, and taken him to breakfast in the dining room. She stated that he had been given "all his medicines right before breakfast," and that when he had become "fussy and loud and was tired," she assisted him back to his room and to bed, "and he has been sound asleep ever since." On 8/26/11 at 1:05 pm, Patient 1 was observed asleep in bed, in the same position as was observed at 10:55 am.On 8/26/11 at 2:25 pm, Patient 1 was observed in bed asleep. During a concurrent interview, Staff I stated that she had gotten him up for lunch, he had become tired, and she put him back to bed. During an interview on 1/5/12 at 9:40 am, the facility's pharmacist (Pharm G) concurred that complete chart reviews by the facility's pharmacist should have included a review of the repeated UTIs with pain, and of the comments that Patient 1's UTIs were correlated with an increase in Patient 1's negative behaviors. She further stated that the pharmacist should have reviewed all of Patient 1's prostate workups. She agreed that Patient 1's negative behaviors may not have been due to psychosis or mood disorders, and yet the behaviors were treated with multiple psychotherapeutic medications. She stated that the notes regarding falls should have been considered. She did not respond to questions regarding the possible correlations between Patient 1's falls, confusion, and sedation; and the amounts of sedative and central nervous system depressant medications he had received. On 9/1/11, Patient 1 was transferred to an acute care hospital. He died on 9/12/11. The admitting and "discharge" (time of death) diagnoses were: dementia; UTI, pneumonia, protein malnutrition, sepsis; an infection of the blood that triggers a defensive response which creates tiny blood clots that can lead to organ failure, and Systemic Inflammatory Response Syndrome a process in which multiple factors overwhelm the body and cause organs to stop functioning. Therefore, the facility failed to ensure Patient 1 was free from unnecessary drugs when multiple psychotherapeutic (related to the treatment of mental and emotional disorders) medications, and Vicodin (an opiate-containing pain medication) were administered for behaviors identified by the facility as related to recurrent urinary tract infections (UTIs). Additionally, the facility failed to recognize, report, and address adverse side effects; repeated falls, recurrent UTIs, increased agitation and aggression, confusion, wandering and increased sedation, that Patient 1 demonstrated from the use of multiple psychotherapeutic medications. These failures had a direct or immediate relationship to the health, safety, or security of patients.
230000221	Oroville Hospital Post-Acute Center	230008810	B	27-Mar-12	E7T211	6841	A 166 T22 DIV5 CH3 ART3-72311(a)(2) Nursing Service--General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The facility failed to implement Patient 1's "Behavior Disturbance" care plan, resulting in Patient 1's ability to elope from the facility. Patient 1 was able to walk through the facility's main lobby, past the front desk, and exit the building through the front door. He wandered outside of the building, through a parking lot, and down two steep driveways that were approximately one-quarter mile long. He then crossed a heavily travelled two lane, two-way street, without an intersection or stop lights, and went into a market, where he was later found by a facility staff member. This failure had the potential to result in Patient 1 becoming lost, injured, or killed. During an interview on 12/7/11 at 10:10 am, Patient 1 stated that he remembered leaving the facility in the morning on 12/5/11. Patient 1 explained that he "just wanted to go outside and buy some cigarettes" and that he "has done this before."Patient 1's record, reviewed on 12/7/11, contained the following documentation. Patient 1 was admitted to the facility on 7/12/11 with diagnoses that included bipolar disorder, altered mental status, lack of coordination, muscle weakness, and an abnormal gait. The MDS (minimum data set, an assessment tool), dated 10/24/11, revealed that Patient 1 had short and long term memory problems, his ability to make decisions was severely impaired, walked with an unsteady gait, and had fallen during the past 30 days. A Wandering / Exit Seeking Evaluation form, dated 10/19/11, identified that Patient 1 was "...considered at an elevated potential for exit seeking / elopement. Instructions on the form directed staff to ...proceed to care plan as potential for exit seeking/elopement." However, a care plan addressing Patient 1's exit seeking behavior and risk of elopement was not developed at this time Nurses notes, dated 10/26/11, described Patient 1 as being "out of bed all night," and that he "had to be 1:1 (one staff person assigned to constantly be with one specific patient) due to the risk of elopement." During the day, Patient 1 "continued to wander..looking for a way out of the facility." The nurse's note, dated 11/2/11 at 1:40 am, read, Patient 1 "was complaining of right lower abdominal pain... stated that he wants to go to the hospital, and he was going to walk there himself if we don't send him out." Patient 1 was transported to the hospital at 1:35 am. The next entry, written at 2:15 am, read, Patient 1 "returned from the hospital by himself...they [hospital staff] didn't know he left..." On 11/21/11, Patient 1 eloped from the facility. The corresponding nurses note written at 11 am, read, Patient 1 "walked out the front door and down to the hospital" stating, "I was told I'm a free man....I decided I'm done, I'm ready to go home." "He was assisted back to the facility and placed on 1:1 and every 15 minutes check." The Post Exit Seeking Evaluation, dated 11/22/11, indicated that Patient 1 "slipped by administrative staff, walked down hill to local hospital, was greeted by staff, and redirected back to facility, no injuries noted."During an interview on 12/7/11 at 11 am, Administrative (Admin) Staff B stated that Patient 1 had been placed closer to the nursing station on 10/27/11 so he could be observed more closely by facility staff. She also stated he had become more verbal about leaving the facility on 11/22/11, when he eloped from the facility the first time.Following Patient 1's elopement on 11/22/11, a Behavioral Therapy Care plan, was developed to address his exit seeking / elopement behavior. The goal was for Patient 1 not experience any injury related to elopement attempts. The planned intervention to prevent this behavior from recurring was for Patient 1 to have 1:1 supervision for one and a half shifts (12 hours), after that, staff were to check on Patient 1 every 15 minutes. During an interview on 12/7/11 at 11:40 am, Licensed Nurse (LN) A stated that on 12/5/11 he saw Patient 1 in his room before 7:30 am, and at approximately 7:35 am, Patient 1 was not in his room. LN A stated he thought Patient 1 had gone to the courtyard to smoke a cigarette. When LN A could not find Patient 1 in the facility, he initiated the "Dr. Wander" system (facility plan for notifying staff that a patient was missing) by making an announcement over the intercom. LN A stated that he looked for Patient 1 outside the building, "because that is where he went last time he was looking for cigarettes." When LN A was unable to find Patient 1 on the facility grounds, he took his personal car and drove down to Tower Mart. There, he found Patient 1 inside, attempting to purchase cigarettes and obtain a cab. LN A stated that Patient 1 was away from the facility for approximately 30 minutes.The facility's narrative account of the incident, documented on a Post Exit Seeking Evaluation form, dated 12/5/11, read, "Patient 1 was standing at nurses station, when no staff were in immediate area, Patient 1 walked to and out front door, walked to Tower Mart, where he was located and escorted back to the facility." According to Google Maps, Tower Mart is located 0.3 miles from the facility. There is a 1.5% grade between the facility Tower Mart, and the route taken by Patient 1 did not have sidewalks or pedestrian paths. Patient 1's Behavioral Therapy Care plan was updated on 12/6/11. The new plan was for Patient 1 to have 1:1 supervision while awake, and every 15 minute checks while resting.During an interview on 12/7/11 at 12:20 pm, Certified Nurse Assistant (CNA) C stated that her assignment for the day was to care for Patient 1 who was a 1:1, in addition to her 12 other assigned patients. CNA C stated she would not be able to continuously watch Patient 1 and take care of her other patients. Therefore, the facility failed to implement Patient 1's "Behavior Disturbance" care plan of 1:1 supervision for twelve daytime hours, resulting in Patient 1's ability to elope from the facility. Patient 1 was able to walk through the facility's main lobby, past the front desk, and exit the building through the front door. He wander outside of the building, through a parking lot and down two steep driveways that were approximately one-quarter mile long. He then crossed a heavily travelled two lane, two-way street, without an intersection or stop lights, and went into a market, where he was later found by a facility staff member. This failure had the potential to result in Patient 1 becoming lost, injured, or killed. This violation had a direct relationship to the health, safety, or security of patients.
230000221	Oroville Hospital Post-Acute Center	230009003	B	25-Apr-12	T2OF11	5729	F 151 483.10(a)(1)&(2) RIGHT TO EXERCISE RIGHTS FREE OF REPRISAL The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights. The facility failed to protect Residents 1, 2, and 3's right to be free of coercion and reprisal, when they were threatened with discharge from the facility, if they would not agree to sign a new form about stricter smoking rules. Resident 1, 2, and 3 had been found in possession of tobacco and or lighters and the facility threatened them with discharge, if they did not agree to sign the new smoking form.1. Resident 1, a 60 year old female, was admitted to the facility on 12/7/11 with diagnoses that included a seizure disorder. The facility's minimum data set (MDS, an assessment tool), dated 12/14/11, described her as being understood and able to reason, think, and understand clearly. The MDS indicated the facility had determined it was not feasible to discharge Resident 1 to the community and had no plan to discharge the resident. Resident 1's record contained a nurses note, dated 1/1/12, that read, "...Follows all rules and regs (regulations) reg (regarding) smoking rules..." Resident 1's record contained a physicians progress note, dated 1/28/12, that showed the physician did not plan to discharge her and had planned to continue supportive care.On 2/8/12 at 8 am, Resident 1 stated that on 2/3/12, Administrative (Adm) Staff A asked her to sign the new form about following the facility's smoking policy and told her she would be issued a 30 day notice to leave the facility if she did not agree to sign it. Resident 1 stated she refused to sign the new form because she had already signed a smoking policy upon admission. Resident 1 stated she felt she was being singled out. Resident 1's record contained a social progress note, dated 2/6/12, that showed she refused to sign the new smoking policy and was issued a 30 day notice (discharge).On 2/8/12 at 8:40 am, Resident 1 stated that when she called her physician on 2/3/11, he was unaware she was being discharged from the facility. Resident 1 stated she did not understand why she would be sent to a homeless shelter, as told to her by Adm Staff A, when she had family living in town. Resident 1 stated she was worried that she would have a seizure at the homeless shelter and die. On 2/8/12 at 11:20 am, Adm Staff C explained that earlier in the week, Residents 1 and 2 had cigarettes (no matches) in their possession during a smoke break she supervised. Adm Staff C confirmed the new smoking form was developed because she brought this to the attention of Adm Staff A and the facility's administration on 2/3/12.On 2/8/12 at 11:30 am, Adm Staff A confirmed the new smoking form was developed on 2/3/12 after Resident 1 and 2 were found with cigarettes. When Adm Staff A was asked how she determined that Resident 1 no longer needed long term care and that transfer to a homeless shelter with no medical supervision was appropriate, she confirmed she was not qualified to determine that and had not received medical guidance. Adm Staff A recalled that she told Resident 1 that she would revoke the discharge notice if the resident would sign the form. Adm Staff A confirmed that the facility was "not actually trying to discharge" Resident 1 but gave her the notice to get her to sign the form and to impress upon her the seriousness of the situation.On 2/8/11 at 3 pm, Adm Staff B was asked if the facility intended to discharge Resident 1, she stated that they were trying to "scare her into compliance" to sign the smoking form. Adm Staff B confirmed they would not have discharged Resident 1. 2. Resident 2, a 51 year old female, was admitted to the facility on 12/7/11. The facility's MDS, dated 12/14/11, described her as able to think, reason, and understand clearly. On 2/8/12 at 8:15 am, Resident 2 (Resident 1's roommate) confirmed that on 2/3/12, when Adm Staff A asked her to sign the new smoking form, Adm Staff A was not frustrated with her, because she signed without objection. Resident 2 stated that when Adm Staff A approached Resident 1 to sign, she had acted totally different towards Resident 1, was not nice, and was on a "power trip." Resident 2 stated that Adm Staff A told Resident 1, "You have 30 days to get out; vacate the premises," if she did not sign the form. Resident 2 stated that Adm Staff A did not explain the discharge to Resident 1 but said, "You'll be transported to the (a local homeless shelter)." Resident 2 stated that she feared Resident 1's seizures made it unsafe for her to be sent to a homeless shelter.3. Resident 3, a 59 year old male, was admitted to the facility on 1/11/12. The facility's MDS, 1/18/12, described him as able to think, reason, and understand clearly. On 2/8/12 at 1:55 pm, Resident 3 stated he was asked to sign the form by Adm Staff A and she told him that if he did not sign or got caught with any smoking items, he would get "kicked out or get a discharge notice." Resident 3 stated that he felt he had no choice, so signed the form and it made him feel angry towards the facility staff.Therefore, the facility failed to ensure Residents 1, 2, and 3's right to be free of coercion and reprisal was protected, when they were verbally threatened with a written Notice of Proposed Transfer/Discharge to leave the facility, if they would not agree to a new form about smoking rules.This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients.
230000626	Osterman's Facility #1, Inc.	230009020	B	01-Mar-12	GMNC11	1698	A064 1418.91(a) Health & Safety Code 1418 (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.Based on interview and record review, the facility failed to report an incident of suspected abuse that occurred between Direct Care Staff (DCS) C and Client 1 to the Department within 24 hours. As a result, DCS C worked at the facility for two days following the incident. This had the potential to negatively effect the physical or emotional well being of Client 1 and put all clients in the home, at risk for being abused.Findings: On 1/30/12, the facility notified the California Department of Public Health of an incident of suspected abuse that occurred on 1/27/12. During an interview on 2/13/12 at 2:30 pm, DCS B stated that on 1/27/12 at 4:30 pm, she witnessed an incident where DCS C hit Client 1. DCS B stated she reported this incident three days later, on 1/30/12, to Administrative Staff (Admin) A.A facility policy titled, "Abuse, Neglect, and Exploitation of Residents" read as follows, "an employee of the facility who suspects abuse of a facility client is to verbally report the incident as soon as possible to their immediate supervisor and immediately to the Department of Health Services. The Department of Health and Licensing will be called within 24 hours."During an interview on 2/13/12 at 3:20 pm, Admin A confirmed that the incident had not been reported to the Department within 24 hours after DCS B witnessed the incident.Therefore, the facility did not report an allegation of abuse within 24 hours to the California Department of Public Health.
230000626	Osterman's Facility #1, Inc.	230009058	B	01-Mar-12	GMNC11	2673	A 008 W&I 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. Based on interview and record review, the facility failed to ensure that Client 1 remained free from abuse when Direct Care Staff (DCS) C hit him. This had the potential to result in physical or psychological harm to Client 1. Findings: On 1/30/12, the California Department of Public Health was notified by Administrative Staff (Admin) A that DCS C had hit Client 1 on 1/27/12.A review of Client 1's record disclosed that he was a 52 year old admitted to the facility with diagnoses that included severe mental retardation. It was noted in the current comprehensive functional assessment that he was nearly non-verbal and had a history of behaviors that included hitting and yelling. During an interview on 2/13/12 at 2:30 pm, DCS B stated that on 1/27/12 at 4:30 pm, Client 1 and DCS C were standing next to each other in the kitchen. DCS B said she saw Client 1 tap DCS C on the arm and the side of her body, then she saw something out of the corner of her eye and heard a slap. DCS C then turned to her and stated, "Yes, I hit him and you can tell on me if you want." DCS B stated she thought that DCS C had hit Client 1 on his hand.During an interview on 2/13/12 at 9 am, Admin A stated that on 1/30/12 DCS C was terminated. Following her termination, DCS C called DCS D and admitted that she had hit Client 1.Admin A provided a statement from DCS D. It was written in the statement that DCS C admitted she had hit Client 1 and had been fired. During an interview on 2/15/12 at 4:05 pm, DCS D confirmed the contents of the statement.A facility policy titled, "Abuse, Neglect, and Exploitation of Residents" read as follows, "physical abuse is any action which may cause or causes physical or emotional harm or injury." The facility failed to ensure that Client 1 remained free from abuse when DCS C hit him. The violation of this regulation had a direct relationship to the health, safety, or security of clients.
230000221	Oroville Hospital Post-Acute Center	230009174	B	27-Mar-12	OYYB11	3224	A 880 T22 DIV5 CH3 ART5-72527(a)(9) Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The facility failed to protect Patient 1 from physical and verbal abuse when Certified Occupational Therapy Assistant (COTA) A continued therapy exercises after Patient 1 requested to stop. As a result, Patient 1 fell. When Patient 1 began calling out "Help me," COTA A responded by telling Patient 1 to "Shut up." On 11/9/11, Patient 1's record was reviewed. Patient 1 was admitted to the facility on 10/21/11 with diagnoses of fractured femur (thigh bone), difficulty in walking, a history of prior fall, and rehabilitant needs. The Minimum Data Set, (MDS-a patient assessment tool), dated 10/28/11, described Patient 1 as alert and able to voice her needs, she had limited range of motion in all extremities, her balance was unsteady, and she needed extensive two person assistance with bed mobility, transferring, and toileting activities.During an interview on 11/9/11 at 10 am, Patient 1 recalled the event that occurred in the therapy room on 11/5/11 at 5:45 pm. Patient 1 stated that she was having a lot of pain that day. During the therapy session, Patient 1 told COTA A that she could not stand any longer and just wanted to lay down, but COTA A kept pushing her to do more (standing exercises) at the transfer pole. Patient said, "That's when I lost my grip and fell to the floor." "I was in pain and yelling for help, and COTA A kept telling me to shut up." During an interview on 1/20/11 2:15 pm, Certified Nursing Assistant (CNA) B stated that she was walking past the therapy room on 11/5/11 at approximately 5:45 pm, when heard someone repeatedly yelling, "Help me," and another person saying, "Shut up, shut up." CNA B said that she went into the therapy room to investigate and found COTA A in the room, and Patient 1 on the floor by her wheel chair and the transfer pole. CNA B stated that she asked Patient 1 what happened and Patient 1 told her, "I could not stand and she (COTA A) was pushing me too hard and I lost my grip and fell to the ground." CNA B stated that as she was returning to the therapy room with help to assist Patient 1 back into her wheelchair she heard COTA A say to Patient 1, in a mean voice, "you never let me help you; you don't follow my instructions; you keep using your left arm when I tell you not to."Therefore, the facility failed to keep Patient 1 free from physical and verbal abuse when COTA A continued therapy exercises after Patient 1 requested to stop. As a result, Patient 1 fell. And, when Patient 1 began calling out "Help me" COTA A responded by telling Patient 1 to "Shut up." The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients.
230000221	Oroville Hospital Post-Acute Center	230009206	B	10-Apr-12	O6L311	8193	F 353 483.30(a) SUFFICIENT 24-HR NURSING STAFF PER CARE PLANS The facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: Except when waived under paragraph (c) of this section, licensed nurses and other nursing personnel.Except when waived under paragraph (c) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff to provide nursing and related services to attain the highest practicable physical, mental, and psychosocial well-being of each resident. This failure led to neglect, and to the mental anguish and potential physical harm to, at least, two residents (Residents 1 and 2). 1. Resident 1's health record was reviewed on 2/15/12 and 2/16/12. Resident 1, a 70 year old, was admitted to the facility on 2/9/12, recovering from sepsis (blood infection) and pneumonia. The facility's initial Nursing Admission Evaluation form, dated 2/9/11, stated that Resident 1 was alert and oriented and had full bowel and bladder (urine and feces) control. Resident 1 needed extensive assistance with repositioning in bed, transferring to a commode, ambulating, and/or personal hygiene. Nursing notes further stated that upon admission, Resident 1 had a "red perigroin [front pelvic area and area between the legs] rash extending to her buttocks."A "Potential for Skin Integrity Impairment Care Plan" for Resident 1, dated 2/10/12, indicated that she was to be turned every 1-2 hours while in bed, and to be kept clean and dry. During an observation and interview on 2/16/12 at 9:30 am, Resident 1, was alert and oriented and in her bed. She stated that early in the morning of 2/12/12, she had the call light on because she needed assistance to use the toilet or a bed pan. She said, "I waited and waited and waited and couldn't wait any longer and peed in my [pants]." She further stated that the certified nursing assistant (CNA) came in, apologized for taking so long, and cleaned her up. She stated that she was upset that she urinated on herself and felt sorry for the CNA who was "so tired," working all by herself. 2. Resident 2's health record was reviewed on 2/15/12 and 2/16/12. Resident 2, a 78 year old, was admitted to the facility on 6/17/11 with diagnoses that included difficulty walking, history of fall, obesity, and renal and ureteral disorder (problems pertaining to the urinary system). Nurse's notes, dated from 1/1/12 to 2/2/12, included Resident 2, had "on each buttock...deep tissue injury...need to reposition frequently and shift off buttocks...resident is extremely obese, moving is very difficult for him...in need of frequent attention," and, "is a two person extensive assist with bed mobility, toileting and transfers...CNA staff have been inserviced on transferring resident via hoyer [mechanical full body sling lift] from bed to chair for patient safety and CNA safety."Resident 2's Potential for Skin Impairment Care Plan, dated 2/3/12, instructed staff to "Turn approx. every 2-3 hours", and "Keep skin clean and dry."Interdisciplinary Progress notes, dated 10/7/11, documented that Resident 2 had had a fall on 10/5/11. Resident 2's Fall Risk Care Plan, most recently updated 2/3/12, instructed staff to remind resident to use his call light for assistance, to keep the resident clean and dry, and to keep him on scheduled toileting every two hours. During an observation and interview on 2/16/12 at 8:40 am, Resident 2 was in his wheel chair and was alert and oriented. He stated that on the night shift of 2/11/12, there was only one CNA working in his area. He stated that, because of his obesity, he needed assistance in placing his urinal and that, on that night he waited so long for his call light to be answered that he urinated on himself and on the sheets. He stated that it made him feel "so bad, for me being wet, and for [the CNA] to have to clean me and change my sheets."Resident 2 further stated that, later that night (2/11/12), the battery from his television remote had fallen onto the floor. When he leaned to reach it, he fell over and his head and weight was being held from hitting the floor by his bedside table. He yelled, the CNA ran in and, by herself, had to push from beneath him to help him back into bed. Resident 2 said, "I felt bad for her because she worked her rear off that night." On 2/15/12, 2/16/12, and/or 2/17/12, confidential interviews were conducted with seven CNAs, representing all three shifts. Per the interviews, at the start of the day shift on 2/12/11, CNAs discovered residents on both the East and West Halls who were wet and with wet linens. Statements during interviews and record reviews indicated the following:On each night shift (noc - 10:30 pm to 6:30 am), two CNAs were supposed to be assigned to West Hall, one to the "front" and one to the "back". Two additional CNAs were suppose to be assigned work the East Hall, which was similarly divided. One CNA on the night shift could provide adequate care to a maximum of 18 to 22 residents, depending on the amount of individual care needed. On the night shift of 2/11/12, starting at 10:30 pm, only one CNA had come to work for the West hall. There were 40 residents on the West Hall, some with mandated instructions that two staff assist with bed mobility, transferring and toileting. In the back of West Hall, all but three of 18 residents were incontinent and/or in need of assistance. In the front of West Hall, 22 residents were recovering from acute illnesses and/or surgeries, with half of them needing assistance with mobility and toileting.Per one night CNA and two day CNAs, the night CNA had to periodically leave residents to make phone calls to off-duty CNAs in a vain attempt to get additional help. During the night, residents had to wait extended periods of time for their call lights to be answered. One resident fell (Resident 2). By morning, the night CNA had cleaned, reclothed, and changed the bedding of all incontinent residents and for those that had soiled while waiting for assistance. She was able to do this at least once for each resident during her shift. With answering residents' call light, and attempting to do all of her routine resident care duties, the night CNA could not, alone, clean and change linen for those who had repeat episodes of soiling in their beds. Also, on the night shift of 2/11/12, only one regular CNA, and the new CNA she was to orientate, had come in to work East Hall. The one CNA, with her orientee, could not ensure that their residents were clean and dry at the end of their shift.During an interview on 2/15/12 at 8:50 am, Scheduler (Sched. A) stated that there were always supposed to be at least two fully orientated CNAs on each of the two halls (East and West). She stated that the orientee was receiving her second shift of orientation and was not expected to be able to handle the assignment of a regular CNA. During an interview on 2/16/12 at 5:00 pm, Director of Nursing (DON B) had no comment when shown that, on the night shift 2/11/12 schedule, there was only one CNA scheduled and assigned for West Hall, and only one CNA scheduled for East Hall.The facility's document titled, Abuse, Neglect and Misappropriation of Resident Prohibition Policy, dated 10/1010, stated, "Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." Therefore, the facility failed to ensure sufficient nursing staff to provide nursing and related services to attain the highest practicable physical, mental, and psychosocial well-being of each resident. This failure led to neglect, and to the mental anguish and potential physical harm to at least two residents.
230000221	Oroville Hospital Post-Acute Center	230009274	B	20-Nov-12	D84K11	4360	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 ensure adequate supervision was provided to implement Patient 1's "Behavior Disturbance" care plan. As a result of this failure, Patient 1 was able to elope from the facility. On the afternoon of 4/12/12, Patient 1 was able to walk through the facility's main lobby, past the front desk, and exit the building through the front door. He wandered through a parking lot and down two steep driveways. He then crossed a heavily travelled two lane, two-way street and walked to a gas station approximately half of a mile from the facility, where he was later discovered by the local police department. This failure had the potential to result in Patient 1 becoming lost, injured, or killed. Patient 1 was admitted to the facility on 9/29/12 with diagnoses that included dementia, shortness of breath and difficulty in walking. The Minimum Data Set (MDS), a patient assessment tool, dated 3/16/12, indicated that Patient 1 had difficulty understanding and being understood.During an interview on 4/19/12 at 7:30 am, Patient 1 was unable answer to questions; he used nonsensical words, and was unable to verbalize any recall of the incident described above.A Behavior Evaluation and Review form, dated 10/3/11, and a "Behavioral Disturbance Care Plan" initiated on 12/30/11, identified that Patient 1 wandered through out the facility. The care plan directed nursing staff to visually check and document Patient 1's whereabouts every 15 minute.During an interview and record review on 4/19/12 at 8 am, Assistant Director of Nurse (ADNS) A stated that Patient 1 was on 15 minute checks and that staff noted Patient 1's location and signed their initials on a "Patient Visual Check Flow Sheet" to show that the check was done. Patient 1's "Patient Visual Check Flow Sheet" for 4/12/12 was reviewed with ADNS A. There were initials for the entire shift up to and including 4:15 pm, Patient 1's location and initials were blank between 4:30 and 5 pm. During an interview and record review on 4/19/12 at 12 pm, Social Service Assistant (SSA) B confirmed that interdisciplinary progress note, dated 4/13/12, noted that the police department contacted the facility on 4/12/12 at 4:15 pm, regarding Patient 1's whereabouts. The police informed the facility that Patient 1 was found approximately a half mile away, at a local gas station. SSA B confirmed that the "Patient Visual Check Flow Sheet" indicated that the patient was in the facility at 4:15 pm. SSB also confirmed that this could not be true as the police had called the facility at that time stating that they had found Patient 1 approximately a half mile away from the facility.An Interdisciplinary progress note, dated 4/12/12, showed that, "Certified Nursing Assistant (CNA) C, in charge of Patient 1... Stated that she had last seen him at 3:45 pm when she had given him an afternoon snack." The note also showed, "CNA C had pre-filled... three 15 minute check, 45 minutes prior to the scheduled times..., and had taken a 30 minute break without notifying the other CNA she was working with, or the charge nurse."During an interview on 4/19/12 at 12:30 pm, ADNS A confirmed that CNA C left the floor without ensuring that someone was covering visual checks for Patient 1, which put him at risk for injury.Therefore, the facility failed to ensure adequate supervision was provided to implement Patient 1's "Behavior Disturbance" care plan. As a result of this failure, Patient 1 was able to elope from the facility. On the afternoon of 4/12/12, Patient 1 was able to walk through the facility's main lobby, past the front desk, and exit the building through the front door. He wandered through a parking lot and down two steep driveways.He then crossed a heavily travelled two lane, two-way street and walked to a gas station approximately half of a mile from the facility, where he was later discovered by the local police department. This failure had the potential to result in Patient 1 becoming lost, injured, or killed. These violations had a direct or immediate relationship to the health, safety, or security of patients.
230000221	Oroville Hospital Post-Acute Center	230009275	B	20-Nov-12	D84K11	3566	F241 483.15(a) DIGNITY AND RESPECT OF INDIVIDUALITY The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The facility failed to ensure Patient 2 was treated with consideration, respect, and full recognition of dignity and individuality when Licensed Nurse (LN) E knelt down, positioning himself at Patient 2's seated level, then yelled in the patient's face. Patient 2 stated that she felt scared and humiliated. LN E's behavior had the potential to increase Patient 2's anxiety and negatively impact her psychosocial well-being. Patient 2, an 81 year old female, was admitted to the facility on 12/6/12 with diagnoses that included chronic pain, dementia, weakness, and anxiety. The Minimum Data Set (MDS), a patient assessment tool, dated 3/10/12, described Patient 2 as alert, able to understand and make herself understood, with no hearing deficit. Patient 2 has short term memory problems and was unable to recall the incident that had occurred three days earlier on 4/22/12. During an interview on 4/25/12 at 11:30 am, Nurses Assistant (NA) D stated that on 4/22/12 at 7:30 pm, she was walking down the hall toward the north nurse's station when she heard yelling. When she reached the nurse's station she saw LN E on his knees, in front of and nose to nose with Patient 2. LN E was yelling at Patient 2, telling her she needed to listen and wait for help. NA D stated that LN E looked mad and his tone seemed angry. NA D explained that she then offered to help and took Patient 2 to her room. During an interview on 4/25/12 at 1:15 pm, LN E stated that on 4/22/12 at 7:30 pm, he was working at the nurse's station and Patient 2 was sitting in her wheelchair at the nurse's station waiting for a CNA to help her to bed. LN E stated that he was glancing up from his work to check on Patient 2, and when he looked up again she was gone. LN E stated that he went to Patient 2's room, and found her out of her chair with the fall alarm going off. LN E said that he assisted Patient 2 into her wheelchair and took her back to the nurse's station. LN E stated that he knelt down in front of Patient 2's wheelchair, and was talking loudly in her face, explaining that she needed to wait for assistance before attempting to go to bed. LN E stated that Patient 2 was a fall risk and was trying to get her to understand that if she did not wait for assistance she might fall. LN E acknowledged that Patient 2 was a small woman, and that his large stature and behavior may have scared her. During an interview on 4/25/12 at 1:40 pm, with Social Service Assistant B and Patient 2, Patient 2 stated, "The man behind the counter yelled in my face." Patient 2 was unable to recall why she was behind the counter or exactly what was said. Patient 2 repeated, in a very tearful voice, "He yelled at me." Patient 2 said that she "felt sad, scared and humiliated." Therefore, facility failed to ensure Patient 2 was treated with consideration, respect, and full recognition of dignity and individuality when Licensed Nurse (LN) E knelt down, positioning himself at Patient 2's seated level, then yelled in the patient's face. Patient 2 stated that she felt scared and humiliated. This had the potential to increased Patient 2's anxiety and negatively impacts her psychosocial well-being. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients.
230000221	Oroville Hospital Post-Acute Center	230009340	B	20-Nov-12	K4KN11	3591	F223 483.13(b), 483.13(c)(1)(i) FREE FROM ABUSE/INVOLUNTARY SECLUSION 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. The facility failed to protect two female residents from sexual abuse when Resident 1 grabbed/fondled their breast and genital area.During an interview on 5/22/12 at 4:45 pm, Certified Nursing Assistant (CNA) C stated that on 5/1/12, after dinner, she was walking down the hallway and as she passed the dining room she witnessed Patient 1 and Patient 2 sitting in their wheelchairs; Patient 2's shirt was pulled up and Patient 1 was fondling her exposed breast.Patient 2, an 83 year old female, was admitted to the facility on 11/17/08 with diagnoses that included Alzheimer disease, Parkinson's, and depression. The Minimum Data Set (MDS), a patient assessment tool, dated 2/28/12, indicated that Patient 2 had severely impaired cognitive skills, was unable to make her own decisions, and required extensive assistance with all physical care.Patient 1, a 79 year old male, was admitted to the facility on 12/22/11 with diagnosis that included mental disorder, dementia and mood disorder. The MDS, dated 3/13/12, indicated that Patient 1 had impaired cognitive skills, but was able to understand and usually able to make himself understood.Patient 1's record contained an interdisciplinary progress note, dated 4/12/12, that identified Patient 1 was having "behaviors of public sexual acts" and that nursing staff were to visually check and document Patient 1's whereabouts every 15 minute due to his behavior.During an interview on 5/21/12 at 3 pm, Social Service Director (SSD) A stated that while investigating the witnessed incident of Patient 1 fondling Patient 2 in the dining room on 5/1/12, she discovered that there were prior incidents involving Patient 1 and Patient 3.Patient 3, a 56 year old female, was admitted to the facility on 3/25/12 with diagnoses that included toxic encephalopathy, renal disease, and depression. The MDS, dated 5/4/12, described Patient 3 as alert, cognitively intact and able to make her own decision. During an interview on 5/21/12 at 4:15 pm, Patient 3 stated that approximately two months ago she was in the front hallway returning to her room when Patient 1 wheeled up to her and grabbed her breast. Patient 3 stated that she told Patient 1"No."Patient 1 released her then again attempted to grab her breast.Patient 3 further stated that approximately two weeks after the above mentioned incident, when she was in the same area of the facility, Patient 1 grabbed her crotch. Patient 3 again told Patient 1 "No."Patient 1 released and immediately attempted to grab Patient 3 again.Patient 3 stated that a group of staff were in the hall at that time and she reported the incident to one of the staff.On 5/22/12 at 10:25 am, the Dietary Department Supervisor (DDS) stated that while assisting Patient 3 back to her room on either 4/24 or 4/25/12, Patient 3 told her that she felt a little uncomfortable because Patient 1 had grabbed her crotch and had previously grabbed her breast. DDS stated that she did not report the incidents.Therefore, the facility failed to protect two female residents from sexual abuse when Resident 1 grabbed/fondled their breast and genital area. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients.
230000221	Oroville Hospital Post-Acute Center	230009391	B	20-Nov-12	F6JK11	9995	F 309 483.25 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. The facility failed to provide the necessary care and services in accordance with physician orders and facility policies to ensure Patient 1's respiratory status was properly monitored and treated after he developed pneumonia. And, the facility failed to give Patient 1's responsible party, (RP) an accurate description of Patient 1's illness when there was a significant deterioration in the patient's condition. These failures cannot rule out that the facility's actions may have contributed to Patient 1's death on 9/14/11.Patient 1 was admitted to the facility on 7/12/06 with diagnoses that included mental retardation and lung disease. Patient 1 was diagnosed with a new onset of pneumonia on 9/12/11. The facility's Minimum Data Set (MDS, an assessment tool), dated 8/14/11, described Patient 1 as able to understand others and be understood when communicating. Patient 1 had a court appointed responsible party (RP) because he was not capable of making sound decisions for himself. Patient 1 passed away on 9/14/11. On 11/8/11, Patient 1's record was read. Patient 1 had a document, dated 5/20/11, titled, "Physician orders for life-sustaining treatment (POLST)," which stated, "Do not attempt resuscitation/DNR (Allow Natural Death)." The document also stated to provide "comfort measures only." The document stated to "Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction (manage breathing problems) as needed for comfort. Antibiotics only to promote comfort. Transfer if comfort needs cannot be met in current location."The nurse's notes, dated 9/11/11 at 6 pm, showed that Patient 1 complained of a cough. Patient 1's physician was contacted by phone and orders were received to obtain a chest x-ray, and to start Patient 1 on antibiotic pills. On 9/12/11, Patient 1's chest x- ray results came back positive for pneumonia. In the nursing note, dated 9/13/11 at 9 pm, LVN A described Patient 1 as having a temperature of 101.4 degrees, he was short of breath; his breathing rate was 42 breaths per minute (normal is 12 to 18 breaths per minute) with wheezing (a whistling or rattling sound in the lungs that happens when there is obstruction in the air passages) in all four areas of his lungs, and he had vomiting and diarrhea. The nursing note read that Patient 1's physician was notified, new physician's orders were obtained, and Patient 1 was put on "Alert charting." The nurse's note stated that Tylenol was given for Patient 1's temperature, that there were no signs or symptoms of side effects from antibiotics and that she would continue to monitor Patient 1.The above referenced physician's order, written on 9/13/11 at 8:50 pm, read, "Monitor O2 sats" (the amount of oxygen saturation level in the blood that is measured with a non-invasive device attached to the fingertip. A normal O2 sat is 95 to 100%). The physician ordered that if the O2 sat was less than 90%, to administer oxygen as necessary and to give Albuterol and Atrovent (medication that is inhaled from the mouth to help difficulty breathing) every four hours as needed for shortness of breath. On 9/14/11 at 2:20 am, LVN B documented, in the nurse's notes, that an order was received to start giving an IM antibiotic (intramuscular/injectable antibiotic) and that Patient 1's RP was notified. There was no documentation in the 9/14/11 2:20 am note or any further nursing note that described Patient 1's condition, why he needed and was prescribed an injectable antibiotic instead of the pills he had been receiving, what his present vital signs were or what information had been discussed with Patient 1's responsible party.There were no additional notes after the 9/13/11, 9 pm entry, that described whether Patient 1's condition was improving or worsening, what Patient 1's vital signs were, what Patient 1's O2 sats were, if he was receiving any oxygen, if any breathing treatments had been administered or what comfort measures had been provided. Patient 1 died on 9/14/11 at 8:50 am (11 hours and 50 minutes later). On 11/8/11 at 2:10 pm, Licensed Nurse A (LN A) was interviewed. LN A confirmed that she remembered Patient 1 and the evening of 9/13/11 very well. LN A stated that she reviewed Patient 1's POLST before she contacted his physician. LN A stated that she did not contact Patient 1's RP because she thought Patient 1 was comfort care only (do not seek to cure or treat illness aggressively). LN A stated that Patient 1 looked like he was close to death and that he "wouldn't last very much longer." On 7/3/12 at 10 am, a concurrent interview and review of Patient 1's record was conducted with LN B. LN B stated that he remembered Patient 1 and that he had heard that Patient 1 had died. LN B confirmed that he received information that Patient 1 had been placed on "Alert charting" when he received report from the previous shift. LN B stated that he remembered obtaining an order for an IM antibiotic because Patient 1 could not swallow his antibiotic pill. LN B confirmed that Patient 1 was congested on 9/14/11. LN B stated that on the night he cared for Patient 1, he did not recall what he told Patient 1's RP when he phoned her to tell her that Patient 1 was prescribed an IM antibiotic. LN B confirmed that did not take any vital signs, obtain an O2 sat, listen to how Patient 1's lungs sounded or give him any breathing treatments on the night shift between 9/13 and 9/14/11. On 11/8/11 at 1:50 pm, LN C was interviewed. LN C confirmed that he remembered Patient 1 and the morning of 9/14/11 very well. LN C stated that he was aware that Patient 1 was on "Alert charting" and the report that he received from the nurse on the previous shift was that he had some lung congestion. LN C stated that vital signs were due by 10 am so they had not been taken yet and that he did not perform an O2 sat or assessment because he had all shift to obtain that information. LN C stated that Patient 1 passed away at 8:50 am on 9/14/11. On 11/9/11 at 8:25 am, an interview occurred with Patient 1's RP. RP stated that she received a telephone call at 2:30 am on 9/14/11 to inform her that Patient 1 had a cough and that his doctor ordered some antibiotics. RP stated that no one told her that Patient 1 had pneumonia or that he was so sick that he might not survive this infection. RP stated that she was, "shocked," when she received a call on 9/14/11 at 8:50 am informing her that Patient 1 had been found dead during the morning medication administration. RP stated that regardless of Patient 1's DNR status, her expectations were that she would have been informed about Patient 1's pneumonia and be given the opportunity to make a decision whether or not to send Patient 1 to the hospital so he could receive more aggressive treatment. RP stated that Patient 1 had not been sick recently and that she would have directed the facility to send Patient 1 to the emergency room for further evaluation.On 11/15/11, two of the facility's policy and procedures were reviewed. 1. The facility's policy titled, "Alert Charting Policy," dated 8/09, stated that the nurse's responsibility was to: * Evaluate the patient when a change from baseline (normal condition) was observed or reported. Examples given were abnormal vital signs (blood pressure, pulse and temperature), shortness of breath, congestion and signs and symptoms of infection. * Place the patient on alert charting and enter the patient's name on the 24-Hour Report. * Document the observed/reported change and plan of action in the patient's medical record. * Notify the patient's authorized representative. Document the notification in the patient's medical record and check on the Alert Charting Form. * Document until resolution or stabilization. 2. The facility's policy titled, "24-hour follow up system policy," dated 9/09, stated that it was a system to monitor and communicate changes in patient condition: * Examples of occurrences that should be placed on the 24-hour report were changes in condition, changes in level of care and abnormal vital signs.* The nursing staff should observe, evaluate, document change in the medical record and care plan, place the resident on alert charting and place the patient's name in the appropriate section of the 24 hour report. * The reports were to be archived for 12 months. On 11/8/11 at 3:15 pm, Staff D (SD) was asked to retrieve the 24-hour report for Patient 1. SD stated that the record was not available because she was instructed to shred the report because it was not a permanent part of the record.On 11/15/11 at 12:10 pm, an interview occurred with the Nursing Administrator (NA). NA was asked whether her staff adequately monitored Patient 1's change of condition when he developed pneumonia, implemented the facility's "Alert charting" and "24 hour follow up system" policy and procedures, initiated all available treatments and gave Patient 1's conservator an accurate description of his illness before Patient 1 died. NA shook her head side to side indicating no. Therefore, the facility failed to provide the necessary care and services in accordance with physician orders and facility policies to ensure Patient 1's respiratory status was properly monitored and treated after he developed pneumonia. And, the facility failed to inform Patient 1's responsible party, (RP) then there was a significant deterioration in the patient's condition. These failures cannot rule out that the facility's actions may have contributed to Patient 1's death on 9/14/11. These violations had a direct relationship to the health, safety or security of patients.
230000221	Oroville Hospital Post-Acute Center	230009465	AA	05-Mar-14	ILGC11	8423	F333 483.25(m)(2) RESIDENTS FREE OF SIGNIFICANT MED ERRORS The facility must ensure that residents are free of any significant medication errors. The Department determined that the facility failed to ensure Resident 1 received daily injections of an antibiotic, Rocephin, to treat a urinary tract infection (UTI) as ordered by her physician on 3/9/12 at 12:20 am. This failure resulted in Resident 1 developing urosepsis; a life-threatening bacterial infection of the blood from the urinary tract infection. Urosepsis requires treatment with antibiotics and if untreated, urosepsis can progress to septic shock. Resident 1 developed septic shock and died on 3/11/12. Resident 1 was admitted to the facility on 11/7/2000 with diagnoses that included an irregular heartbeat, urosepsis, dementia, developmental delay, and Parkinson's disease. The Minimum Data Set (MDS - a resident assessment tool), dated 03/07/12, described Resident 1 as having disorganized thinking, short and long term memory problems, and severely impaired decision-making ability. She was totally dependent on staff assistance in transfers, dressing, eating, toileting and bathing. She required the use of a wheelchair to move about the facility. Resident 1's nursing notes revealed that Resident 1 was not eating well in early 2/2012. On 2/14/12 the physician ordered a urine analysis (a test to determine if there is bacteria/infection in urine) with culture and sensitivity (a test that identifies the type of bacteria and the antibiotic medications that would kill the bacteria). The tests, completed on 2/16/12, showed that Resident 1 had a urinary tract infection. On 2/16/12 at 1:15 pm, Resident 1's physician ordered an antibiotic; Nitrofurantion 100 mg twice a day for seven days. Resident 1's Medication Administration Record (MAR) for 2/2012 showed that the medication was started on 2/16/12 at 8 pm, and completed the seven full days of treatment on 2/24/12 at 8 am. On 3/6/12, Resident 1 again began refusing meals and medications. A urinalysis sample obtained early (3:00 am) on 3/7/12 was sent to the lab for an analysis and culture. The initial urine analysis, which indicated an infection was present, was reported back to the facility and a nurse ' s note dated 3/7/12 at 6:45 pm reads "Notified MD of urine culture, & (results) faxed to MD per request. "The final urine analysis which showed the specific bacteria causing the infection was available to the facility by 5:00 pm and a nurse ' s note dated 3/8/12 at 10 pm reads " UA (urine analysis) report in, notified M.D. Requests that results be faxed to him. Done. "Two and a half hours later at 12:32 am on 3/9/12, the physician faxed the report back to the facility. That fax returned by the physician had an order he had written at 12:20 am that reads: "Please give Rocephin 1 gram (the adult dose of an antibiotic for an adult) IM (injection into the muscle) every 24 hours for 7 days "Review of Resident 1's record including the nursing notes and the March 2012 Medication Administration Record (MAR) shows that order was never recorded and the medication, Rocephin, was not administered to Resident 1. Resident 1's facility record does not contain any nursing notes for the day of 3/9/12. The "ADL (Activities of Daily Living) Flowsheet" shows no nursing assistance was provided to Resident 1 during the day shift of 3/9/12. The next Nurse ' s note in the record is dated 3/10/12 at 1:30 pm and comments that Resident 1 is alert but only in that she recognizes her name; she is " refusing medications " ; but did each 80% of her lunch... and " Received no new orders." The following nurse ' s note written on 3/11/12 at 1:30 pm, documents Resident 1's temperature was 100.1, she was alert but only that she recognizes her name, and she is unable to swallow. Resident 1's physician and her responsible party were notified of the resident's change of condition. The next nursing note is timed to indicate is was written at 4:30 pm and contains the following information about recent events: Resident 1 ' s temperature was 101.8; she was seen by the physician who gave an order to start Rocephin (an antibiotic) and to give Tylenol for fever; the Tylenol was administered and the fever had come down to 100.0; at 3:20 pm, Resident ' s physician was with her and started an intravenous (IV) line in her right hand; but at 4 pm, the IV was discontinued because it had infiltrated causing fluid to enter the surrounding tissue rather than the vain ... The following nurse ' s note, dated 3/11/12 at 10:30 pm, reads: "The CNA (certified nursing assistant) informed me that the resident had stopped breathing." The record also contains a phone order form the physician timed at 3 pm on 3/11/12 for the following four specific treatments: * Rocephin 1 gram with lidocaine (a numbing medication to reduce the pain of the injection) IM (to be injected into the muscle) with 26 gage (smaller needle) one dose to be done stat (immediately) and continued (daily) for 10 days. * Tylenol 10 grains by suppository every 4 hours as needed for temperature above 100.5? * O2 (oxygen) 2 lt (liters) per minute to keep oxygen saturation above 90% * D5 1/2 NSS 1000cc (IV: intravenous fluids) to run at 135cc/hr for one bottle and then discontinue. The MAR for March 2012 shows that 3 of the 4 orders above, for Tylenol, oxygen and the IV fluids were each transcribed onto the MAR and then documented that each of these three treatments were administered. However the MAR does not contain a transcription of the order for Rocephin and there is no documentation in the MAR, in the nurse' s notes or elsewhere in Resident 1 ' s record that the antibiotic was given to Resident 1. On 6/6/12 at 3:10 pm, Licensed Nurse (LN) A stated she talked with the physician on the evening of 3/8/12 and faxed him a copy of Resident 1's lab results confirming that the resident had a UTI. LN A stated that she did not remember any mention of an order for Rocephin at that time. On 6/6/12 at 9:30 am, LN B stated he worked with two other nurses the night of 3/9/12 and barely remembered Resident 1. He stated he checked the fax machine "Two to three" times that night and did not remember seeing an order for Rocephin.On 6/20/12 at 4:15 pm, LN C who worked with LN B on the night of 3/9/12, stated that he had no knowledge of an order for Rocephin. A review of the facility's emergency drug supply showed that it contained Rocephin, however the supply was not accessed and the medication was not administered to Resident 1 as ordered on 3/9/12. On 6/6/12 at 5:15 pm, the Director of Nurses stated that she had reviewed all of the documents regarding unusual occurrences and medication errors and was unable to locate any reference to the failure to administer Rocephin to Resident 1 on 3/9/12. Resident 1's physician's progress note, dated 3/11/12, read, "Called to see resident because of fever, change in condition, when I saw her patient was obtunded, doesn't respond to painful stimuli, hand cold but dry. Temperature 102, blood pressure 100. Chest is clear respirations (breathing) labored. Heart rate 108 regular rhythm. E-coli (type of bacteria) UTI. Rocephin ordered on 3/9/12, but order was not carried out. Impression: Urosepsis, probable pending septic shock." During an interview on 6/7/12 at 4:25 pm, Resident 1's physician verified that he had faxed the order for Rocephin to the facility late on 3/9/12 and "someone picked it up." The physician stated, "We might have been able to prevent it (urosepsis) if she (Resident 1) had gotten the first shot." A certified copy of Resident 1's Death Certificate, dated 3/22/12, listed the cause of death on 3/11/12 as "Urosepsis." Therefore, the facility failed to ensure Resident 1 received daily injections of an antibiotic, Rocephin, to treat a urinary tract infection (UTI) as ordered by her physician on 3/9/12 at 12:20 am. This failure resulted in Resident 1 developing urosepsis; a life-threatening bacterial infection of the blood from the urinary tract infection. Urosepsis requires treatment with antibiotics and if untreated, urosepsis can progress to septic shock. Resident 1 developed septic shock and died on 3/11/12. This violation of regulations presented an imminent danger of death or serious harm to the resident or a substantial probability that death or serious physical harm would result and was a proximal cause of the resident's death.
230000221	Oroville Hospital Post-Acute Center	230009587	B	20-Nov-12	JVBH11	4713	F241 483.15(a) Dignity and Respect of Individuality The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.The facility failed to treat Patient 1 with dignity and respect when Licensed Vocational Nurse (LVN) E directed and assisted Certified Nursing Assistants (CNA) to shower the patient against his will. This resulted in Patient 1 experiencing anxiety, agitation, and emotional harm. During an interview on 2/23/12 at 5:30 pm, Complainant A (C A) stated that Patient 1 told her he was forcefully given a shower against his will. She stated that Patient 1 said to her, "The bastard held me down!" C A said that the incident had occurred on a Thursday, Patient 1's usual shower day, between 1/26/12 and 2/9/12, and that Certified Nurse Assistant (CNA) B, "May have some knowledge of the incident." Patient 1's clinical record was reviewed on 2/24/12. Patient 1 was a 62 year old male admitted to the facility on 5/9/05 with diagnoses that included alcohol dependency and bipolar disorder. The facility's Minimum Data Set (MDS - an assessment tool), dated 11/14/11, described Patient 1 as having severely impaired thought processes, however, he was usually able to understand and be understood by others, and that he needed the assistance one person to help him with bathing. A Behavioral Disturbance care plan, dated 7/2/11, addressed Patient 1's behavior of rejecting care. One of the care plan goals was for Patient 1 to have all his needs met.A planned approach to meet this goal, read, "If appropriate, stop giving care when patient is hostile, protect patient's dignity, and ensure safety, try later." During an observation on 2/24/12 at 3:55 pm, CNA D approached Patient 1 and asked him if he wanted a hot shower. Patient 1 responded, "Absolutely not! Last time they dragged me in there!" Patient 1's Shower/Bath sheets data for the months of 1/2012 and 2/2012 showed that Patient 1's last shower was given on 1/21/12.A nurse's note, dated 2/23/12 (no time), indicated that Patient 1 had become upset when he was asked to take his shower. It further indicated that the last time Patient 1 was given a shower, staff made him take the shower. During an interview with CNA B, on 3/9/12 at 10:15 am, she stated that on 1/21/12 at 11 am, she reported to Licensed Nurse (LN) E that Patient 1 refused to take a shower. CNA B stated that LN E told her and CNA C to put Patient 1 in a shower chair and give him a shower. CNA B replied to LN E, "We do not want to do this!" and suggested other forms of care such as a bed bath. CNA B stated that LN E wheeled Patient 1 to the shower room and Patient 1 was yelling that he did not want to take a shower all the way down the hallway. CNA B stated that she and CNA C then proceed to give Patient 1 a shower as directed by LN E while LN E held Patient 1's shower chair from behind. CNA B stated Patient 1 was very upset from the time he was offered a shower until he was back in his room.During an interview with CNA C on 3/9/12 at 10:40 am, she stated that on 1/21/12 at 11 am, she entered Patient 1's room and the room smelled of urine. She said that Patient 1 was sitting in his wheelchair with urine "Pouring" out of the back of his adult incontinence briefs onto the seat of his wheelchair. CNA C stated that she notified LN E. LN E then went to Patient 1's room with CNA C and told her to give Patient 1 a shower. When Patient 1 heard the word shower, "He looked like he was about to cry." CNA C stated that she offered Patient 1 a bed bath, but before he could answer her LN E told her, "Get him (Patient 1) in the shower!" LN E then pulled Patient 1 down the hall in a shower chair. CNA C stated, "Patient 1 was combative while in the shower; he continually refused to have a shower the entire time of the incident." During an interview with LN E on 3/9/12 at 11:15 am, he stated that Patient 1 was sitting in his wheelchair in "Overly saturated adult incontinence briefs." LN E stated that CNA B and CNA C asked him to help them with Patient 1 because, "The patient was upset about taking a shower." LN E said that he redirected Patient 1 by explaining the importance of a shower after which Patient 1 agreed to a shower. LN E said that he provided stand by assistance to prevent injury to the staff or patient.LN E's comments regarding the incident were not confirmed by witnesses, CNA B and C.Therefore, the facility failed to protect Patient 1's dignity when he was forced to take a shower against his will.This violation caused or occurred under circumstances likely to cause significant anxiety or other emotional trauma.
230000221	Oroville Hospital Post-Acute Center	230009595	B	20-Nov-12	K4KN11	4197	F226 483.1 (c) DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to implement their abuse prohibition policy on three separate occasions when Patient 1 sexually abused two female patients (Patients 2 and 3). Patient 3 reported the sexual abuse to the Dietary Department Supervisor (DDS) however, DDS did not report the incident to facility administration or the California Department of Public Health as required by law and facility policy. As a result of this failure, Patient 3's allegation of sexual abuse was not investigated, Patient 1's behavior was not addressed, other facility patients were not protected, and Patient 2 was also sexually abused by Patient 1. The facility's Abuse, Neglect and Misappropriation of Patient Property Prohibition Policy, dated 10/2010, consisted of seven components to ensure patients were not subject to abuse. The first addressed the screening for persons with abusive behaviors. The second component training, noted that employees received training on the facility's abuse prohibition policies and related policies and procedures during their "orientation, annually, and more often as determined by the facility." The third component, prevention, included, "Facility supervisors immediately intervene and correct reported or identified situations in which abuse, neglect or misappropriation of patient property is at risk for occurring." The fourth addressed identification of causes or triggers for potential or actual abuse situations. The fifth component, investigation, described the facility's investigation and reporting requirements and read, "The facility conducts a thorough investigation of allegations of ...abuse," and "reports investigation findings to the state agency within five working days." The sixth component was to ensure the patient was protected from harm during the investigation. The last component described the facility's responsibility to report allegations of abuse to administration and state agencies as required by law. On 5/21/12 at 4:15 pm, Patient 3 stated that approximately two months ago she was in the front hallway, returning to her room, when Patient 1 wheeled up to her and grabbed her breast. Patient 3 stated that she told Patient 1"No" and Patient 1 released his grip and immediately attempted to grab her breast again. Patient 3 also reported that approximately two weeks after the above mentioned incident, while in the same area of the facility, Patient 1 grabbed her crotch. Patient 3 again told Patient 1 "No" and he released momentarily and immediately attempted to grab Patient 3 again. Patient 3 stated that there was a group of staff in the hall at that time and she reported it one of them.During an interview on 5/22/12 at 10:25 am, Dietary Department Supervisor (DSS) B confirmed that while assisting Patient 3 back to her room on either 4/24 or 4/25/12, Patient 3 told her that she felt a little uncomfortable because Patient 1 had grabbed her crotch and that there had been a prior incident where he had grabbed her breast. DSS confirmed that she did not inform the facility's Abuse Coordinator or report Patient 3's allegation to the state survey and certification agency.In-service documentation provided by the facility showed that on 4/10 and 4/25/12, DDS received training on the facility's abuse prevention policy and mandated reporter requirements. Therefore, the facility failed to implement their abuse prohibition policy when Patient 3 reported an incident of sexual abuse to the Dietary Department Supervisor (DDS), and the DDS did not report the incident to facility administration or the California Department of Public Health as required by law and facility policy. As a result of this failure, Patient 3's allegation of sexual abuse was not investigated, Patient 1's behavior was not addressed, other facility Patients were not protected, and Patient 2 was also sexually abused by Patient 1. This failure had a direct or immediate relationship to the health, safety, or security of patients.
230000327	Orchard Hospital D/P SNF	230009977	B	24-Jan-14	KM4S11	6321	F 225 483.13(c)(1) (ii)-(iii), (c)(2)-(4) Investigate/Report Allegations/IndividualsThe facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. 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). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. 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). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.The facility failed to report the bruising of unknown cause to the Department for Patient 9 which related to the facility's policies and procedures, for abuse not being developed and/or implemented for the identification, investigation, and reporting of suspicious injuries or bruising as suspected abuse. This had the potential for the possibility of further abuse to occur.Patient 9, was a 96 year old female, admitted to the facility on 8/7/12, with diagnoses that included heart problems, diabetes, and anemia.On 6/20/13 at 9 am, Patient 9's record was reviewed after an incident of abuse was reported on 6/7/13.A Minimum Data Set (MDS, an assessment tool), dated 4/13/13, indicated that Patient 9 required limited to extensive assistance with activities of daily living (dressing, transferring, toilet care, and hygiene). Patient 9's care plans indicated she was alert and oriented with some confusion at times. On 5/4/13 at 8:30 pm, Licensee Nurse (LN) K documented, and faxed the following information to Patient 9's physician. Patient 9 ..."...had a large purplish/reddened area on her right areola with light purple area on her right anterior upper arm." Patient 9's..." right axillary region was swollen compared to her left axillary area. The area was tender upon palpation without signs or symptoms of infection." Patient 9 .."was unaware of how these areas appeared."On 6/20/13 at 11 am, Administrative (Admin) Nurse B and C were interviewed concerning the facility's policy on Abuse and Patient 9's large area of bruising to her right breast, and arm.Admin Nurse C stated and confirmed that the facility's abuse policy did not address investigating or reporting unknown injuries or bruising.On 6/20/13 at 11:05 am, Admin Nurse B stated that he did not report the bruising on Patient 9's right breast, underarm, and forearm according to the federal guidelines for reporting suspected abuse. Admin Nurse B also confirmed he did not do an investigation on Patient 9's unknown bruising. Admin Nurse B had no records that LN K, who discovered the bruising, had reported the incident to the abuse coordinator, Ombudsman, police, or the Department of Public Health (DPH). On 6/20/13 at 1 pm, Patient 9's right breast and arm were observed and had no bruising. A concurrent interview with Patient 9 was conducted. She stated that she was not aware of how the bruising had occurred and denied she had fallen or had been mishandled by staff during transfers. On 6/20/13 at 3 pm, LN K was interviewed. She confirmed that she had not reported the unknown bruising to the Admin Nurse B, DPH, or the Ombudsman. LN K could not confirm that Patient 9's bruising was not caused by rough handling or a possible fall and felt that her physician was the only one that required notification.On 6/20/13 at 3:30 pm, Admin Nurse B and C both confirmed that the facility's abuse policy did not address the guidelines of reporting or investigating unknown injures and that Patient 9's incident had not been reported within the mandatory 24 hours. The facility's failure to report an injury of suspicious or unknown cause to the Department within the required 24 hours related to the policies and procedures lacking the instructions for identification, investigation, and reporting of such injuries, put all patients within the facility at risk of abuse. These violations had a direct relationship to the health, safety or security of patients.
230000221	Oroville Hospital Post-Acute Center	230011355	B	16-Apr-15	LK6Y11	11889	T22 DIV5 CH3 ART3-72311(a)(3)(B) Nursing Service?General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient.T22 DIV5 CH3 ART3-72313(a)(2) Nursing Service?Administration of Medication (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. The facility failed to notify the physician of Patient 2's persistent, severe head pain (after recent brain surgery), to follow the physician's orders to administer inhalant (breathed in) medication and oxygen when needed for Patient 2's change in respiratory condition, and failed to initiate Cardio Pulmonary Resuscitation (CPR), in accordance with the Physician Orders for Life-Sustaining Treatment (POLST), when Patient 2 was found unresponsive, breathless, and pulseless. Patient 2 died on 1/13/13. Patient 2's record was reviewed. Patient 2 was a 76 year old male admitted to the facility on 12/21/12 for rehabilitation, with the goal to discharge home as soon as possible. Review of the physician's admission history and physical (H&P) examination, dated 12/21/12, indicated Patient 2 had diagnoses that included a history of bleeding in the brain, benign (not cancer) tumor removal, chronic obstructive lung disease, aortic stenosis (narrowing of the aortic valve of the heart), high blood pressure, chronic back pain, weakness, and anxiety. The physician documented Patient 2, "has capacity to understand and make decisions," his lungs were, "clear," and vital signs (blood pressure [BP], heart rate [HR], respiratory rate [RR], and temperature [T]) were within normal limits: BP 135/69, HR 60, RR 18, and T 97.2 F (Fahrenheit). Patient 2's record contained a document, dated 12/21/12, titled, "Physician Orders for Life-Sustaining Treatment" (POLST), which read, "Attempt Resuscitation/CPR...Full Treatment...interventions use intubation, advanced airway intervention, mechanical ventilation and defibrillation/cardioversion as indicated." On 1/4/13, Patient 2 was, "stable for transfer" to an out of area hospital for a pre-scheduled surgical procedure (Craniotomy-surgical removal of part of the skull bone). Patient 2 was readmitted to the facility on 1/9/13, with diagnoses that included chronic obstructive lung disease, high blood pressure, chronic pain, generalized weakness and anxiety, aortic stenosis, and abnormal gait (unsteady walking) for rehabilitation with a discharge goal to discharge home, as soon as possible. Review of the physician's re-admission H&P examination, dated 1/9/13, indicated Patient 2 had, "scattered rhonci (coarse rattling respiratory sounds usually caused by secretions in bronchial airways), Cranioplasty (surgical repair of a defect in the skull bone), Craniotomy, Rt. (right-sided) hemiplegia (weakness)" diagnoses, and the capacity to understand and make his own decisions. However, the physician's 1/9/13 admission orders indicated Patient 2 could not understand and/or make healthcare decisions, indicating the patient's wife as a surrogate decision maker. Patient 2 had, "good" rehabilitation potential and CPR was to be provided. Review of Patient 2's care plans, initiated on 1/9/13 and 1/10/13, indicated Patient 2 had a surgical incision (24 stitches) to his head and discoloration to his left eye (18.0 x 16.0 x 0-unit of measure not stated e.g., inches or centimeters), behind his left ear (22.0 x 12.0 x 0-unit of measure not stated), and on his left arm (generalized). Patient 2 could not care for himself, was unable to walk, required maximum assistance from staff for mobility and transfers, and was dependent on staff for activities of daily living, such as bathing and feeding. Patient 2 had impaired swallowing, requiring special positioning when taking oral fluids/foods, making him a risk for aspirating (inhaling) fluids/foods into his lungs which can cause increased congestion, shortness of breath, infection, and respiratory failure/death. Patient 2 was to be observed and assessed for signs and symptoms of infection, aspiration (shortness of breath, elevated Temperature, rhonci/wheezing, coughing), and heart dysfunction (headache, chest pain, dizziness, vision changes, abnormal BP, and edema (excess body fluid)). The record contained a physician's order, dated 1/9/13, for oxygen to be administered at 2 liters per hour, as needed (PRN), and DuoNeb (combination of two medicines, ipratropium bromide and albuterol sulfate, used to help open airways) three times daily via inhalant mask for congestion, as needed. On 1/11/13, the physician ordered to discontinue routine DuoNeb and keep DuoNeb 0.5/3 milligrams, every 4 hours, as needed, for congestion, bilateral (both lungs). The nurse's admission note, dated 1/9/13, indicated Patient 2's vital signs were within normal limits: BP 138/68, HR 72, RR 16, T 97.6 F. Patient 2 had even, unlabored breathing with congestion bilaterally, and no cough. Review of nursing progress notes indicated the following: On 1/10/13 at 2 pm, Patient 2's pain was poorly controlled and new pain medication orders were received, the nurse noted the patient had not urinated during the shift and abdomen was slightly distended. The physician was notified and a Foley catheter (a tube inserted into the bladder so urine can drain into a collection bag) was placed with a return of clear yellow urine; On 1/11/13, nurses noted that Patient 2 was able to make his needs known with delayed speech; On 1/12/13 at 7 am, Patient 2 complained of a headache (severe 8/10 pain), there was no documentation that the physician was notified on this day. After being medicated with Methadone and Dilaudid (strong narcotics), Patient 2's pain was 4-5/10, moderate. Patient 2 stated his pain was, "tolerable" through the day shift and urine color was, "straw" (different from clear yellow on 1/10/13). At 9:50 am, Patient 2 continued to have pain, requiring pain medication and his urine was, "dark amber" colored (different from, "straw" colored); On 1/13/13 at 12 pm, Patient 2 complained of a headache (severe and worsened 10/10 pain) requiring pain medication. There was no indication that the physician was notified at this time. At 3:30 pm, Patient 2 was noted to be congested, bilaterally. There was no documented evidence of oxygen saturation level monitoring or administration, as ordered by the physician, for bilateral congestion. At 4 pm, a Certified Nurse Assistant (CNA) reported to a nurse that Patient 2 was not breathing and the nurse could not obtain a respiratory rate or heart rate; Patient 2 was now unresponsive. The physician was called and ordered Patient 2 to be transported to the morgue; On 1/13/13, after the above 4 pm entry, a nurse made an assessment note, timed 11:30 am, that Patient 2 was, "noted unable to articulate any words. Offered thickened H2O (water)-took small sips. Residents facial expression showed distress also noted movement of legs & feet. When asked if hurt Resident gestured with both his arms spread far apart & nodded yes. When asked where he put hand on head. Medicated for pain by RN...cool washcloth rubbed on face & back of neck. Resident appeared calm-less distress. Noted audible (can hear aloud without using stethoscope) Rhonci." There was no documentation that the physician was notified of this significant change in Patient 2's condition; and On 1/13/13 at 5:45 pm, a nurse documented, "Called to residents room stat (immediately). Resident presented without respirations, without pulse, cool to touch on face, face pale - lips without color. Staff called 9-1-1, LVN (Licensed Vocational Nurse) retrieved crash cart (equipment used to emergency resuscitation efforts). Resident remained non-responsive, without pulse or respirations. MD called - orders received to transport to mortuary." Review of the January 2013 medication administration record (MAR) for Patient 2 indicated the following: On 1/9/13 at 4:30 pm, Patient 2 was restless and given Xanax (a benzodiazepine used to treat anxiety) and complained of 10/10 pain and was given Oxycodone (an opioid pain medication used to treat moderate to severe pain); On 1/10/13 at 10 am, Patient 2 complained of a headache (severe 9/10 pain), was medicated with Percocet 10/325 mg, and no effectiveness after medication administration was documented. At 11:45 pm, Patient 2 remained in severe 9/10 pain, was medicated with Percocet 10/325 mg, with a 8/10 severe pain result timed at 11:30 pm (15 minutes before the medication was given); On 1/11/13 at 9 am, Patient 2 complained of a headache (severe 8/10 pain), was given Dilaudid 4 mg, with no documentation of effectiveness after medication administration. At 12 pm, Patient 2 complained of a headache (severe 8/10 pain), was given Dilaudid 4 mg, with no documentation of effectiveness after medication administration. At 3 pm, Patient 2 complained of a headache (severe 8/10 pain), was given Dilaudid 4 mg, with no documentation of effectiveness after medication administration; On 1/12/13 at midnight, Patient 2 complained of a headache (severe 8/10 pain), was given pain medication that was documented to be effective with a new severity of 3/10 (mild pain). At 9 am, Patient 2 complained of a headache (severe 8/10 pain), was given Dilaudid 4 mg, with no documentation of effectiveness after medication administration. At 12 pm, Patient 2 complained of a headache (severe 8/10 pain), was given Dilaudid 4 mg, with no documentation of effectiveness after medication administration. At 3 pm, Patient 2 complained of a headache (severe 8/10 pain), was given Dilaudid 4 mg, then was described to be "resting." At 6 pm, Patient 2 complained of a headache (severe 8/10 pain), was given Dilaudid 4 mg, the result was described as "effective, rest" (at 7 pm); On 1/13/13 at 9 am, Patient 2 complained of a headache (severe 8/10 pain), was given Dilaudid 4 mg, the result was "asleep." At 11:45 am, Patient 2 complained of a headache (severe 10/10 pain), was given Dilaudid 4 mg, with no documentation of the effectiveness after medication administration. (Patient 2 was found unresponsive at 4 pm by a CNA). On 10/21/13 at 10:25 am, Administrative Nurse (AN) C was interviewed and confirmed that Patient 2 died on the afternoon of 1/13/13. AN C stated that she was called to the room, she found Patient 2 unresponsive, with no pulse, cold and pale. AN C stated she did not know Patient 2's CPR status (desire for cardiopulmonary resuscitation efforts) when she entered the room and did not start CPR because he felt cold, looked pale, and she thought he was gone (dead). AN C stated she called the physician and he ordered Patient 2 to be taken to the mortuary, after pronouncing the patient dead over the telephone. On 10/21/13 at 11:40 am, during an interview and record review, AN A confirmed that there were two separate entries in the nurse's notes for 1/13/13 that described Patient 2 as having congestion and that there was no documentation that oxygen was administered, or that the PRN DuoNeb breathing treatment was given, as ordered by the physician. On 1/29/13, the physician's discharge summary documentation indicated, "Expired" as Patient 2's condition on discharge. The "Cause of Death" section was blank. Therefore, the facility failed to notify the physician of Patient 2's persistent, severe head pain (after recent brain surgery), to follow the physician's orders to administer inhalant medication and oxygen when needed for Patient 2's change in respiratory condition, and failed to initiate CPR, in accordance with the POLST, when Patient 2 was found unresponsive, breathless, and pulseless. Patient 2 died on 1/13/13. These violations had a direct and immediate relationship to the health, safety, or security of patients.
250001440	ORMISTA HOUSE	250009725	A	13-Feb-13	OQLY11	6799	483.470(g)(2) W-436 - The facility must furnish, maintain in good repair, and teach clients to use and to make informed choices about the use of dentures, eyeglasses, hearing and other communications aids, braces, and other devices identified by the interdisciplinary team as needed by the client. 483.410(a)(1) W-104 - The governing body must exercise general policy, budget, and operating direction over the facility. 483.460 (c)(4) W-339- The facility must provide clients with nursing services in accordance with their needs. These services must include other nursing care as prescribed by the physician or as identified by client needs. On April 18, 2012, an unannounced visit was made to the facility to investigate an entity-reported event regarding Client A's fall from bed that resulted in a fracture to the right femur (upper leg). It was determined that the facility failed to ensure bed side rails for Client A were in a safe and functioning condition, and which were able to lock in place. This failure allowed Client A to dislodge one side rail, fall to the floor, and suffer a fracture of the right femur. Additionally, the facility failed to follow their policy and procedure, and provide needed nursing care for safe transfer of Client A to an emergency room, after the client fell from bed and facility staff were unable to reach the Registered Nurse. On April 18, 2012, Client A's record was reviewed. He was admitted to the facility on July 24, 2003, with diagnoses including severe mental retardation, cerebral palsy (a disorder characterized by impaired voluntary movements); and self-abusive behavior. The client was non-verbal, but made his needs known by loud vocalizations. Movement of his upper extremities was spastic; he was wheelchair-bound and unable to walk. Client A had frequent temper outbursts that were evidenced by self-injurious behavior, screaming, and pushing others. He lacked safety awareness both within the home and in the community. Client A had an undated physician's order that indicated: "Side rails on bed anytime in bed." The order did not indicate the reason for side rail use. According to the Qualified Mental Retardation Professional (QMRP), Client A needed the side rails for safety because the client moved around a lot and needed them to prevent falling from bed.On April 18, 2012, at 8:30 a.m., during an interview with Direct Care Staff 4 (DCS4), she stated she was working the night shift on April 16, 2012, and was in the facility when Client A fell from bed. She stated, between 4 a.m. and 5 a.m., after hearing a loud bang, she went to Client A's room, and found him lying on the floor, on top of a side rail, next to his bed. She stated the client was taken to an emergency room for treatment. DCS4 stated Client A needed the side rails to prevent him from falling out of bed. The emergency room records, dated April 16, 2012, were reviewed. Client A was found to have a right femur fracture, and a splint was applied to his right upper leg along with a soft cast to his right lower leg. He was given a prescription for Tylenol #2 (Tylenol with codeine) for his pain. On April 19, 2012, at 12 p.m., the Facility Manager (FM) was interviewed. She stated Client A attended an out-of-facility day program five days a week. Since his fracture he was unable to attend, and became very upset each day when he could not go. She stated he could not attend the program for at least four weeks until the splint and cast were removed. On April 18, 2012, at 9:30 a.m., the side rails in use at the time of the incident were observed. They were made of wood and consisted of two horizontal slats. Latches were on both ends of the side rails, and were observed to slide back and forth easily. They were easily unlatched when in place on the bed and did not have the capacity to lock into place. On April 18, 2012, at 11:10 a.m., the FM was interviewed. She stated after the fall, the side rail was checked. It was determined that the client was possibly able to disengage the unlocking sliding latches, dislodge the side rail, and raise it out of the slot on the bedframe. On April 19, 2012, at 12:05 p.m., the maintenance supervisor was interviewed. He stated he made the side rails, but did not follow any printed instructions for their construction. He stated he followed the instructions of the QMRP concerning dimensions.On April 18, 2012, at 10 a.m., the QMRP was interviewed. She stated, when she was notified of Client A's fall and swollen right knee, on April 16, 2012, at 5:30 a.m., she was told by Direct Care Staff 4 (DCS4) that the client needed to be taken to emergency room for evaluation. She stated the Registered Nurse (RN) made the decision to transport Client A by facility van, rather than call 911. During an interview with the RN on April 18, 2012, at 10:10 a.m., she stated she did not give instructions to transport Client A by facility van to emergency room. She stated a telephone message was left for her about the incident, and by the time she returned the call to the facility, the client had already been placed in a wheelchair and transported by facility van to emergency room. She stated the facility did not call 911, or notify Client A's physician. During an interview with DCS4 on April 18, 2012, at 10:20 a.m., she stated it was the decision of the QMRP, the FM, and DCS4 to place client A in a wheelchair and transport him by facility van to the emergency room. She stated the FM and DCS4 lifted the client from the bed into a wheelchair, and did not immobilize the right leg during transport. She stated staff did not call 911, or notify the physician.A facility document, titled, "Policy & Procedures on Assessments and Notifying Primary Physician", indicated, "...the RN will make judgment in a timely manner on whether a face to face assessment is necessary...Thereafter, RN will notify MD for a consult and/or come to an agreement w/MD (with MD) to determine whether the client requires medical services from an Urgent Care facility and/or a hospital emergency room...In an emergency, DCS (Direct Care Staff) will call 911 immediately then notify the RN or QMRP. RN will also notify the MD." Client A suffered pain, physical harm, and the inability to attend his day program for four weeks. This was due to the facility's failure to maintain the client's side rails in a safe and functioning condition. Additionally, the facility failed to provide needed nursing service and follow their policy and procedure for performing an assessment and safe transfer to the emergency room after the client suffered a fracture of the right leg. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.
910000004	Osage Healthcare & Wellness Centre	910010591	B	17-Apr-14	E19311	1737	California Code of Regulations Title 22 Section 72601(a) Alterations to existing buildings licensed as skilled nursing facility 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 April 10, 2013 at 8:30 a.m., an unannounced visit was made to the facility to initiate an annual Recertification survey. Based on observation, interview and record review, the facility failed to comply with the requirements from Office of Statewide Health Planning and Development (OSHPD), the authority having jurisdiction for the alteration and construction work in health care facilities by: Removing the exhaust hood and stove in the kitchen and changing the kitchen to a rehabilitation room without permits and/or approvals from OSHPD. During general observation of the facility and review of the facility floor plan on April 10, 2013 at 10:23 a.m., there were noted alterations to the facility floor plan. The evaluator observed the following: A review of the facility floor plan indicated that there was a kitchen located in the east front building near the director of nursing office. However this room had been changed to a rehabilitation room. During an interview with the maintenance supervisor on April 10, 2013 at 10:23 a.m., at the time of the observation he stated he was not aware if the facility had submitted plan or had approval for the change. On April 10, 2013 at 2:30 p.m., during an interview with the administrator, she stated no plans ahd been submitted to OSHPD for the change to remove the facility kitchen. The violations had a direct relationship to the health, safety and security of all patients of the facility.
910000004	Osage Healthcare & Wellness Centre	910011182	A	24-Dec-14	E5DY11	8945	72315. Nursing Service-Patient Care. (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The Department received an entity reported incident (ERI) on September 27, 2012, alleging a staff to patient abuse during care resulting in the patient (Patient 1) sustaining a reddish/purplish discolored left eye. The licensed vocational nurse (LVN 1) failed to report the incident timely. Based on observation, interview, and record review, the facility failed to: 1. Ensure Patient 1 was free from physical abuse. 2. Follow its policy regarding reporting abuse to the administrator immediately. Patient 1 was physically abused by a certified nursing assistant (CNA1) resulting in a left eye contusion requiring further evaluation at a general acute care hospital?s (GACH) emergency room with a final diagnosis of blunt head and face trauma. On October 5, 2012 at 7:10 a.m., an unannounced complaint investigation was conducted. A review of a SOC 341, a report of suspected dependent adult/elder abuse, dated September 26, 2012, and timed at 12 p.m., indicated CNA1 was suspected of assault and battery on Patient 1. According to an abuse investigation conducted by the facility on September 26, 2012, LVN 1, CNA2, and CNA 3 heard a noise from Patient 1?s room and they all went to the room to investigate. They saw CNA1 at the patient?s bedside and Patient 1 informed LVN1 that CNA1 had struck her in the face. LVN1 asked CNA1 what happened and he stated the patient was resisting care and being difficult. LVN1 asked CNA1 did he hit the patient and he stated, ?No.? The investigation indicated LVN1 failed to report the incident. The facility?s investigation conclusion indicated they found the abuse incident unsubstantiated due to the following reasons: 1. There were no witnesses. 2. CNA1 appeared to be honest and sincere. 3. CNA1 has been a CNA 12 years without any other allegations. The investigation conclusion further indicated it was clear the patient was hurt with left eye bruising, but CNA1 could not explain what happened. The CNA failed to handle the situation in the safest manner, when the patient was resisted to care, for this reason, the facility decided to terminate CNA1 and report to the CAN board. A review of Patient 1?s Face Sheet indicated the patient was an 88 year-old female who was admitted to the facility on May 7, 2012. Her diagnoses included hypertension (high blood pressure) and dementia with psychosis (brain diseases that cause long term loss of the ability to think and reason clearly that is severe enough to affect a person's daily life). According to a Minimum Data Set (MDS/ a standardized assessment and care screening tool), dated September 3, 2012, indicated the patient was modified independent and usually had the ability to be understood and understand others. The MDS indicated the patient had some memory problems, but was able to recall staff names and faces. Patient 1 was non ambulatory and required extensive assistance with all activities of daily living, except eating. The MDS under E0800, Rejection of Care, indicated a ?0? indicating the patient did not exhibit any behaviors of resisting care. A review of the facility?s Interview Record, dated September 26, 2012, and timed 10:30 a.m., indicated Patient 1?s roommate (Patient 2) was interviewed. According to interview record, Patient 2 stated she was in the room watching television and she saw CNA1 transfer Patient 1 from the wheelchair to the bed. Patient 2 stated Patient 1 was kicking, striking out, and resisting care. Patient 2 stated she heard some slapping sounds coming from Patient 1?s bed direction and then heard Patient 1 yell over and over, ?You hit me in my eye.? Patient 2 stated then the nurses came in and she stopped paying attention. Another facility?s Interview Record, dated September 26, 2012, and timed at 3:20 p.m., LVN1 indicated she heard a loud noise on September 25, 2012, at approximately 9:30 p.m., which she thought someone had fallen. She stated she went to Patient 1?s room and saw CNA1 and asked him was everything alright and he stated yes. However, Patient 1 stated, ?Can you take your son out of here, because he kicked me in my eye and I cannot see.? LVN1 stated she checked Patient 1, but there was no bruise or discoloring noted. LVN1 stated she informed the charge nurse, LVN2, what happened and he stated he would inform the director of nurses. A review of the facility?s policy titled, Reporting Abuse to the Administrator, and dated January 1, 2012, indicated the facility?s staff, consultants, attending physicians, volunteers, and visitors must promptly report any incident or suspected neglect, abuse, mistreatment, or misappropriation of resident property to the administrator. A review of an interview record of CNA2?s interview, conducted by the facility on September 26, 2012, without a time, indicated she heard a loud noise from Patient 1?s room on September 25, 2012 at 9:30 p.m., and went to see what happened with LVN 1 and CNA3. CNA2 stated she heard LVN 1 asking what happened and stated to CNA 1, ?If her eye is black tomorrow, you are in trouble.? At 7:10 a.m., October 5, 2012, Patient 1 was observed in her room with a slight dark ring around her left eye, ten days after the incident occurred, and stated, ?He hit me, I don?t know his name, or why he hit me?it was during my bad time.? On October 5, 2012, at 9:10 a.m., during an interview, the director of nurses (DON) stated on the 26th of September, 2012 in the morning, a CNA (CNA 5) saw Patient 1 with a bruise around her left eye. The DON stated Patient 1?s roommate, Patient 2, stated someone had hit Patient 1 in the eye the night before. The DON stated, once the family member was notified, they requested for Patient 1 to be seen by a physician and the patient was transferred to the emergency room. The DON was asked what the policy was regarding an alleged abuse, she stated, ?I would have expected them to notify me immediately and send the CNA home, but they did not.? During the concurrent interview, the assistant administrator stated LVN 1 and 2 were written up and CNA 1 was taken off the schedule with plans to terminate him. On October 5, 2012 at 11:30 a.m., the director of staff development (DSD) stated the CNA should have asked for help, if Patient 1 was combative during care. At 1:45 p.m., on October 5, 2012, during an interview, Patient 2, Patient 1?s roommate stated, ?I told them she was screaming and yelling, and he (CNA 1) kept telling her to keep still and I heard some ?pops? and I thought she was hitting him, but then I heard her yell he hit me in the eye.? A review of Patient 2?s face sheet indicated the patient was re-admitted to the facility on August 13, 2012, with diagnoses that included hypertension (high blood pressure) and esophageal reflux (condition wherein stomach contents regurgitate or back up (reflux) into the esophagus [a long cylindrical tube that transports food]). A review of a MDS, dated September 10, 2012, indicated Patient 2 had the ability to be understood and understands others with memory intact with good recall without cueing required. A review of the GACH?s emergency room?s records indicated the patient arrived on September 27, 2012, at 10:46 p.m., two days after the incident occurred and after the family insisted the patient to be seen by a physician. The patient?s total Glasgow Coma Scale (GCS) for eye opening, motor, and verbal had a total score of 15 (neurological scale that aims to give a reliable, objective way of recording the conscious state of a person with a total score of 15). The records indicated the patient had bruising around the left eye and the physician wanted the patient to be further evaluated. The vital signs were within normal limits (Blood pressure 115/89, heart rate 66, respiratory rate 16, and oxygen level at 99% room air). A computerized tomography (CT), uses a computer that takes data from several X-ray images of structures inside the body, was ordered of the patient?s facial bones and head due to the trauma without any fractures or bleeding noted. The ER Discharge final impression included blunt head and facial trauma. The Patient 1 was discharged from the GACH on September 28, 2012, at 4:17 a.m. and transported back to the facility by ambulance. The facility failed to: 1. Ensure Patient 1 was free from physical abuse. 2. Follow its policy regarding reporting abuse to the administrator immediately The above violations jointly, separately, or in any combination presented a substantial probability that death or serious physical or mental harm would result.
920000029	Oakpark Healthcare Center	920010469	B	12-Feb-14	I7HC11	5094	Title 22, Division 5, Chapter 3, Article 6 ? 72601 (a)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 January 24, 2014 at 1:30 p.m., an unannounced visit was made to the facility to investigate a complaint allegation that the facility was undergoing construction. Based on observation, interview and record review, the facility failed to obtain required approvals from the Office of Statewide Health Planning and Development (OSHPD), the authority having jurisdiction for alteration and construction work in healthcare facilities, as evident by performing the following work without first obtaining the required permits: 1. Renovating the entrance/lobby, dining room, nursing station, social service office, beauty shop, employee lounge and the shower rooms. 2. Installation of recessed lighting fixtures. On January 24, 2014, during a tour of the facility with the Administrator, it was observed that construction renovations were in progress. There was plastic sheathing separating the lobby and the hallway in front of the nurses? station. The renovation was in progress in the lobby and the dining room. The renovation had already been completed in the following areas: shower rooms, extension of the social service office, conversion of the beauty shop to an employee lounge, conversion of the employee lounge to a rehab room with installation of a new wall for the beauty shop, installation of recessed lighting and re-facing the nurses? station.The Administrator was interviewed by the evaluator as they took the tour of the facility and she stated she did not know if the facility had approval from OSHPD for the renovations and that she had to call and ask the owner. When the owner called, the Administrator was informed that no permit from OSHPD was obtained for the renovation.A review of the OSHPD report dated January 27, 2014, indicated: 1. Unapproved renovations in progress have blocked or removed the main entrance and lobby from service. 2. Several areas and rooms that have been renovated and are currently in the process of being renovated with new and/or altered wall framing, removal of at least one bathroom, new floor covering and wall finishes. 3. The unauthorized installation of at least 120 recessed lighting fixtures, switches, electrical conductors and appurtenances without required review, permits or approval from OSHPD. 4. The unauthorized installation of at least 25 surface mounted lighting fixtures, switches, electrical conductors and appurtenances in the exit access corridor without required review, permits or approvals from OSHPD 5. The unauthorized installation of several ceiling mounted exhaust fans that penetrate the fire resistive roof-ceiling assembly without required opening protection or dampers. 6. Several HVAC (heating, ventilation and air conditioning) duct penetrations of the bottom membrane of the fire resistive roof-ceiling assembly in the unauthorized renovated areas that were missing the required fire damper and/or smoke/fire damper and appears to have been altered without required review, permits or approvals from OSHPD. 7. The unauthorized installation and alteration of electrical power receptacle outlets and miscellaneous electrical alterations without required review, permits or approvals from OSHPD. 8. The unauthorized installation of new replacement window and door assemblies without required permits, plan approval, inspection, testing or approvals from OSHPD. 9. The unauthorized installation of replacement hand-rails in the exit access corridor without required review, permits or approvals from OSHPD. 10. The unauthorized alterations of plumbing fixtures and piping in the newly renovated areas. Alterations included the removal of an existing bathroom for an apparent office use or expansion, installation of new shower valves and appurtenances in the two shower rooms as well as new sinks in the nurse utility room and beauty shop without required review, permits or approvals from OSHPD. 11. The unauthorized removal or disabling of fire alarm system components in areas where the unauthorized work is in progress. 12. The counter for the newly nurse station encroaches excessively into the required width of the exit access corridor. The facility failed to obtain required approvals from the Office of Statewide Health Planning and Development (OSHPD), the authority having jurisdiction for alteration and construction work in healthcare facilities, as evident byperforming the following work without first obtaining the required permits: 1. Renovating the entrance/lobby, dining room, nursing station, social service office, beauty shop, employee lounge, and the shower rooms. 2. Installation of recessed lighting fixtures. These violations had a direct relationship to the health, safety, or security of all patients.
920000029	Oakpark Healthcare Center	920011543	AA	16-Sep-15	WFEC11	13933	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. On 3/7/13, at 1:30 p.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care. Based on interview and record review, the facility failed to provide Resident 1 with the necessary care and services in accordance with the comprehensive assessment, plan of care and physician?s orders by failing to: 1. Ensure licensed nurses monitored the condition of a left heel wound for signs and symptoms of infection (such as odor, presence of fluid or drainage, and increased temperature of the area), response to treatment, changes in size and color, and presence of pain. 2. Follow the physician?s order to obtain a wound consultation in a timely manner. 3. Implement the recommendation by the wound consultant physician to have a follow up evaluation a week after the initial evaluation. 4. Implement pain management interventions when the resident manifested pain to the affected left leg/foot and had increased behavioral manifestations of crying and continuous yelling for help. On 1/16/13, Resident 1's left heel was evaluated by a wound consultant physician who diagnosed infected gangrene (dead tissue caused by an infection or lack of blood flow) on the left heel. On the same day, Resident 1 was transferred to a general acute care hospital (GACH) where she was diagnosed and treated for severe pain to the left heel, gas gangrene [potentially deadly form of tissue death caused by a bacteria. Gas gangrene causes very painful swelling, foul smelling discharge, and when the swollen area is pressed, gas can be felt as a crackly sensation (crepitus)] with foul smelling drainage, creamy-yellowish in color and, osteomyelitis (infection of a bone) of the left heel, urinary tract infection, and septicemia (blood poisoning, a life-threatening complication of an infection), which caused Resident 1?s death on 1/27/13 at the GACH.A review of the clinical record indicated the Resident 1 had been initially admitted to the facility on 5/11/12 and was transferred to GACH seven times, with the last readmission dated 11/12/12. Resident 1?s diagnoses included chronic kidney disease Stage 4 (advanced kidney damage), diabetes mellitus (high blood sugar levels), anemia (deficiency of red blood cells), and dementia (a group of thinking and social symptoms that interferes with daily functioning).The admission nursing assessment documented the resident was readmitted with a Stage 2 (skin is broken) wound to the left heel measuring three centimeters (cm) by two (cm).The Minimum Data Set (MDS -standardized assessment and care planning tool) dated 11/25/12, indicated the resident had memory problems, was able to communicate verbally, had daily behavioral symptoms not directed toward others, required extensive assistance with transfer, dressing, and walking, and required total assistance with toilet use, personal hygiene, and bathing. A review of the readmission physician?s orders included monitoring pain every shift, treatment to the left heel with Vitamin A & D ointment twice a day, and acetaminophen (pain medication) 325 milligrams (mg) orally one tablet as needed (PRN) for mild pain. The psychoactive (mind altering) medications ordered on readmission were Remeron 15 mg orally for depression manifested by poor appetite, Xanax 0.25 mg every six hours PRN for anxiety manifested by crying out, ?Help me,? and Haldol 0.5 mg orally at night for dementia with psychosis (mental disorder characterized by a disconnection with reality) manifested by continuous yelling out, ?Help me.?The plan of care developed upon readmission on 11/12/12, included the resident?s problem of potential for leg pain and edema due to peripheral neuropathy (pain from nerve damage) due to diabetes. The approaches included assess when the resident complained of pain and check extremities for pulses, color, coolness, and swelling. The plan of care addressing the resident?s psychoactive medications for behavioral manifestations included in the approaches to listen attentively and attempt to resolve or discuss area of upset. The approaches did not include determining if the behaviors were the result of pain.On 11/13/12, the treatment order to the left heel was changed to cleansing the left heel wound with normal saline solution (treated salty water, free from germs), apply triple antibiotic and cover with a dry dressing twice a day for 30 days. On 11/26/12, the psychiatrist evaluated the resident and ordered to increase the Haldol to twice a day and added Trazadone (antidepressant) 50 mg for depression manifested by crying and tearfulness. On 12/5/12, Haldol was increased to three times a day. On 1/10/13, the psychiatrist discontinued Haldol (not effective) and ordered Depakote Sprinkles (mood stabilizer) 125 mg twice a day for continuous yelling for help. On 12/19/12, a telephone physician?s order was obtained to change the left heel wound treatment to cleanse the wound with normal saline solution, apply Santyl ointment (debridement agent that removes dead tissue from wounds) twice a day and cover with a dry dressing for 21 days due to non-healing wound. The physician also ordered to have a wound care consultation which was not done until 1/1/13, 13 days after it was ordered on 12/19/12. The reason for the licensed nurse to call the physician and obtain new orders related to the wound was not documented in the clinical record. From readmission to 12/19/12, there was no documentation of the progress of the left heel wound; there was no description of the wound condition such as size, depth, pain, color, swelling, temperature, drainage, and response to the treatment. There was no documentation the wound had deteriorated from a Stage 2 (superficial) to having presence of dead tissue [Stage 3, 4 or undetermined (UTD - the base of the sore cannot be seen due to dead tissue])On 1/1/13, Wound Consultant 1 documented on 1/1/13, the left heel wound measured 6 cm in length, 3 cm in width and UTD depth; 100 percent black necrotic (dead) tissue; no evidence of active infection; no drainage; pulses were not present (blood flow was not detected though pulse sensation). Wound Consultant 1 documented there was no need of debridement (removal of dead tissue) at the time, recommended vascular study on the left lower extremity, and to monitor the wound for visible or expressible liquid drainage or other signs of infection under or around the eschar (dead tissue) which would require debridement. Wound Consultant 1 documented to arrange another wound consultation for the following week, which was not done until 15 days later, on 1/16/13.Between 1/1/13 and 1/16/13, there was no documented evidence the licensed nurses monitored the condition of the wound for presence of drainage, presence of pain to the wound or other signs of infections as recommended by Wound Consultant 1. On 1/16/13, Wound Consultant 2 documented the left heel wound measured 9 cm in length, 10 cm in width and UTD depth (the wound increased in size since 1/1/13); had 100 percent black necrotic; foul odor and diagnosed infected gangrene. According to the licensed nursing noted dated 1/16/13, timed at 3 p.m., Resident was screaming and yelling without apparent reason. At 3:30 p.m., another nurse documented the resident continued to yell repeatedly and complaining of severe pain to the left heel, pain medication not effective, and the attending physician (Physician 1) was called. At 4 p.m., the same nurse documented Physician 1 ordered to transfer the resident to a GACH due to uncontrollable pain. At 4:30 p.m., the same nurse documented the family was at Resident 1?s bedside trying to control the resident.Resident 1 was transferred to a GACH on the same day 1/16/13, at 5:30 p.m., where according to the GACH clinical record review, the resident arrived in severe pain and was given Morphine Sulfate intravenous (IV), was diagnosed with gas gangrene on the left heel, and the wound was described as having foul smelling drainage, creamy-yellowish in color. The resident was admitted to the GACH and was further diagnosed with osteomyelitis (infection of a bone) of the left heel, urinary tract infection, and septicemia. The resident underwent surgical debridement of the left heel wound on 1/20/13. Resident 1 expired on 1/27/13 at the GACH.Since Resident 1?s admission to the facility on 11/12/12 to the date of transfer on 1/16/13, the weekly licensed nursing notes lacked documentation of the progress of the left heel wound and a description of its condition; presence or absence of pain to the wound area was not addressed. There was no documentation pain management related to the wound was provided. There was no new order for pain medication since admission. On 1/11/13 Tylenol #3 (acetaminophen and codeine, a narcotic pain medication) one tablet orally twice a day PRN was ordered for severe pain. On 1/14/13, the physician added Tylenol # 3 three times a day routinely for pain management. A review of the Medication Administration Record (MAR) since the month of 12/2012 until 1/16/13 indicated for the pain monitoring every shift the resident had no pain, 0/10 (in a pain scale from zero to ten, zero indicating no pain and 10 the worst possible pain). However, the MAR also had documentation the nurses administered Tylenol 325 mg 11 times during the month on 12/2012 for pain rated 3/10-4/10 on the head or the back; three times from 1/1/13 to 1/8/13 for leg pain rated 5/10; Tylenol #3 ten times from 1/11/13 to 1/16/13 for left heel pain rated 7/10-8/10. Since Resident 1?s admission to the facility on 11/12/12, to the date of transfer on 1/16/13, there was no documentation the interdisciplinary team (IDT) including the psychiatrist and the attending physician, addressed as possible causative factors for the resident?s increased behavior manifestations the deterioration of the wound to the left heel and possible presence of pain. Since admission, the resident was given routinely the antipsychotic medication Haldol for crying out for help. The behavior increased despite increased of the Haldol dosage. Haldol was changed to the mood stabilizer Depakote on 1/10/13. The antidepressant Remeron was given every night since admission for poor appetite. The antianxiety medication Xanax (Alprazolam) was given PRN crying out for help during the month of 11/2012 a total of four times, during the month of 12/2012 a total of 25 times, and from 1/1/13 to 1/16/13, Xanax was given 11 times. The antidepressant Trazadone for crying out for help and tearfulness was added to the medication regimen on 11/26/12.The IDT did not rule out the behaviors were related to pain from the left heel wound which was not responding to treatment.On 3/7/13, at 1:30 p.m., during an interview, the director of nursing (DON) stated the resident needed multiple transfers to the GACH and had several skin break down during the different admissions. On 3/7/13, at 3:40 p.m., during another interview, the DON stated on 1/1/13, Wound Consultant 1 explained to Responsible Party 1 the condition of the wound and it was not gangrenous. The DON stated the facility did not learn Resident 1 had gangrene until Wound Consultant 2 evaluated the resident on 1/16/13. On 6/20/13, at 10:30 a.m., during another interview, the DON explained the delay in obtaining the wound consultations was related to the fact the provider of wound consultants did not have enough physicians to visit residents and the facility had to change providers. The DON could not explain the lack of documentation by the licensed nursing staff regarding the progress of the wound and pain management.The facility failed to provide Resident 1 with the necessary care and services in accordance with the comprehensive assessment, plan of care and physician?s orders by failing to: 1. Ensure licensed nurses monitored the condition of a left heel wound for signs and symptoms of infection (such as odor, presence of fluid or drainage, and increased temperature of the area), response to treatment, changes in size and color, and presence of pain. 2. Follow the physician?s order to obtain a wound consultation in a timely manner. 3. Implement the recommendation by the wound consultant physician to have a follow up evaluation a week after the initial evaluation. 4. Implement pain management interventions when the resident manifested pain to the affected left/foot and had increased behavioral manifestations of crying and continuous yelling for help. On 1/16/13, Resident 1's left heel was evaluated by a wound consultant physician who diagnosed infected gangrene (dead tissue caused by an infection or lack of blood flow) on the left heel. On the same day, Resident 1 was transferred to a general acute care hospital (GACH) where she was diagnosed and treated for severe pain to the left heel, gas gangrene [potentially deadly form of tissue death caused by a bacteria. Gas gangrene causes very painful swelling, foul smelling discharge, and when the swollen area is pressed, gas can be felt as a crackly sensation (crepitus)] with foul smelling drainage, creamy-yellowish in color and, osteomyelitis (infection of a bone) of the left heel, urinary tract infection, and septicemia (blood poisoning, a life-threatening complication of an infection) which caused Resident 1?s death on 1/27/13 at the GACH.The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of Resident 1?s death.
950000036	OLIVE VISTA BEHAVIORAL HEALTH CENTER	950009514	B	20-Sep-12	TB3811	6978	Nursing Services-Patient Care 72315(b) Each patient shall be treated as individuals with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. Patients? Rights 72527(a) (9) The facility shall establish and implement written policies and procedures which shall include patients the right to be free from mental and physical abuse.On June 16, 2010, at 12:00 p.m., an unannounced visit was made to the facility to investigate a complaint regarding an incident of alleged staff to patient sexual abuse.Based on interview and record review, the facility failed to implement its abuse policy by failing to:Ensure that Patient A was not subjected to sexual assault (forcefully kissing), harassment (always near patient), and emotional abuse (intimidation and threats) by Staff 1, which consequently resulted in Patient A feeling frightened and obligated to participate in an unwanted relationship with Staff 1that included kissing and the receipt of love letters from Staff 1.On June 14, 2010, the Department received an Entity Reported Incident report from the facility that indicated that on June 8, 2010, at 6 p.m. Patient A made a claim to the DMH (Department of Mental Health) Liaison that a female (CNA) Staff 1 kissed Patient A on the mouth twice with closed lips.Patient A was an 18 year old female who was admitted to the facility, on March 24, 2010, with diagnoses that included schizophrenia (a mental disorder characterized by a breakdown of thought processes and by poor emotional responsiveness).The comprehensive assessment, dated April 1, 2010, indicated that Patient A had no memory problems, was independent in cognitive skills for decision-making and able to make herself understood and understand others. The assessment also indicated that she spoke clearly, was ambulatory and independent in all activities of daily living.On June 18, 2010, at 10:10 a.m., Patient A stated during the abuse investigation that after she was admitted to the facility, on March 24, 2010, she occasionally saw and spoke to Staff 1 during the 3-11 shift. Patient A stated that On April 25, 2010, Staff 1 approached her and told her, ?I like you!? Patient A thought it was ?cool.? As time went on, Staff 1 would try to come closer to her whenever she can. But whenever she (Patient A) socializes with other patients, Staff 1 will become jealous. Patient A also stated that one evening, when Staff 1 first tried to kiss her, in the hallway, she leaned back and hesitated because she felt threatened, but felt that if she refused, Staff 1 would have retaliated. As Staff 1 continued to kiss her over a period of time, she would allow Staff 1 to kiss her on her lips while her lips are closed. Patient A further stated that Staff 1 kissed her on two other occasions and sent her two love letters. When Staff 1 told patient A that she wanted to be her ?girlfriend?, Patient A said that she was not happy and told Staff 1 that she felt awkward and uncomfortable. Staff 1 then became upset and told her, ?If you don?t be my girlfriend, I?ll write something bad in your chart and you?ll go back to jail.? This frightened Patient A because she did not want to return to jail. On June 6, 2010, Patient A decided to report Staff 1 to Staff 4 and turned in the love letters. This had been going on for less than two months.On June 16, 2010, at 12:10 p.m., during an interview with Staff 3 regarding the alleged abuse incident, Staff 3 (Program Manager) stated that on June 8, 2010, at 6:00 p.m., Patient A had informed Staff 4 about Staff 1 who had kissed her two times. Staff 4 informed Staff 2 and Staff 3 on the same day. Staff 1 was immediately suspended.According to a written declaration dated June 8, 2010 by Patient A, on or about April 25, 2010, Staff 1 approached Patient A and said ?I like you!? Patient A said she thought it was cool. But later when she was hanging around some friends at the facility, Staff 1 started to get jealous. Patient A further indicated in the declaration that the first time Staff 1 came towards her to kiss her, she wasn?t sure if she wanted to kiss her back. She then leaned back at first and then she allowed Staff 1 to kiss her three times on the lips with her lips (Patient A) closed. Patient A stated that she did like girls and was not into guys. When Staff 1 told her that she wanted her to be her girlfriend, Patient A informed Staff 1 that she wasn?t ?cool about it?. Staff 1 then became angry and said ?If you don?t be my girlfriend, I?ll write something bad in your chart and you?ll go back to jail.? Patient A stated she was scared because she did not want to go back to jail and felt uncomfortable around Staff 1. Patient A informed Staff 4, but nothing was done. Staff 1 as evidenced in her letters to Patient A said that she would even leave her friends for the patient, which made Patient A feel awkward. After Patient A gave the letters to staff, the patient hasn?t seen Staff 1 and felt relieved. Attempts to contact Staff 1 for an interview, on July 7, 2010, at 1:30 p.m., were unsuccessful. There was no answer and no voice mail to leave a message. Staff 1 was hired by the facility, on December 4, 2009, and worked at the facility for seven months. Staff 1 was terminated, on June 12, 2010, for kissing Patient A. The review of the Record of Counseling dated June 11, 2012, on June 8, 2010, revealed that a female resident (Patient A) made a claim to the Department of Mental Health (DMH) liaison that Staff 1 kissed her on the mouth while her lips were closed on two occasions. Consequently, Staff 1 was placed on an investigative suspension and was subsequently, terminated on June 12, 2012, due to Gross Misconduct which is a violation of the facility?s Progressive Discipline. During an interview on July 9, 2010, at 3:00 p.m., Staff 2 (Administrator) stated that Staff 1 had been terminated on June 12, 2012, due to her poor professional behavior.The review of the facility's abuse policy and procedure indicated that the patients have the right to be free from abuse and neglect by anyone including staff members, other patients, visitors, volunteers, family, friends, or any other individual. The facility?s staff failed to ensure that the patient was free of any type of abuse by failing to: Ensure that Patient A was not subjected to sexual assault (forcefully kissing), harassment (always near patient), and emotional abuse (intimidation and threats) by Staff 1, which consequently resulted in Patient A feeling frightened and obligated to participate in an unwanted relationship with Staff 1 that included kissing and the receipt of love letters from Staff 1.The facility?s failure to implement their abuse policies and procedure placed Patient A and other patients at risk for potential sexual abuse.These violations had a direct relationship to the health, safety and security of patients.
950000036	OLIVE VISTA BEHAVIORAL HEALTH CENTER	950009828	B	03-Apr-13	SVD411	6492	CCR Title 2272315 Nursing Service-Patient Care (b) Each person shall be treated as an individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. Based on observation, interview, and record review, the facility failed to implement their abuse policy and procedures by failing to: 1. Ensure that Resident A was not subjected to verbal and physical abuse by Employee 1. Employee 1 cursed at Resident A, and held both of Resident A?s right and left wrists and forearms down on the bed and would not let go. Employee 3 had to ask Employee 1 three times to let go of Resident A.Resident A is a 31 year-old male who was first admitted to the facility on May 28, 2008, with a diagnosis of Schizophrenia. On April 30, 2010, an unannounced visit was made to the facility to investigate an entity reported incident regarding an allegation of verbal aggression (threats, name calling, cursing, profanity, etc.).A review of the facility?s Internal investigation report indicated that on April 21, 2010, at 3:15 p.m., Employee 1 held both of Resident A?s right and left wrists and forearms down on his bed and engaged in verbal aggression towards the resident. The administrator removed the employee from the schedule pending the conclusion of the investigation. The Registered Nurse assessed Resident A as having no apparent injury, redness/discoloration, nor pain. Employee 1 was on administrative leave since April 21, 2010, and was subsequently terminated on April 22, 2010.During an interview conducted with Employee 1 on June 17, 2010, at 4:20 p.m., he stated Resident A had asked him if he could do his own accucheck (fingerstick/ blood draw). Employee 1 told him ?No?, and that he had to do it for him. Resident A then walked away to his room and Employee 1 went to follow Resident A into his room. When Employee 1 went into the bedroom of Resident A, the resident was already lying down on the bed and started cursing at Employee 1 when he saw him enter his room. Resident A said to him ?Get out of my f?ing room f?ing a?hole!? Employee 1 then walked up to the middle of his bed and Resident A kicked him in the stomach. Employee 1 then stated Resident A tried to get up from the bed to hit him, so Employee 1 grabbed Resident A?s wrists to protect himself from being hit.Employee 1 further stated that during his Professional Assault Crisis Training, he was taught to back away and cover himself when a resident becomes agitated. But he further stated it was important to communicate to the resident and was thinking about how the resident needed to have his accucheck done at the time. He also stated that he did not swear at the resident. The only word he remembered saying was ?stop? when Resident A kicked him. During an interview with Employee 2, on April 30, 2010, he stated that he was in the hallway at the time of the incident and saw residents outside Resident A?s room. He went in and saw Resident A lying flat on the bed with Employee 1 standing over him, holding his wrists down, and saying ?Why the f?k did you do that?!? He further stated that Resident A looked scared. He then heard Employee 3 tell Employee 1 three times to leave the room and report to her office before he finally let go of Resident A and left the room. He further heard Employee 1 say to Employee 3 ?He kicked me!? Employee 2 then asked Resident A if he was okay and Resident A said nothing and stayed in his room.During an interview with Employee 3 on April 30, 2010, she said when she heard yelling coming from Resident A?s room she ran to the room and heard a slapping sound. When she arrived, she saw Resident A lying flat on the bed with Employee 1 standing over him holding his wrists down saying ?Why the f?k did you do that?? She then said to Employee 1, ?You need to let him go.? Employee 1 did not respond. She then repeated herself saying ?You need to let him go.? Employee 1 still did not respond. Finally Employee 3 said a third time, ?You need to let him go?, and saw Employee 1 finally release his hold on Resident A and leave the room. She then told Employee 1 that he needed to report to her office and asked why he used that language. He told her because Resident A kicked him in his abdomen and that he did not realize he was swearing. She then asked him why he didn?t ask for help. He told her his voice was hoarse. She then asked him why didn?t he call in sick and he responded that he did not want to bother anyone. A review of Employee 1?s personnel file indicated that he was hired on March 18, 2009, as a certified nursing assistant. He had a performance evaluation on March 20, 2010, and was rated as very good to superior. He had also attended and completed a Professional Assault Crisis Training class on March 17, 2010. According to the Record of Counseling Form dated April 22, 2010, Employee 1 was observed interacting with a resident on south unit and his conduct was inappropriate. Therefore, he was being placed on suspension effective April 22, 2010, for investigation of his conduct. A review of the Employee Status Change Form dated April 23, 2010, indicated that Employee 1 was terminated for misconduct. An attempt was made to interview Resident A on April 30, 2010. He stated he remembered Employee 1 and then remained silent. Then he abruptly started to cursing and yelling to an imaginary person who was not in the room, so the interview was cancelled. He did not appear to have any bruises or marks on his arms and wrists.A review of the Quarterly Minimum Data Set assessment dated March 5, 2010, indicated Resident A had no cognition or behavior problems. However there was a care plan dated September 8, 2009, that indicated Resident A had a behavior problem of physical aggression in the form of an overt expression of anger. During an interview with Employee 4, on June 23, 2010, she stated that she has trained employees in Professional Assault Crisis Training. She further stated that in general, when a resident exhibits signs of aggression, it is important to communicate with the resident to identify the cause of the aggression and that it is also important to stay out of striking range of a resident when they exhibit aggression. She defined striking range as the span of resident?s arm or leg plus a full step. This violation had a direct relationship to the health, safety, and security of Resident A.
950000036	OLIVE VISTA BEHAVIORAL HEALTH CENTER	950012770	B	21-Nov-16	5WXC11	9892	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. The facility failed to ensure Resident 1 was assessed and received the appropriate treatment and services for his skin rash and intense itching, which had not resolved after treatment with hydrocortisone cream for seven days. Consequently, this resulted in a delay in diagnosis, treatment, and services for Resident 1, who ultimately tested positive for scabies, which had the potential to result in the spread of scabies to other residents in the facility. On 8/19/15, at 2 p. m., an unannounced visit was made to the facility to investigate an entity reported incident (ERI) of unrelated allegations. During a general observation of the facility, on 8/19/15, at 2:15 p.m., with Employee A, Resident 1 was observed ambulating in the patio with other residents from two other stations (South and East nursing stations) and staff members. Resident 1 was observed vigorously scratching over his abdomen with the shirt on as he walked in the hallway. During an interview, Resident 1 stated he had been itching for "several days." Employee A acknowledged Resident 1 had a skin rash and had been itching. A review of Resident 1's clinical record indicate Resident 1 was admitted to the facility on 5/2/14, with diagnoses that included schizophrenia (a mental disorder characterized by a breakdown of thought processes and by impaired emotional responses), hypertension (high blood pressure) and diabetes (high sugar in the blood). The Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 5/16/15, indicated the resident had no short and long term memory recall problems and was independent in all level of activities of daily living and had no skin problems. A review of Resident 1's medical records contained a physician's order dated 8/12/15 to apply: 1. Hydrocortisone cream 10% to both extremities topically (applied to a surface on or in the body) one time a day for redness and itching for 7 days. Hydrocortisone cream is used to treat a variety of skin conditions (e.g., insect bites, poison oak/ivy, eczema, dermatitis, allergies, rash, itching of the outer female genitals, anal itching. reduces the swelling, itching, and redness that can occur in these types of conditions. 2. Ketoconazole cream 2% to the right thumb topically two times a day." This cream is used to treat ringworm; fungal skin infection that causes a red scaly rash on different parts of the body), jock itch (fungal infection of the skin in the groin or buttocks), athlete's foot (fungal infection of the skin on the feet and between the toes, fungal infection of the skin that causes brown or light colored spots on the chest, back, arms, legs, or neck, and yeast infections of the skin). According to the Davis Drug Guide for Nurses, Ninth Edition, during hydrocortisone cream treatment the nurse should assess the affected skin before and daily during therapy, note the degree of inflammation and pruritus, and notify the physician or other health care professional if symptoms of infection (increased pain, erythema, purulent exudate) develop. On 8/19/15, 2:15 p.m., Resident 1 was taken to his room by Employee A for observation of the skin and assessment. A body assessment was conducted on Resident 1, by Employee A, in the presence of the Evaluator. During the assessment, the Evaluator observed Resident 1's arms were dry, with tiny black dots and raised red papules (small solid round bumps rising from the skin). There were more reddened skin rashes to the front upper body parts, webbed spaces of the fingers of the hands, waist, both armpits and the groin areas with an open lesion (wound). Resident 1 stated, "I could not take this anymore, can I see the doctor now?" Employee A acknowledged by saying, "Remember, you refused treatment sometimes?" Resident 1 again stated, "Can I go to the doctor now, I can't take this anymore", and continued to scratch his abdomen vigorously. During an interview with Employee A on 8/19/15, at 3 p.m., he stated, "I've seen the Resident 1's skin rash and he was on Hydrocortisone cream (anti-itch cream) for itching and antifungal cream to his right thumb, but he refused treatment sometimes." A review of the clinical record did not contain an assessment of Resident 1's skin rash by the nurses nor the physician from 8/12/15, through 8/19/15. There was no documented evidence of an assessment of the resident's rash by Employee A who indicated he had seen the resident's skin rash. A review of Resident 1's medical records contained a physician's order dated 8/12/15, to apply Hydrocortisone cream 10% to both extremities topically one time a day for redness and itching for 7 days and Ketoconazole cream 2% to the right thumb topically two times a day." According to the Medication Administration Record (MAR) Resident 1 refused treatments on 8/15/15, 8/16/15, and 8/17/15. There was no documented evidence the physician was notified about the resident's refusal of the treatments on 8/15/15, 8/16/15, and 8/17/15. On 8/19/15, at 3 p.m. a review of Resident's 1 medical record indicated in the nurse's note, dated 8/12/15, 7 a.m. to 3 p.m., ?Resident right thumb with lifted white nail appears moist, also skin rash to armpits, and feet. Resident also claimed that his buttock area had rashes but refused to allow the nurse to assess the area. Received an order for Hydrocortisone for skin rash and ketoconazole cream for fungal nail, will continue to monitor." There was no documented evidence the nurses continued to monitor and assess the resident's rashes to include a description of the skin rash to the armpits and feet. Further review of the medical records indicated there was no documented evidence of a daily re-assessment of Resident 1's skin rashes and the non-effectiveness of the treatment before, during, and after the 7th day of treatment had expired. There was no documented evidence the physician was notified that the treatment was not effective as evidenced by the resident's statement that he had been itching for several days. On 8/19/15, at 3:10 p.m., during an interview with Employee A, he stated Resident 1 refused the treatment, and refused the skin rash to be assessed, and that the physician was not notified. On 8/19/15, at 3:30 p.m., during an interview, Employee A and Employee C confirmed that the physician had not seen, assessed, and re-assessed the resident's skin condition. Employee C stated, she would call Resident 1's physician right away and will request for a referral to be seen by a dermatologist (specializes in skin conditions). On 8/20/15, at 2 p.m., during a follow-up call to Employee A, he stated the resident was not seen by the physician, but the doctor had ordered to increase the use of the Hydrocortisone cream to 10% twice daily until 9/9/15, and the anti-fungal medications. Employee A also stated the dermatology appointment was set for 8/31/15, (11 days later). On 8/20/15, at 3:30 p.m., during a follow-up visit to the facility, Employee B stated the resident was on his way to see a physician at the clinic. On 8/21/15, at 9 a.m., a review of the clinic ' s report dated 8/20/15, indicated Resident 1 had "Dermatophytosis (ringworm-fungal infection of the skin). On 8/21/15, at 10 a.m., during a telephone interview with Resident 1's physician, he stated his clinic does not perform skin scrapings (test used to detect skin conditions), but he could call in for a prescription of Ivermectin tablet (drug used to treat parasitic infections, that includes lice and scabies. drugs.com revised on 05/2010). On 8/21/15, at 3 p.m., during a follow-up visit to the facility, Employee A stated the resident was seen by the Dermatologist in the morning of 8/21/15, and had skin scraping done. The result indicated the skin scraping was positive for scabies. He stated the resident will be given Elimite cream (a cream applied to skin to treat scabies, Davis Drug Guide for Nurses, 2005. Employee A stated the resident's roommates and partner will also be treated. According to the Centers for Disease Control (CDC) guidelines dated 2/08: "Human scabies is caused by an infestation of the skin by the human itch mite. The adult female scabies mites burrow into the upper layer of the skin where they live and deposit their eggs.) The microscopic scabies mite almost always is passed by direct, prolonged, skin to skin contact with a person who is already infected. Institutions such as nursing homes and extended care facilities are often sites of scabies outbreaks. Some immunocompromised, elderly, disabled, or debilitated persons are at risk for a severe form of scabies called crusted or Norwegian scabies. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs. The mites in crusted scabies are much more numerous (up to 2 million per patient). Because they are infested with such large numbers of mites, persons with crusted scabies are very contagious to other persons. In addition to spreading scabies through brief skin to skin contact, persons with crusted scabies can transmit scabies indirectly by shedding mites that contaminate items such as their clothing, bedding, and furniture. Persons with crusted scabies should receive quick and aggressive medical treatment for their infestation to prevent outbreaks of scabies. The most common signs and symptoms of scabies are intense itching (pruritus), especially at night, and a pimple-like (papular) itchy rash." The above violation had a direct relationship to the health, safety or security of Resident1.
950000036	OLIVE VISTA BEHAVIORAL HEALTH CENTER	950012771	B	21-Nov-16	5WXC11	8951	483.65 INFECTION CONTROL, PREVENT SPEAD, LINENS The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection. The facility failed to: 1) Identify immediately highly suspicious rashes that were indicative of scabies for Residents 1, 6, 7, and 8. 2) Report to the Public Health Department two or more suspicious cases of rashes as an outbreak of scabies 3) Prevent transmission of scabies infection and control the infection by administering treatments and prophylaxis treatments to residents, roommates, and the facility's staff timely. 4) Conduct surveillance and tracking of suspicious rashes indicative of scabies for Residents 1, 2, 3, 4, 5, 6, 7, and 8. This deficient practice resulted in a delay in identifying and treating scabies for Residents 1, 6, 7, and 8 with rashes, and also had the potential to spread scabies to all residents, staff and visitors in the facility. On 8/19/15, at 2 p. m., an unannounced visit was made to the facility to investigate an entity reported incident (ERI) of unrelated allegations. During a general observation of the facility, on 8/19/15, at 2:15 p.m., with Employee A, Resident 1 was observed ambulating on the patio with other residents from two stations and staff (South and east nursing stations). Resident 1 was observed vigorously scratching over his abdomen with the shirt on as he walked in the hallway. During an interview, Resident 1 stated he had been itching for "several days." Employee 1 acknowledged Resident 1 had skin rashes and had been itching. The facility had not identified Resident 1 as having scabies on 8/19/15. According to the clinical record, Resident 1 was being treated with hydrocortisone cream for 7 days for a skin rash. During an interview, with Resident 1, on 8/19/15, at 2 p.m., he complained he had been itching for several days. Resident 1 further stated he couldn't take it anymore and wanted to see the doctor "Now". A body check was done in the presence of Employee A, and was observed Resident 1's arms were dry, with tiny black dots and raised red papules (small solid rounded bumps rising from the skin). Further observation indicated more reddened skin rashes to the front upper body parts, webbed spaces of the fingers of the hands, waist, both armpits and the groin areas with an open lesion (wound). Resident 1 stated, "I cannot take this anymore, can I see the doctor now?" "Can I see to the doctor now, I can't take this anymore" and continued to scratch his abdomen vigorously. The resident was eventually seen by the dermatologist on 8/21/15, two days later. A skin scraping was done, which tested positive for scabies (test procedure used to identify presence of mites and eggs from skin). On 8/24/15, during a subsequent visit to the facility, during resident interviews at 2:30 p.m., the following were observed: 1. Resident 2 was observed with multiple red discolorations in the upper abdomen. However, the resident was not complaining of itching. Resident 2 claimed he was treated with, "some creams days ago, and had been itching a long time (resident was unable to recall exact date)." 2. Resident 3 was observed complaining of itching around his right finger webs. Resident 3 was uncooperative with the interview and did not want to be assessed by the facility staff and be interviewed. 3. Resident 4 was observed scratching his right wrist and complaining of pruritus (itching). Resident 4 stated he had been itching for two weeks. Upon closer observation, the rash was observed dry, discolored, clustered raised pin-point with open lesion. Resident 4 stated staff assessed his skin on 8/21/15, but was not treated. 4. Resident 5 was observed scratching intensely all over her body during the interview. Both of Resident 5's arms were observed with scattered multiple pimple-like red open lesions. Resident 5 stated she was "scraped for scabies (test procedure used to identify presence of mites and eggs from skin) before (unable to state when)." Resident 5 also stated, "My doctor said it was scabies but the test result was negative." She also stated she was given the Elimite (medication used to treat scabies). However, the resident stated she was still itching all day and all night despite receiving Benadryl (used to treat sneezing, runny nose, itching and other allergies) at night and Atarax (used to treat anxiety disorders and allergic skin conditions) during the day. On 8/24/15, at 2:45 p.m., the administrator presented a list of thirteen additional residents that were identified with skin rashes and treated with Elimite as well as their roommates. The administrator stated all these residents with the rashes were scheduled to be seen by the dermatologist on 8/26/15. Of the 13 residents seen by the dermatologist, Residents 1, 6, 7, 8) tested positive for scabies. A review of Resident 6's clinical record indicated, the resident was initially admitted to the facility on 5/14/14, to the East wing of the facility. A review of the dermatology note dated 8/25/15, indicated "Complained of itching to hands, legs, and abdomen times one month. Positive for scabies. Treatment with Elimite (FDA approved for the treatment of scabies)." Resident 7 was initially admitted to the facility on 5/14/15, to the East wing of the facility. A review of the dermatology note dated 8/25/15 notes "Patient has rash to arms, hands, times one month. Severely pruritic papules with superficial burrows to trunk and upper extremities. Positive for mites. Elimite cream. Repeat in one week, Ivermectin (an oral antiparasitic agent) 3 mg tablets 5 tablets times one then repeat in one week." Resident 8 was initially admitted to the facility on 12/15/14, to the South Wing of the facility. A review of the dermatology note dated 8/26/15: "Pruritic (itchy) erythematous (reddening of the skin) papules (solid elevation of the skin) with superficial burrows to abdomen, and bilateral legs. Positive for scabies. Ivermectin and Elimite cream as instructed." According to Centers of Disease Control (CDC) and Prevention http://www.cdc.gov/parasites/disease/.html: Burrows are caused by the female scabies mite tunneling just beneath the skin. The intense itching of scabies leads to scratching, that can lead to skin sores. The sores sometimes become infected with bacteria on the skin such as Staphylococcus aureus or hemolytic streptococcus. Sometimes bacterial skin infection can lead to an inflammation of the kidneys called post-streptococcal glomerulonephritis. There was no documented evidence the facility maintained a surveillance and tracking log of the residents who had been identified with highly suspicious rashes indicative of scabies. There was no documented evidence the facility investigated the rashes prior to 8/19/15. The facility did not have a designated Infection Control Prevention professional (IP - healthcare professional with expertise in infection prevention) to handle their infection control program. The facility failed to follow the acute Communicable Disease Control reporting protocol to report cases of two or more suspicious rashes to the Department when Residents 1, 2, 3, 4 and 5 had rashes which was highly suspicious for scabies. The Los Angeles County Dept. of Public Health, Rash/Scabies Outbreak Notification dated 3/30/15, indicated: Scabies outbreak is a reportable situation that requires investigation and follow-up as specified by Acute Communicable Disease Control Program of the Los Angeles Department of Public Health with authority granted by the California Health and Safety Code of Regulations. The above violation has a direct relationship to the health, safety, or security of the residents.
950000036	OLIVE VISTA BEHAVIORAL HEALTH CENTER	950013251	B	2-Jun-17	Z2B411	3901	F223 483.13 (b), 483.13 (c)(1)(i) Free from abuse/involuntary seclusion 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 3/7/14, at 2:56 p.m. an unannounced visit was made to the facility to investigate an entity reported incident of alleged staff to resident abuse. Based on interview and record review, the facility failed to ensure Resident 1 was free from physical abuse from Counselor 1. A review of Resident 1's admission face sheet indicated Resident 1 was admitted to the facility on XXXXXXX 2014. Resident 1's diagnoses included schizophrenia (a mental disorder that causes one to suffer symptoms such as delusions, hallucinations, and disorganized speech and behavior). A review of Resident 1's "Change of Condition Documentation" dated February 23, 2014, at 2:00 p.m. indicated: Resident 1 was walking in the north corridor of the East unit during an independent activity. Resident 1 approached Counselor 1 and slapped him on the back of the neck. In response Counselor 1 turned around and slapped Resident 1 on the left side of the face two times. The incident was documented based on the interviews of staff who witnessed the incident. On March 7, 2014 at 3:45 p.m., an interview was conducted with Certified Nurse Assistant (CNA 1). CNA 1 stated she witnessed Counselor 1 turn around and slap Resident 1 on the face with an open hand. CNA 1 stated, "It wasn't unintentional." CNA 1 stated Counselor 1 also yelled obscenities at Resident 1. On March 7, 2014 at 3:50 p.m., an interview was conducted with Counselor 2. Counselor 2 stated on the day of the incident she did not witness Resident 1 hit Counselor 1 but she did witness Counselor 1 turn around. He looked mad and slapped Resident 1 "multiple times back and forth, more than twice." On March 7, 2014 at 3:53 p.m., an interview was conducted with Resident 1. Resident 1 stated, "I've been shaking ever since then." Resident 1 stated she had experienced pain to the inside of her mouth following the incident but couldn't remember if her mouth had bled. Resident 1 acknowledged that she hit Counselor 1 on the back of the neck, at which time Counselor 1 turned around and slapped her face. On March 7, 2014 at 4:10 p.m., an interview was conducted with the Administrator. The Administrator stated following the incident on February 23, 2014, Resident 1 was assessed and found to have no injuries. The Administrator stated that on the following day Resident 1 complained of pain to her face. Counselor 1 was terminated following the incident. On October 8, 2014 at 8:05 a.m. a telephone interview was conducted with Counselor 1. Counselor 1 stated he was walking down the hall on February 23, 2014 at approximately 2:00 p.m., when he felt something strike him on the back of the neck. Counselor 1 stated he turned around to see who had hit him and as he turned around he accidentally struck Resident 1 one time on the face. A review of the facility's Abuse Prohibition policy dated July 1, 2013, indicated the following: 1. The facility will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients. 2. Abuse is defined as the willful infliction of physical pain, injury, or mental anguish, or the willful deprivation by a caretaker of services which are necessary to maintain physical or mental health including the following: a. Physical Abuse includes hitting, slapping, pinching, kicking, etc. Therefore, the facility failed to ensure Resident 1 was free from physical abuse from Counselor 1. The violation had a direct or immediate relationship to the health, safety, or security of Resident 1.
950000036	OLIVE VISTA BEHAVIORAL HEALTH CENTER	950013353	B	18-Jul-17	RPDW11	8953	F323 Class B Citation 483.25 (d)(1)(2)(n)(1)-(3) Free of accident hazards/supervision/devices (d) 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. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight. On May 31, 2017, at 1:45 p.m., an unannounced visit was made to the facility to investigate an entity reported incident that Resident 1 eloped (left without authorization) during a community outing. Based on interview and record review the facility staff failed to provide adequate supervision for Resident 1. Resident 1 had a history of leaving previous placements without authorization, had been observed looking for ways to leave the facility and had made statements that she wanted to leave the facility without authorization. Resident 1 was taken out on her first community outing with five other residents, accompanied by two staff members. Resident 1 eloped during the community outing and was not located by the facility staff or by local law enforcement. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on XXXXXXX2017, with diagnoses that included schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression) and other uncomplicated stimulant dependence. A review of a care plan dated April 21, 2017, indicated Resident 1 was at risk for elopement related to alcohol/drug seeking behavior as evidenced by the resident stating she wanted to elope from the facility during an outing and was also looking at the fences in West Unit yard. The care plan goal indicated Resident 1 will not attempt to leave the facility without an escort by next review. The listed nursing interventions included monitor the nature and circumstances (i.e. triggers) of attempted elopement during specific activities, involvement of others and adjust care delivery appropriately, staff will encourage the resident to communicate the desire to leave the program in an appropriate manner and remove the resident from environment. According to a Special Treatment Program (STP) - Recreational Services Quarterly Progress Note dated May 25, 2017 at 12 a.m.; Resident 1 actively participated upon prompting in health and fitness groups, unit socials such as dances, canteen, birthday socials and special events, and enjoys visits from her friends and watching television with her peers. The note indicated Resident 1 will receive one outing per week out into the community with staff and peers once she maintains the proper amount of STP hours on a weekly basis. A review of a nurse's note dated May 26, 2017, at 11:35 p.m., indicated on May 26, 2017, at approximately 7:45 p.m., while outside the facility on an outing activity, Resident 1 opportunistically eloped by running away from facility staff. Staff searched immediate and surrounding areas, but could not locate the resident. The facility and local police department were immediately notified. The police department arrived at the facility at 9 p.m. and a missing person report was filed. A review of an undated and untimed facility's Interview/Debriefing Narrative Record, indicated at 6:45 p.m., Behavioral Specialist (BS) 1 communicated with South Unit staff that she was going on an outing to Store 1. BS 1 and BS 2 left with six residents. While inside Store 1 as a group, BS 1 noticed Resident 1 wandering away from the group, BS 1 redirected the resident back to the group and the resident complied. While BS 1 was assisting another resident, BS 1 turned around and noticed that Resident 1 was missing from the group. BS 1 immediately searched the store while BS 2 stayed with the other residents. BS 2 notified Store 1's manager and Resident 1 was overhead paged multiple times. BS 1 stood at the front of Store 1's exit after paging Resident 1, searched the area multiple times, and went back to the van to see if Resident 1 was there, but Resident 1 was nowhere to be found. The narrative record indicated the facility and police department were notified and the group headed back to the facility. During an interview on May 31, 2017, at 1:45 p.m., the Administrator stated that Resident 1 has not been found. The Administrator stated that this was Resident 1's first incident of elopement since being admitted to the facility. According to the Administrator, Resident 1 was at a board and care facility before coming to the facility and has a history of running away from there. During an interview on May 31, 2017, at 1:51 p.m., BS 1 stated that the incident happened on a Saturday, around 6:45 p.m., when they went out on an outing to Store 1. BS 1 stated that as the group was walking into Store 1, Resident 1 stopped by the carts area to look at some candies. BS 1 stated that she called Resident 1 and told her to stay with the group. BS 1 stated that she saw Resident 1 walking towards the group, so she turned around to check on the other residents and when she looked back, Resident 1 was gone. BS 1 stated that she searched the store, overhead paged the resident, and went to the exit doors to make sure the resident does not leave the store, but could not locate Resident 1. According to BS 1, Resident 1 had a history of elopement from another facility, but has been doing well in the facility and reached a level that allows her to participate in outings. On May 31, 2017, at 2:50 p.m., during an interview, Resident 2 stated that within five minutes of walking into Store 1, Resident 1 went missing. Resident 2 stated that she was walking next to BS 1 and another resident and Resident 1 was walking behind them. Resident 2 stated that BS 1 was checking something on her cellphone and when BS 1 turned around and looked back, Resident 1 was gone. According to Resident 2, during outings, facility staff instructs them to stay together, not to wander off, and to inform them if they want to look or buy something, so the staff can go with them. A review of the facility's policy and procedure titled "Outings" revised on November 28, 2016, indicated community excursions will be based upon the resident's choice, needs, abilities and capabilities. Notification of all proposed excursions will be sent to Center Executive Director and Center Nurse Executive/Resident Care Director to ensure adequate support staff during the excursions. Center/Community staff to resident/patient ratio will vary according to type of outing, number of residents, and will be based on the resident's tolerance and level of ability. Staff facilitating excursion will be knowledgeable of emergency procedures and vehicle equipment use as evidenced by documentation of competency training. A review of the facility's undated policy and procedure titled "Supervision Level Protocol and Guidelines," indicated the interdisciplinary team will continually evaluate the need for intensive supervision of residents who present with cognitive, behavioral, medical or other conditions that put them or other residents at risk. The team will provide increased levels of supervision as appropriate to ensure optimal resident safety and outcome. For all residents who do not have another supervision level ordered, general supervision will be maintained at all times. Residents on general supervision are able to move around the facility at will (except in areas that are designated as nonresident areas for safety reasons, but will be cued to groups/activities as needed). The facility failed to provide adequate supervision for Resident 1. Resident 1 had a history of leaving previous placements without authorization, had been observed looking for ways to leave the facility and had made statements that she wanted to leave the facility without authorization. Resident 1 was taken out on her first community outing with five other residents, accompanied by two staff members. Resident 1 eloped during the community outing and was not located by the facility staff or by local law enforcement. These violations had a direct relationship to the health, safety, or security of the resident.
950000036	OLIVE VISTA BEHAVIORAL HEALTH CENTER	950013354	B	18-Jul-17	RPDW11	8756	Title 22 Section 72541 B Citation Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. On May 31, 2017, at 1:45 p.m., an unannounced visit was made to the facility to investigate an entity reported incident that Resident 1 eloped (left the facility without authorization) during a community outing. Based on interview and record review, the facility failed to ensure that an unusual occurrence involving Resident 1 was reported to the Department within 24 hours, in accordance with the State law and the facility's policy and procedures. An incident involving Resident 1 eloping during a community outing was not reported to the Department within 24 hours. This deficient practice had the potential to put Resident 1's safety at risk. The Department received an Entity Reported Incident on May 30, 2017, indicating that on May 26, 2017, at 7:15 p.m., during a community outing to Store 1, Resident 1 opportunistically eloped by leaving the area out of staff's line of sight. Staff alerted security personnel with security personnel assisting to search immediate and surrounding areas and Resident 1 not found. The licensed personnel immediately notified the local police department, the local police department arrived to the facility and a missing person report was filed. The local police department conducted a thorough search of surrounding area, Resident 1 not located. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on XXXXXXX 2017, with diagnoses that included schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression) and other uncomplicated stimulant dependence. A review of a care plan dated April 21, 2017, indicated Resident 1 is at risk for elopement related to alcohol/drug seeking behavior as evidenced by the resident stating she wanted to elope from the facility during an outing, also looking at the fences in West Unit yard. The care plan goal indicated Resident 1 will not attempt to leave the facility without an escort by next review. The listed nursing interventions included monitor the nature and circumstances (i.e. triggers) of attempted elopement during specific activities, involvement of others and adjust care delivery appropriately, staff will encourage the resident to communicate the desire to leave the program in an appropriate manner and remove the resident from environment. According to a Special Treatment Program (STP) - Recreational Services Quarterly Progress Note dated May 25, 2017 at 12 a.m.; Resident 1 actively participates upon prompting in health and fitness groups, unit socials such as dances, canteen, birthday socials and special events, and enjoys visits from her friends and watching television with her peers. The note indicated Resident 1 will receive one outing per week out into the community with staff and peers once she maintains the proper amount of STP hours on a weekly basis. A review of a nurse's note dated May 26, 2017, at 11:35 p.m., indicated On May 26, 2017, at approximately 7:45 p.m., while outside the facility on an outing activity, Resident 1 opportunistically eloped by running away from facility staff. Staff searched immediate and surrounding areas, but could not locate the resident. The facility and local police department were immediately notified. The police department arrived at the facility at 9 p.m. and a missing person report was filed. A review of an undated and untimed facility's Interview/Debriefing Narrative Record, indicated at 6:45 p.m., Behavioral Specialist (BS) 1 communicated with South Unit staff that she was going on an outing to Store 1. BS 1 and BS 2 left with six residents. While inside Store 1 as a group, BS 1 noticed Resident 1 wandering away from the group, so BS 1 redirected the resident back to the group and the resident complied. While BS 1 was assisting another resident, BS 1 turned around and noticed that Resident 1 was missing from the group. BS 1 immediately searched the store while BS 2 stayed with the other residents. BS 2 notified Store 1's manager and Resident 1 was overhead paged multiple times. BS 1 stood at the front of Store 1's exit after paging Resident 1, searched the area multiple times, and went back to the van to see if Resident 1 was there, but Resident 1 was nowhere to be found. The narrative record indicated the facility and police department were notified and the group headed back to the facility. During an interview on May 31, 2017, at 1:45 p.m., the Administrator stated that Resident 1 has not been found. The Administrator stated that this is Resident 1's first incident of elopement since admitted to the facility. According to the Administrator, Resident 1 was at a board and care facility prior to admission and has a history of running away from there. During an interview on May 31, 2017, at 1:51 p.m., BS 1 stated that the incident happened on a Saturday, around 6:45 p.m., when they went out on an outing to Store 1. BS 1 stated that as the group was walking into Store 1, Resident 1 stopped by the carts area to look at some candies. BS 1 stated that she called Resident 1 and told her to stay with the group. BS 1 stated that she saw Resident 1 walking towards the group, so she turned around to check on the other residents and when she looked back, Resident 1 was gone. BS 1 stated that she searched the store, overhead paged the resident, and went to the exit doors to make sure the resident does not leave Store 1, but could not locate Resident 1. According to BS 1, Resident 1 had a history of elopement from another facility, but has been doing well in the facility and reached a level that allows her to participate in outings. On May 31, 2017, at 2:50 p.m., during an interview, Resident 2 stated that within five minutes of walking into Store 1, Resident 1 went missing. Resident 2 stated that she was walking next to BS 1 and another resident and Resident 1 was walking behind them. Resident 2 stated that BS 1 was checking something on her cellphone and when BS 1 turned around and looked back, Resident 1 was gone. According to Resident 2, during outings, facility staff instructs them to stay together, not to wander off, and to inform staff if they want to look or buy something, so the staff can go with them. During an interview on May 31, 2017, at 3:27 a.m., the Administrator stated that unusual occurrences should be reported to the Department within 24 hours. The Administrator stated that the Program Supervisor completed the initial fax/24 hour report and faxed it to the Department on May 27, 2017, at 4 p.m., but did not double check if the fax went through. The facility's fax transmission verification report was reviewed with the Administrator and showed that the fax did not go through and was addressed to the wrong fax number. A review of the facility's policy and procedure titled "Accidents/Incidents" revised on November 28, 2016, indicated all accidents/incidents, witnessed or unwitnessed, will be reported to the supervisor. The supervisor will notify the Center Executive Director (CED) and Center Nurse Executive (CNE) of the accident/incident. Notification of appropriate leadership will be made through Risk Management System (RMS) based on the level of severity. Notification of state reportable events will be made using RMS except in states that require reporting through the state database. The CED and/or CNE will verify that state reporting occurs within required timeframes and via appropriate method of reporting. The facility?s failure to ensure that an unusual occurrence involving Resident 1 was reported to the Department within 24 hours, in accordance with the State law and the facility's policy and procedures had a direct relationship to the health, safety, or security of the resident.
960001306	OASIS HOUSE	960013099	A	7-Apr-17	0D0F11	5940	W&I 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 development 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. On October 6, 2016 at 6:30 a.m. an unannounced visit was made to the facility to conduct a Fundamental Survey. The facility?s licensed vocational nurse (LVN) failed to: Ensure the safety of Client 2 while the client was in bed with the side rail down. LVN 1 stepped away from Client 2?s bedside when the side rail was down resulting in Client 2 falling from the bed sustaining an injury to the head. Client 2 was taken to the hospital emergency department and received sutures to the forehead. A review of the face sheet, on October 12, 2016, indicated Client 2 was admitted to the facility on XXXXXXX 2008 with diagnoses that included profound intellectual disability (cognitive ability that is markedly below average level, incapable of self-care), spastic quadriplegia (most severe form of spastic cerebral palsy and affects all four limbs, the trunk and the face) and 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). Client 2 was non-verbal and wheelchair bound. During a review of the clinical record for Client 2 on October 12, 2016, the summary of General Event Report dated March 25, 2016, indicated Client 2 fell out of bed on March 24, 2016, around 10:00 p.m., causing a laceration above the right eyebrow and was taken to the hospital emergency department and received multiple sutures. During a telephone interview with LVN 1, on October 27, 2016 at 4:05 p.m., she stated on March 24, 2016 around 10:00 p.m., she went into Client 2?s bedroom, Client 2 was wet and lying on his right side in his bed. LVN 1 stated she put the upper side rail down and walked away from the client to get diapers from the closet which was located at the foot of Client 2?s bed. LVN 1 stated Client 2 was laughing and moving in bed, when she turned around she saw that the client was falling out of his bed. LVN 1 stated she rushed towards the top of the client?s bedside to prevent the client from falling and she was not able to break the client?s fall. Client 2 fell on the floor. LVN 1 stated blood was coming from the client?s head above his right eye. LVN 1 stated she called ?911? immediately and applied pressure to Client 2?s head to keep the client from bleeding. She stated the bed rails should have been up when she stepped away from the client. During an interview with the qualified intellectual disabilities professional/administrator (QIDP/ADM), on October 12, 2016 at 11:41 a.m., he stated the licensed vocational nurse 1 (LVN 1) was changing Client 2's adult diaper/clothes while Client 2 was in bed and LVN 1 stepped away from Client 2?s bed with the side rail down to go get supplies for Client 2. The QIDP stated LVN 1 heard a loud sound and returned immediately to Client 2's room. LVN 1 observed the side rail on the bed was down and the client was on the floor. During a telephone interview with RN 1, on January 27, 2017 at 9:20 a.m., she stated on March 25, 2016 at 12:00 p.m., she arrived to the facility and assessed Client 2. She stated Client 2 had approximately ten (10) sutures to the laceration on the right eyebrow, it was swollen and there was mild bruising around the right eye area and bridge of the nose. She stated Client 2 moves around in the bed and bed side rails are used as a safety measure. She further stated staff should put the bed side rails up if they walk away from Client 2?s bedside. A review of the nurses? notes dated April 13, 2016 at 11:41 a.m., indicated Client 2 had a healing laceration to the mid forehead over the client's right eyebrow related to the fall. The nurses? note indicated the registered nurse (RN) removed 10 sutures from Client 2?s forehead per recommendation from the client's recent hospitalization. A review of the physical therapy annual evaluation, dated September 1, 2016, indicated Client 2 has a semi-electric hospital bed with half rails. Client 2?s bed mobility and transferring was dependent upon staff. Client 2 has bilateral lower extremity strength and range of motion is limited by abnormal muscle tone. Client 2?s spasticity limits functional movement. A review of the occupational therapy annual evaluation, dated September 7, 2016 indicated, Client 2 has a high risk for falls. A review of the hospital emergency room after care instructions, dated March 25, 2016 at 12:55 a.m., indicated Client 2 sustained a laceration to the right eyebrow and received sutures. Further instructions indicated take Tylenol for pain as needed, keep the dressing to the wound clean and dry, follow up with Client 2?s primary physician to check the wound in two (2) days and suture removal in seven (7) days. The facility?s licensed vocational nurse (LVN) failed to: Ensure the safety of Client 2 while the client was in bed with the side rail down. LVN 1 stepped away from Client 2?s bedside when the side rail was down resulting in Client 2 falling from the bed sustaining an injury to the head. The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.
630013784	Oak Fence Congregate Living Health Facility	980013215	B	23-May-17	8PUI11	5513	Title 22 ? 72315. Nursing Service-Patient Care. (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. ? 72527. Patients'Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. On April 4, 2017, at 12:10 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient Rights. Based on interview and record review, the facility failed to ensure Patient 1 was treated as an individual with dignity and respect, and had the right to be free from mental abuse, including: Failure to ensure Patient 1 was not mentally abused and was treated with dignity and respect by Licensed Vocational Nurse 1 (LVN 1), who threw medications at Patient 1, after Patient 1 requested LVN 1 to give the medications with apple sauce to facilitate swallowing the medications. As a result, Patient 1 felt hurt, uncomfortable, humiliated, and scared. On April 4, 2017, at 9:35 a.m., during a telephone interview, Patient 1 stated on the evening of March 19, 2017, LVN 1 threw the medications (two pills) at her, when she requested apple sauce to take with her medications, because she has difficulty swallowing. LVN 1 had an attitude, told Patient 1 she forgot the apple sauce, and threw the medications at the patient. Patient 1 stated she felt hurt, uncomfortable, humiliated, and scared. On April 4, 2017, a review of the clinical record indicated Patient 1 was admitted to the facility on XXXXXXX 2017, with diagnoses including chronic kidney disease (progressive loss of kidney function) secondary to lupus nephritis (an inflammation of the kidneys caused by systemic lupus erythematosus, a disease of the autoimmune system). Patient 1 was discharged home on XXXXXXX 2017. A review of the Daily Shift Nurses' Progress Notes form dated March 4, 2017, indicated Patient 1 was alert and oriented, needed extensive assistance from the staff for bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene, and needed limited assistance in eating. A review of LVN 1?s employee file included a "Disciplinary Action Form" dated March 20, 2017. The form indicated LVN 1 was given a formal written warning regarding not treating with respect and not providing appropriate care to a patient on March 17 and again on March 19, 2017. The form indicated Family Member 1 was very upset and complained multiple times, and Patient 1 stated that LVN 1 threw medications at her, and Patient 1 was scared and uncomfortable. LVN 1 signed the form on March 22, 2017, indicating LVN 1 was aware of a broken rule or performance standard not met. On April 4, 2017 at 1:20 p.m., during an interview, Charge Nurse 1 (CN 1) stated on March 19, 2017, at night, she received, over the telephone, a complaint from Family Member 1 about LVN 1 throwing medications at Patient 1 and not answering Patient 1?s call light. CN 1 stated she had a conversation with LVN 1 and she asked whether LVN 1 threw medications at Patient 1. LVN 1 said she tossed the medications at Patient 1, because the patient asked for apple sauce. LVN 1 also told CN 1 that she did not answer Patient 1?s call light promptly, because she was busy caring for other patients. LVN 1 told CN 1 she would apologize to Patient 1. CN 1 was unable to provide documented evidence the facility investigated the incident. When the Evaluator asked whether LVN 1 was assigned to provide care to Patient 1 after the incident, CN 1 stated LVN 1 took care of Patient 1 again on XXXXXXX 2017, on the day Patient 1 was discharged home. On April 4, 2017 at 1:55 p.m., during a concurrent interview, CN 1 and Registered Nurse 1 (RN 1), both stated LVN 1 should have not thrown the medications at Patient 1, and should have treated the patient with respect and dignity. On April 4, 2017, the Evaluator requested RN 1 to provide the facility?s policy and procedure on Abuse Prevention and in-service training to staff on abuse prevention, but RN 1 was unable to provide any policy, stating there were no policies and procedures on abuse prevention, protection, investigation, reporting or training. On May 10, 2017 and May 12, 2017 at 2:10 p.m. and 3:35 p.m., respectively, during telephone interviews, LVN 1 denied throwing the medication at Patient 1. When LVN 1 was asked about the Disciplinary Action Form, she confirmed signing the form. The facility failed to ensure Patient 1 was treated as an individual with dignity and respect, and had the right to be free from mental abuse including: Failure to ensure Patient 1 was not mentally abused and was treated with dignity and respect by Licensed Vocational Nurse 1 (LVN 1), who threw medications at Patient 1, after Patient 1 requested LVN 1 to give the medications with apple sauce to facilitate swallowing the medications. As a result, Patient 1 felt hurt, uncomfortable, humiliated, and scared. The above violation had direct or immediate relationship to the health, safety, or security of Patient 1.
020000115	Oakland Healthcare & Wellness Center	020013578	A	27-Oct-17	H85F11	12271	Title 22 Sections: 72313 and 72311 California Code of Regulations, title 22, section 72313, subdivisions (a)(1),(7),(b),(c) and section 72311, subdivisions (a)(3)(F)(b). ? 72313. Nursing Service - Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order. (7) Patients shall be identified prior to administration of a drug or treatment. (b) No medication shall be used for any patient other than the patient for whom it was prescribed. (c) The time and dose of the drug or treatment administered to the patient shall be recorded in the patient's individual medication record by the person who administers the drug or treatment. Recording shall include the date, the time and the dosage of the medication or type of the treatment. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record. ? 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (F) Any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). The facility violated the aforementioned regulation by failing to ensure Resident 1 was free of a medication error that jeopardized his health when: Registered Nurse (RN) 1 gave Resident 1 methadone (an opioid narcotic used to treat pain or to help with detoxification in people with opioid dependence) without a physician's order; RN 1 did not identify Resident 1 before she gave Resident 1 methadone; RN 1 gave Resident 1 methadone intended for another resident (Resident 2); RN 1 did not document the in the medication administration record (MAR) the date, time, or amount of methadone she gave Resident 1; RN 1 did not notify Resident 1's physician upon discovery of the medication error, and; RN 1 did not document attempts to notify Resident 1's physician of the medication error. Resident 1 had episodes of vomiting and experienced an altered level of consciousness that required a hospital stay and treatment with Narcan (a medication for the emergency treatment of opioid overdose) for methadone poisoning (symptoms include vomiting, weakness, and an altered/decreased level of consciousness). Review of Resident 1's face sheet (a document that gives resident information at a quick glance), dated 7/14/17, indicated Resident 1 was admitted to the facility on 6/21/17 with multiple diagnoses that included atherosclerotic heart disease (narrowing and hardening of the heart arteries), heart failure, chronic kidney disease, Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), generalized weakness, and a referral for physical therapy. Review of Resident 1's Physical Therapy (PT) Evaluation and Plan of Treatment notes, dated 6/22/17, indicated Resident 1 needed PT services to improve his leg muscle strength, standing balance, activity tolerance and safety awareness to assist with transfers (i.e. moving from sitting to standing) and walking. During an interview with RN 1 on 8/28/17, at 7:33 a.m., RN 1 stated that during the day shift on 7/24/17, a CNA approached her at 11 a.m. and told her a resident (Resident 2), who was in the room adjacent to Resident 1, was in pain and asked RN 1 to give him pain medication. RN 1 stated she prepared methadone solution and proceeded to give the medication to Resident 1 and did not ask the resident for his name. RN 1 stated she gave 15 milliliters (150 milligrams) of methadone to Resident 1. RN 1 also stated that after she gave the methadone, she realized it was the wrong resident after she checked the MAR. RN 1 stated she did not think the methadone was going to harm Resident 1. RN 1 stated that when she worked the afternoon shift on 7/27/17 (three days later) another staff person informed her Resident 1 was in the hospital because of a methadone overdose. RN 1 further stated that she did not notify the Director of Nursing (DON) of the medication error until the evening shift on 7/28/17. In an interview with the DON on 8/23/17, at 2:43 p.m., the DON stated RN 1 called her on 7/28/17 and admitted that she gave methadone to Resident 1 instead of Resident 2 on 7/24/17. According to Resident 1's Physician's Order, dated July 2017, there was no physician's order for methadone. Review of Resident 1's Medication Administration Record (MAR), dated July 2017, did not indicate Resident 1 received methadone. Review of Resident 2's Physician's Order, dated 7/7/17, indicated Resident 2 had an order to receive 210 mg (21 milliliters) of methadone for chronic pain and opioid dependence. During an interview with Physical Therapy Assistant (PTA) 1 on 8/24/17, at 3:36 p.m., PTA 1 stated that on 7/24/17 during the 3 o'clock hour, Resident 1 did not receive physical therapy at all because Resident 1 was sick and vomited. Review of Resident 1's Nurse's Notes, dated 7/24/17 at 7:45 p.m., indicated Resident 1 vomited three times in a large amount during physical therapy and also refused dinner. Review of Resident 1's Medication Administration Record (MAR), dated 7/24/17, indicated Resident 1 did not receive his 5 p.m. scheduled medications because he was "unable to wakeup fully to take his 5 p.m. meds...." Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR - a technique used to facilitate prompt and appropriate communication), dated 7/25/17 at 10 a.m., indicated Resident 1 had a decreased level of consciousness (an impaired ability to remain awake, aware, and oriented). Review of Resident 1's Physician's Telephone Orders, dated 7/25/17 at 10:30 a.m., indicated Resident 1 had a physician's order to be sent to the emergency room for evaluation and treatment. Review of the facility's investigation follow up, dated 8/3/17, indicated the facility received a phone call from the hospital on 7/25/17, during the evening shift, that Resident 1 had methadone in his system. The facility's investigation follow up also indicated RN 1 called the DON on 7/28/17 and admitted she made a mistake and gave medication to the wrong resident. According to "Lexicomp Online," a clinical drug information website, methadone risks include "...Life-threatening respiratory depression...Accidental ingestion of even one dose of methadone...can result in a fatal overdose of methadone...Opioid-na‹ve (use as the first opioid analgesic): Oral...Initial: 2.5 mg every 8 to 12 hours...Use with caution in elderly patients; may be more sensitive to adverse effects. Decrease initial dose and monitor closely when initiating...Elderly may be particularly susceptible to CNS (central nervous system that regulates breathing) depressant, respiratory depression...." [Reference: www.lexicomponline.com]. Review of Resident 1's Emergency Department Note (ED Note), dated 7/25/17 at 11:53 a.m., indicated Resident 1 was admitted to the emergency department with an altered level of consciousness that required a sternal rub (a painful stimulus) to arouse the resident. The ED Note also indicated Resident 1's lab test was positive for methadone. The ED Note further indicated Resident 1 had a diagnosis of methadone poisoning and was admitted to the acute hospital for further treatment. Review of Resident 1's Drugs of Abuse Screen results, dated 7/25/17, indicated Resident 1 was positive for methadone. Review of Resident 1's ED MAR, dated 7/25/17, indicated Resident 1 received the first dose of 0.4 mg of Narcan at 5:13 p.m. while in the ED. Review of Resident 1's ED note, dated 7/25/17 at 6:13 p.m., indicated Resident 1 had a respiratory rate of eight to ten breaths per minute (normal respiratory rates for older patients are 12 to 18 breaths per minute for those living independently and 16 to 25 breaths per minute for those in long term-care). Review of Resident 1's ED MAR, dated 7/25/17, indicated Resident 1 received a second dose of 0.4 mg of Narcan at 6:23 p.m. while in the ED. Review of Resident 1's Registered Nurse note, dated 7/25/17 at 11:43 p.m., indicated was admitted to the hospital at 7 p.m. and that during the shift Resident 1 was sleepy and had a decreased respiratory rate of seven breaths per minute. Review of Resident 1's hospital MAR, dated 7/25/17, indicated Resident 1 received a third dose of 0.4 mg of Narcan at 9:16 p.m. while in the hospital. Review of Resident 1's Hospital Discharge Summary (HDS), dated 7/29/17, indicated Resident 1 was discharged on 7/29/17 with diagnoses that included methadone poisoning. Review of the facility's policy and procedure titled "Preparation and General Guidelines," effective April 2008, indicated "...Medication Administration Administration-General Guidelines...B. Administration...7). Residents are identified before medication is administered. Methods of identification include: a. Checking identification band b. Checking photograph attached to medical record c. If necessary, verifying resident identification with other facility personnel...12). Medications supplied for one resident are never administered to another resident...." Review of the facility's policy and procedure titled "Medication-Errors," last revised 1/1/12, indicated "...Policy: I. All errors related to the administration of medications of treatments will be reported to the Director of Nursing Services, the attending physician and the Administrator immediately...II. Medication Error means the administration of medication: A. To the wrong resident...C. At the wrong dose...E. Which is not currently prescribed...Procedure I. Upon discovery of an error, the DON and the Administrator will be immediately notified. II. The Licensed Nurse will make an immediate assessment of the resident in relation to the nature of the error and continue to monitor the resident closely for any adverse effects from the medication. III. If the error is potentially life-threatening, the error and the assessment should be immediately communicated to the Attending Physician. IV. A medication error report should be completed for all medication errors. V. The medication in error is documented in the MAR. VI. Follow-up notes are written if any adverse effect is noted...." Therefore, the facility violated the aforementioned regulation by failing to ensure Resident 1 was free of a medication error that jeopardized his health when: Registered Nurse (RN) 1 gave Resident 1 methadone (an opioid narcotic used to treat pain or to help with detoxification in people with opioid dependence) without a physician's order; RN 1 did not identify Resident 1 before she gave Resident 1 methadone; RN 1 gave Resident 1 methadone intended for another resident (Resident 2); RN 1 did not document in the medication administration record (MAR) the date, time, or amount of methadone she gave Resident 1; RN 1 did not notify Resident 1's physician upon discovery of the medication error, and; RN 1 did not document attempts to notify Resident 1's physician of the medication error. Resident 1 had episodes of vomiting and experienced an altered level of consciousness that required a hospital stay and treatment with Narcan (a medication for the emergency treatment of opioid overdose) for methadone poisoning (symptoms include vomiting, weakness, and an altered/decreased level of consciousness).
970000145	OLYMPIA CONVALESCENT HOSPITAL	910013582	B	27-Oct-17	None	8541	?483.25 (d) (1) (2) (d) 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. ?483.60 (d) 3) Food prepared in a form designed to meet individual needs; On September 5, 2017, during a Recertification Survey, Resident 4?s clinical record was reviewed. Based on observation, interview, and record review, the facility failed to ensure its residents environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance to prevent injuries, and failed to ensure the food is prepared in a form to meet individual needs, including: 1. Failure to ensure Resident 4, who had difficulty swallowing, was served food designed to meet the individual needs, by not serving a finely chopped chicken. 2. Failure to ensure the diet texture served to Resident 4, who needed supervision and one-person assistance with eating, was verified for safe consumption. 3. Failure to monitor Resident 4 for tolerance of the diet provided and notify the physician and the speech therapist when Resident 4 was having low intake and was spiting food as symptom of inability to swallow. As a result, Resident 4 was placed at risk for choking (partial or complete obstruction of the airway due to a foreign body/object) or aspiration pneumonia (food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach) which could lead to death. On September 5, 2017 at 12:30 p.m., during lunch observation Resident 4's meal card was noted to include fortified mechanical soft finely chopped meat and vegetables. Resident 4's plate included chicken with rice, melons, coleslaw salad, and noodle soup. The chicken was not finely chopped but was cut in pieces. Resident 4 was not consuming much of the meal, was pointing to her throat and was speaking in her native language. Licensed Vocational Nurse (LVN 9) who was assisting Resident 4 on and off (as LVN 9 was assisting other residents with their meal), gave a piece of chicken to Resident 4 who started to slowly chew the piece of chicken. When asked why Resident 4 was not eating, LVN 9 stated that the resident did not like the taste. On September 5, 2017 at 12:40 p.m., during interview, the Social Services Designee (SSD), who could communicate with Resident 4 on the resident's native language, stated Resident 4 was pointing at her neck area saying she was not able to swallow the food. At this time, Resident 4 started coughing when trying to swallow the chicken and spit out. On September 5, 2017 at 12:45 p.m., during interview, LVN 9 stated Resident 4?s diet was supposed to be chopped smaller because of her difficulty with swallowing. On September 6, 2017 at 11 a.m. during an interview, Speech Therapist (ST 1) stated Resident 4 had a swallowing evaluation on February 15, 2017 and the resident was recommended to be placed on puree diet with thin liquids due to risk of aspiration and chocking. Resident 4?s diet was changed on April 11, 2017 to mechanical soft finely chopped. ST 1 stated the nurses needed to notify her if Resident 4 required a re-evaluation. ST 1 further stated that based on the poor intake and history of dysphagia, Resident 4 needed a swallowing re-evaluation. On September 7, 2017 at 10:52 a.m., during an interview, registered nurse 1 (RN 1) stated when a resident's meal intake is low, certified nursing assistants (CNAs) will notify the licensed nurses, who will notify the physician. On September 7, 2017 at 1:30 p.m., during an interview ST 1 stated she had re-evaluated Resident 4 and the diet was downgraded to puree due to difficulty swallowing. A review of the Admission Record, indicated Resident 4 was readmitted to the facility on February 14, 2017 with diagnoses including dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), high blood pressure, CVA (stroke) with left sided hemiparesis (weakness of one entire side of the body). A review of the quarterly Minimum Data Set (MDS - standardized assessment and care planning tool) dated August 21, 2017, indicated Resident 4 had severely impaired cognition (thinking and memory skills) for daily decision-making, was able to communicate and required extensive assistance with one person-physical assist for transferring, personal hygiene, and eating. A review of the Physician?s Order dated July 8, 2015, indicating a fortified mechanical soft, finely chopped meat/vegetable and no added salt, diet. A review of the care plan dated February 15, 2017 developed for Resident 4?s need of therapeutic diet related to diagnoses, included in the goals Resident 4 would receive appropriate diet and consume between 75-100% of meals. The interventions included giving the diet as ordered, monitoring meal consumption, and offering substitutes if consuming less than 50% of the meal. A review of progress note by the ST dated September 6, 2017 indicated that Resident 4 was observed during lunch time on September 6, sitting up in wheelchair in the dining room. Resident 4 was served mechanical soft finely chopped diet. Resident was able to feed self with excessive mastication time and then spitting out instead of swallowing. Further stated that the resident had poor intake, which was communicated by nursing and requested for ST evaluation order. A review of the ST evaluation and plan of treatment dated September 7, 2017 indicated Resident 4 had moderate to severe impaired oral phase, mild pharyngeal swallow, puree diet recommended at this time. Risk factors indicated that due to the documented impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for aspiration, dehydration and further decline in function. The recommendations were to change diet to puree consistency with thin liquids. A review of the facility's revised policy dated June 1, 2017 and titled "Aspiration Precautions" indicated residents at risk for aspiration will have measures implemented to reduce risk. Residents at risk for aspiration will be identified on admission, quarterly, with a change in condition, and daily observation. The attending physician will be notified when a resident displays signs and symptoms of potential aspiration, including: coughing or choking while eating or drinking, slow eating, taking multiple swallows of a single mouthful of food, weight loss because of slow eating or lack of appetite, and weak cough. Residents identified at risk for aspiration, exhibiting signs of impaired swallowing, or displaying symptoms of potential aspiration will have aspiration precautions implemented. Aspirations precautions will be written in the resident's plan of care. Aspirations precautions included to assist with feeding and supervision as indicated in the resident's plan of care. A review of a Physician's Telephone Order dated September 8, 2017 indicated to do a chest x-ray stat (immediately) to Resident 4 due to possible aspiration. The result on the same date indicated slight left lower lobe pneumonia. A review of a Physician's Telephone Order dated September 9, 2017, indicated to transfer Resident 4 to a General Acute Care Hospital (GACH) due to slight lower lobe pneumonia. The facility failed to ensure its residents environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance to prevent injuries, and failed to ensure the food is prepared in a form to meet individual needs, including: 1. Failure to ensure Resident 4, who had difficulty swallowing, was served food designed to meet the individual needs, by not serving a finely chopped chicken. 2. Failure to ensure the diet texture served to Resident 4, who needed supervision and one-person assistance with eating, was verified for safe consumption. 3. Failure to monitor Resident 4 for tolerance of the diet provided and notify the physician and the speech therapist when Resident 4 was having low intake and was spiting food as symptom of inability to swallow. As a result, Resident 4 was placed at risk for choking or aspiration pneumonia which could lead to death. The above violation had direct or immediate relationship to the health, safety, or security of Resident 4.
970000145	OLYMPIA CONVALESCENT HOSPITAL	910013586	B	27-Oct-17	98ND11	10046	? 483.25(g) Assisted nutrition and hydration Based on a resident?s comprehensive assessment, the facility must ensure that a resident? (1) Maintains acceptable parameters of nutritional status, such as usual bodyweight or desirable body weight range and electrolyte balance, unless the resident?s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (2) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. On September 7, 2017, during a Recertification Survey, Resident 6?s clinical record was reviewed. Based on observation, interview, and record review, the facility failed to ensure its residents maintain usual body weight and provide therapeutic diet when there was a nutritional problem, including, 1. Failure to ensure Resident 6, who had swallowing problem and poor oral intake (poor eating), was closely monitored for food intake during breakfast, lunch, and dinner, and for nourishment intake between meals, to ensure promptly re-evaluation of interventions and develop new effective interventions. 2. Failure to implement the facility?s policy and procedure on Nourishment and Snacks, by not recording the percentage consumed and by not notifying the Dietary Manager when Resident 6 refused the nourishment and discussing changing or discontinuing the nourishment. 3. Failure to implement the facility?s policy and procedure on Recording Meal Percentages by not offering Resident 6 substitute food when eating less than 75% (percent). As a result, by September 1, 2017, Resident 6 was identified with a significant weight loss of 17 pounds or 12.87 % in two month, from 132 pounds of body weight on July 6, 2017, to 115 pounds on September 1, 2017. On September 7, 2017, at 12:30 a.m., during an observation in the dining room, Resident 6 was sitting in her wheelchair, awake, alert and was waiting for nursing staff to assist her with eating. Speech Therapist 1 (ST 1) was helping other residents and when she turned her attention to Resident 6 and started to assist her with eating, Resident 6 refused to eat. ST 1 spoke to the resident in her native language and Resident 6 responded by shaking her head. During a concurrent interview, ST 1 indicated the resident had been refusing to eat. According to the admission record, Resident 6 was admitted to the facility on July 6, 2017, with diagnoses including hypertension (high blood pressure); metabolic encephalopathy (a broad category that describes abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function); and dysphagia - oropharyngeal phase (difficulty in either the oral or pharyngeal phases of swallowing. A review of the Physician's Order dated July 7, 2017, indicated mechanical soft finely chopped, no added salt, with thick nectar liquid diet. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated July 13, 2017, indicated Resident 6 had no memory problem and required extensive assistance with one-person physical assist with transfers and personal hygiene. Resident 6 required limited assistance with one-person physical assist with eating. A review of the History and Physical (H&P) Examination dated July 18, 2017, indicated Resident 6 did not have the capacity to understand and make decisions. A Physician?s Order July 26, 2017, indicated to provide Magic Cup (a diet supplement), twice a day, at 10 a.m. and 2 p.m. A review of the Plan of Care dated August 7, 2017, developed for Resident 6?s risk for weight loss, indicated the goal was for the resident to consume 80% - 100% of each meal, every day. The interventions included providing the diet and supplement as ordered, offering alternatives or substitutes to adhere to food preferences, monitoring meal intake and notifying the physician when Resident 6 refused or had an intake less than 50%. A review of the Vital Signs Record form indicated the following weights for Resident 6: - July 6, 2017: 132 pounds (lbs.) - July 9, 2017: 129 pounds - July 16, 2017:124 pounds - July 23, 2017: 122 pounds (10 pounds weight loss in four weeks) - August 1, 2017: 118 pounds - September 1, 2017: 115 pounds (17 pounds weight loss in two months) A total of 17 pounds (12.87 %) severe significant weight loss in two months. A review of the CNA Flow Sheet for the month of August 2017 indicated the following Percentage of Meal Intake: - August 8, 2017, breakfast 25%, lunch 20%, and dinner 25% - August 12, 2017, breakfast 50%, lunch 15%, and dinner 10% - August 13, 2017, breakfast 20%, lunch 30%, and dinner 20% - August 14, 2017, breakfast 50%, lunch 50%, and dinner 25% - August 15, 2017, breakfast 45%, lunch 20%, and dinner 20% There was no documented evidence food substitute was offered to Resident 6 when resident meal intake was below 75%. There was no documented evidence of the amount of supplement (Magic Cup) Resident 6 consumed. On September 9, 2017, at 11:00 a.m., during an interview, the Director of Nursing (DON), she stated if resident is refusing nourishment, the Restorative Nurse or Certified Nurse Assistant should report to the supervisor. The DON stated she is not sure if the RNA or CNA reported the less than 50% meal intake or resident`s refusal of nourishment to the supervisor. The supervisors must then notify the physician and document it. A review of the Nurse?s Notes dated August 16, 2017 indicated a late entry for August 7, 2017 indicated "Resident has weight loss of ? 14 lbs. (10%) within one month. Report to physician and will do weight variance as weekly weight for four weeks." However, there was no documentation this was done. A review of the facility's policy and procedure dated August 1996 and titled, "Recording Meal Percentages," indicated if any resident refuses a meal, or the food eaten is less than 75%, the charge nurse shall be notified, and a substitute food from the same food group is offered to the resident. If the substitute is refused, a nourishment or meal replacement will be offered. Nursing staff are to indicate whether the substitutes were consumed or rejected and are to document all substitutions. A review of the facility's revised policy and procedure dated June 1, 2017 and titled, "Assessment and Management of Resident Weights" indicated if the weight is less than or greater than five pounds from the previous weight, immediately re-weigh and have a licensed nurse verify the accuracy of the weight. The Director of Nursing Services (DNS) or licensed nurse will report weight changes in the medical record and on the 24-hour report, notify the physician and dietitian of significant weight changes, and document the notification in the nurses' notes. Residents with significant weight changes will be weighed at least weekly and discussed at the-resident-at-risk or other clinical meetings to determine the possible causes of the weight gain or loss including goals for care. The IDT care plan will be updated to reflect individualized goals and approaches for managing the weight changes. A review of the facility's revised policy dated June 1, 2017 and titled "Change of Condition Notification" indicated the licensed nurse would notify the resident's attending physician when there is a change in weight of five pounds or more within a 30-day period unless a different stipulation has been stated in writing by the patient's physician. The licensed nurse will notify the resident, the resident's responsible party, or the family/surrogate decision-makers of any changes in the resident's condition as soon as possible. A review of the facility's revised policy and procedure dated June 1, 2017 and titled, ?Nutrition and Weight Variance Committee? indicated the weight of residents will be monitored for variance and the nutrition & weight variance committee, made up by IDT members, will meet monthly to assess and review any residents identified as "at risk" for unplanned weight loss. Prior to each meeting, the Director of Nursing Services (DNS) or designee will compile a list of residents who are at risk for, or in need of, weight change. Residents that meet the following criteria may be included on the list for discussion: a persistent weight loss over a period of 3 months, two percent weight change in one week, five percent weight change in 3 months. Objectives of the nutrition & weight variance committee may include identifying behaviors in the feeding environment that may be contributing to weight loss/gain. Residents on the list will be reviewed monthly until their weight has stabilized. The facility failed to ensure its residents maintain usual body weight and provide therapeutic diet when there was a nutritional problem, including, 1. Failure to ensure Resident 6, who had swallowing problem and poor oral intake (poor eating), was closely monitored for food intake during breakfast, lunch, and dinner, and for nourishment intake between meals, to ensure promptly re-evaluation of interventions and develop new effective interventions. 2. Failure to implement the facility?s policy and procedure on Nourishment and Snacks, by not recording the percentage consumed and by not notifying the Dietary Manager when Resident 6 refused the nourishment and discussing changing or discontinuing the nourishment. 3. Failure to implement the facility?s policy and procedure on Recording Meal Percentages by not offering Resident 6 substitute food when eating less than 75% (percent). As a result, by September 1, 2017, Resident 6 was identified with a significant weight loss of 17 pounds or 12.87 % in two month, from 132 pounds of body weight on July 6, 2017, to 115 pounds on September 1, 2017. The above violation had direct or immediate relationship to the health, safety, or security of Resident 6.
970000145	OLYMPIA CONVALESCENT HOSPITAL	910013580	B	27-Oct-17	98ND11	5967	?483.25 (d) (1) (2) (d) 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. ?483.60 (d) 3) Food prepared in a form designed to meet individual needs; On September 8, 2017, during a Recertification Survey, Resident 15?s clinical record was reviewed. Based on observation, interview, and record review, the facility failed to ensure its residents environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance to prevent injuries, and failed to ensure the food is prepared in a form to meet individual needs, including: 1. Failure to ensure Resident 15, who had difficulty swallowing, was served food designed to meet the individual needs, by not serving a finely chopped diet. 2. Failure to ensure the diet texture served to Resident 15, who needed supervision and set up assistance with eating, was verified for safe consumption. 3. Failure to implement the facility?s policy on Aspiration (food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach) Precautions by not monitoring Resident 15 for signs and symptoms of potential aspiration such as coughing or choking while eating or drinking, slow eating, taking multiple swallows of a single mouthful of food, and lack of appetite. As result, Resident 15 was placed at risk for choking (partial or complete obstruction of the airway due to a foreign body/object) or aspiration which could lead to death. A review of the Admission Record indicated Resident 15 was admitted to the facility on April 5, 2017 and re-admitted on May 17, 2017 with diagnoses included difficulty swallowing. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated August 24, 2017 indicated Resident 15 had moderately impaired cognition (thinking and memory skills) for daily decision-making and required supervision and set-up assistance while eating. On September 8, 2017 at 7:45 a.m., Resident 15 was sleeping in bed with a breakfast tray on the bedside table. The lid of the entr‚e was removed. The Meal Card indicated, "Regular NAS" (regular consistency and no added salt) diet. Resident 15 breakfast tray had one whole pastry and one whole boil egg. A review of the Physician's Order dated May 22, 2017 indicated to give Resident 15 mechanical soft finely chopped, NAS diet. On September 8, 2017 at 11 a.m., during an interview, the Dietary Service Supervisor (DSS) stated Resident 15 should have received a mechanical soft finely chopped diet. DSS further stated the nurses are to match the diet orders with the meal card and tray for accuracy before the trays are passed out to the residents. On September 8, 2017 at 11:50 a.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated she did not have time to check each tray with each diet order. On September 9, 2017 the physician ordered a swallowing evaluation for Resident 15. A review of the Speech Therapy Evaluation and Plan of Treatment report dated September 9, 2017, the Speech Therapist recommended a puree consistency diet with nectar thickened liquids and to provide close supervision. On September 9, 2017 during a lunch observation from 12:18 p.m. to 12:53 p.m. in the dining room, Resident 15 was observed eating lunch unsupervised. A review of the facility's revised policy and procedure dated June 1, 2017 and titled, "Therapeutic Diets," indicated the dietary manager will periodically review the resident's tray card and the physician's dietary orders to ensure that the information is consistent. A review of the facility's revised policy dated June 1, 2017 and titled, "Aspiration Precautions" indicated residents at risk for aspiration will have measures implemented to reduce risk. Residents at risk for aspiration will be identified on admission, quarterly, with a change in condition, and daily observation. The attending physician will be notified when a resident displays signs and symptoms of potential aspiration, including: coughing or choking while eating or drinking, slow eating, taking multiple swallows of a single mouthful of food, weight loss because of slow eating or lack of appetite, and weak cough. Resident 15 was identified at risk for aspiration, exhibiting signs of impaired swallowing, or displaying symptoms of potential aspiration will have aspiration precautions implemented. Aspirations precautions will be written in the resident's plan of care. Aspirations precautions included to assist with feeding and supervision as indicated in the resident's plan of care. The facility failed to ensure its residents environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance to prevent injuries, and failed to ensure the food is prepared in a form to meet individual needs, including: 1. Failure to ensure Resident 15, who had difficulty swallowing, was served food designed to meet the individual needs, by not serving a finely chopped diet. 2. Failure to ensure the diet texture served to Resident 15, who needed supervision and set up assistance with eating, was verified for safe consumption. 3. Failure to implement the facility?s policy on Aspiration Precautions by not monitoring Resident 15 for signs and symptoms of potential aspiration such as coughing or choking while eating or drinking, slow eating, taking multiple swallows of a single mouthful of food, and lack of appetite. As result, Resident 15 was placed at risk for choking or aspiration which could lead to death. The above violation had direct or immediate relationship to the health, safety, or security of Resident 15.
970000145	OLYMPIA CONVALESCENT HOSPITAL	910013575	B	27-Oct-17	98ND11	9363	? 483.25(g) Assisted nutrition and hydration Based on a resident?s comprehensive assessment, the facility must ensure that a resident? (1) Maintains acceptable parameters of nutritional status, such as usual bodyweight or desirable body weight range and electrolyte balance, unless the resident?s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (2) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. On September 18, 2017, during a Recertification Survey, Resident 15?s record was reviewed. Based on observation, interview, and record review, the facility failed to ensure its residents maintain usual body weight and provide therapeutic diet when there was a nutritional problem, including, 1. Failure to ensure Resident 15, who had swallowing problem and poor oral intake (poor eating), was closely monitored for food intake during breakfast, lunch, and dinner, and for nourishment intake between meals, to ensure promptly re-evaluation of interventions and develop new effective interventions. 2. Failure to develop a comprehensive care plan addressing Resident 15's poor nutritional intake, swallowing difficulty, and progressive weight loss, to ensure interventions met Resident 15?s assessed needs. 3. Failure to implement the facility?s policy and procedure on Nourishment and Snacks, by not always recording the percentage consumed and by not notifying the Dietary Manager when Resident 15 refused the nourishment and discussing changing or discontinuing the nourishment. 4. Failure to implement the facility?s policy and procedure on Recording Meal Percentages by not offering Resident 15 substitute food when eating less than 75% (percent). 5. Failure to implement the facility's policy and procedure on Change of Condition Notification by not notifying Resident 15?s attending physician and the responsible party, when there was a progressive weight change in weight of five pounds within a 30-day period. As a result, by September 1, 2017, Resident 15 was identified with a significant weight loss of eight pounds or 7.6 % in one month, from 105 pounds of body weight on August 1, 2017, to 97 pounds on September 1, 2017. A review of the Admission Record indicated Resident 15 was admitted to the facility on April 5, 2017 and re-admitted on May 17, 2017, with diagnosis including difficulty swallowing. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated August 24, 2017, indicated Resident 15 had moderately impaired cognition (memory and thinking skills) for daily decision-making and required supervision and set-up assistance with eating. A review of the initial Medical Nutrition Therapy Assessment, completed on April 7, 2017 by the Registered Dietitian (RD), indicated Resident 15?s daily estimated nutritional needs were 1,470 calories, 49-59 grams of protein, and 1,470 cubic centimeters (cc) of fluids. A review of the Physician's Order indicated the following orders: 1. May 17, 2017 - four ounces of high protein nourishment between meals. 2. May 22, 2017 ? mechanical soft finely chopped, NAS (no added salt) diet. On September 8, 2017 at 7:45 p.m., Resident was observed sleeping in bed. Resident 15?s breakfast tray was on the bedside table. The breakfast tray food items included a whole pastry and one boil egg. A Physician's Order dated May 17, 2017, indicated to give Resident 15 four ounces of high protein nourishment between meals. A review of the Weight Report indicated the following: 1. August 1, 2017 - 105 pounds (lbs.) 2. August 6, 2017 - 102 lbs. 3. August 13, 2017 - 103 lbs. 4. August 20, 2017 - 103 lbs. 5. August 27, 2017 - 98 lbs. 6. September 1, 2017 - 97 lbs. By September 1, 2017, Resident 15 had a significant weight loss of eight pounds or 7.6 % (percent) in one month. A review of the Speech Evaluation and Plan of Treatment report dated September 9, 2017, indicated the speech therapist recommended puree consistencies, nectar thick liquids and close supervision to facilitate safety and efficiency during oral intake. A review the CNA (Certified Nursing Assistant) Flow Sheet from August 1 to September 8, 2017 indicated Resident 15?s meal intake was: - For breakfast, 19 days consumed less than 75 % and seven days were left blank (no documentation). - For lunch, 18 days consumed less than 75 % and 4 days were blank. - For dinner, 13 days consumed less than 75 % and 9 days were blank. A review of the Nourishment Percentage Intake after it was ordered, from August 20 to September 11, 2017, indicated Resident 15 had refused the nourishment 25 times, consumed 50% 18 times, and six times the intake was not documented. Further record review, disclosed no documented evidence a plan of care was developed to address Resident 15?s progressive weight loss and poor appetite, to develop interventions to prevent further weight loss and improve appetite. There was no documentation nursing staff relayed to the physician and the RD Resident 15?s weight loss and poor appetite for new orders and recommendations including evaluation by Speech Therapist (ST). There was no documentation the interdisciplinary team (IDT) including the RD, physician, nurses, ST, and Resident 15?s representative, had addressed Resident 15?s nutritional problem. On September 8, 2017 at 1:35 p.m., during a review of Resident 15?s clinical record with Licensed Vocational Nurse 1 (LVN 1) and concurrent interview, LVN 1 was unable to provide documented evidence a plan of care was developed for Resident 15's weight loss or documentation that the physician, RD, or the Dietary Service Supervisor (DSS) were notified about the resident's poor meal and nourishment intake. LVN 1 further stated, "When residents eat less than 75%, we should offer a meal substitute and document the amount consumed.? On September 12, 2017 at 9:30 a.m., during an interview, the DSS stated she was not aware Resident 15 was having poor meal and nourishment intake. A review of the facility?s policy and procedure revised on June 1, 2017, titled, "Nourishment and Snacks," indicated the percentage of the nourishment consumed by the resident will be recorded on the Medication Administration Record (MAR) by the licensed nurse. Nursing staff will notify the Dietary Manager if the resident refuses the nourishment. Resident refusal may warrant discussion of changing or discontinuing the nourishment. A review of the facility's policy and procedure dated August 1996, titled, "Recording Meal Percentages," indicated if any resident refuses a meal, or the food eaten is less than 75%, the charge nurse shall be notified, and a substitute food from the same food group is offered to the resident. If the substitute is refused, a nourishment or meal replacement will be offered. Nursing staff are to indicate whether the substitutes were consumed or rejected and are to document all substitutions. A review of the facility's policy and procedure revised on June 1, 2017, titled "Change of Condition Notification," indicated the licensed nurse would notify the resident's attending physician when there is a change in weight of five pounds or more within a 30-day period unless the resident?s physician has stated a different stipulation in writing. The licensed nurse will notify the resident, the resident's responsible party, or the family/surrogate decision-makers of any changes in the resident's condition as soon as possible. The facility failed to ensure its residents maintain usual body weight and provide therapeutic diet when there was a nutritional problem, including, 1. Failure to ensure Resident 15, who had swallowing problem and poor oral intake (poor eating), was closely monitored for food intake during breakfast, lunch, and dinner, and for nourishment intake between meals, to ensure promptly re-evaluation of interventions and develop new effective interventions. 2. Failure to develop a comprehensive care plan addressing Resident 15's poor nutritional intake, swallowing difficulty, and progressive weight loss, to ensure interventions met Resident 15?s assessed needs. 3. Failure to implement the facility?s policy and procedure on Nourishment and Snacks, by not always recording the percentage consumed and by not notifying the Dietary Manager when Resident 1refused the nourishment and discussing changing or discontinuing the nourishment. 4. Failure to implement the facility?s policy and procedure on Recording Meal Percentages by not offering Resident 15 substitute food when eating less than 75% (percent). 5. Failure to implement the facility's policy and procedure on Change of Condition Notification by not notifying Resident 15?s attending physician and the responsible party, when there was a progressive weight change in weight of five pounds within a 30-day period. As a result, by September 1, 2017, Resident 15 was identified with a significant weight loss of eight pounds or 7.6 % in one month, from 105 pounds of body weight on August 1, 2017, to 97 pounds on September 1, 2017. The above violation had a direct or immediate relationship to the health, safety, and security of Resident 15.
970000145	OLYMPIA CONVALESCENT HOSPITAL	910013568	A	27-Oct-17	98ND11	15486	? 483.25(g) Assisted nutrition and hydration Based on a resident?s comprehensive assessment, the facility must ensure that a resident? (1) Maintains acceptable parameters of nutritional status, such as usual bodyweight or desirable body weight range and electrolyte balance, unless the resident?s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (2) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. On September 5, 2017, during a Recertification Survey, Resident 14?s record was reviewed. Based on (observation, interview, and record review, the facility failed to ensure its residents maintain usual body weight and failed to provide therapeutic diet when there was a nutritional problem, including, 1. Failure to ensure Resident 14, who had swallowing problem, poor oral intake (poor eating), and needed assistance with eating, was provided with the necessary assistance and the meal and nourishment intake was closely monitored at all meals, to ensure effectiveness of interventions and develop new interventions. 2. Failure to provide Resident 14 with high calorie/protein smoothies with meals as ordered by the physician. 3. Failure to develop a plan of care to include measurable goals and interventions to maintain Resident 14?s nutritional parameters based on individualized assessed needs (assisting resident during meals, difficulty swallowing, and progressive weight loss) of Resident 14 as indicated in the Nutritional/Hydration and Weights, Care Plan and Nutrition/Hydration Management policies and procedures. 4. Failure to implement the facility?s policy and procedures on Recording Meal Percentages by not providing food substitute when Resident 14 ate less than 75%. 5. Failure to implement the facility?s policy and procedures on Assessment and Management of Resident Weights by not re-weighing Resident 14 when there was more than five pounds weight loss from previous weight and by not reporting the weight loss to the physician and RD. 6. Failure to implement the facility?s policy and procedures on Change of Condition Notification by not notifying Resident 14?s attending physician when there was a change in weight of five pounds or more within a 30-day period. 7. Failure to implement the facility's policy and procedures on Nutrition and Weight Variance Committee by not meeting monthly to assess and review Resident 14?s persistent weight loss over a period of 3 months, two percent weight change in one week, five percent weight change in 3 months. As a result, Resident 14 had unplanned significant weight loss of 18 pounds (13.23% of body weight) in three months, was transferred to a General Acute Care Hospital (GACH) where Resident 14 was diagnoses including cachexia (condition that causes extreme weight loss, as well as, muscle wasting) with failure to thrive (inability to perform or to function properly) and severe malnutrition (condition that develops when the body does not get the right amount of the vitamins, minerals, and other nutrients). On September 5, 2017 at 4:52 p.m., Resident 14 was observed lying in bed and drinking a liquid. Resident 14's family member (FM 1) was at the bedside, and upon interview, stated the drink was a blend of different beans, brought from home, to help with Resident 14?s nutrition. FM 1 stated Resident 14 had poor appetite and appeared to be losing weight but did not know if she had in fact a weight loss. According to the Admission Record, Resident 14 was admitted to the facility on April 24, 2017 with diagnoses including dysphagia (difficulty swallowing any liquid including saliva, or solid material). A review of Resident 14's admission Minimum Data Set (MDS - a standardized assessment and care planning tool) dated April 30, 2017, indicated Resident 14 was able to communicate needs, required limited (one-person) physical assistance with eating, was on a mechanically altered (require change in texture of food), and a therapeutic diet (a meal plan that controls the intake of certain foods or nutrients). Resident 14 weighed 134 pounds (lbs.). A review of Resident 14's Monthly Weight Record indicated: 1. On June 2, 2017, Resident 14 weighed 136 pounds. 2. On July 2, 2017, Resident 14 weighed 127 pounds (9-pound weight loss in one month). 3. On August 1, 2017, Resident 14 weighed 123 pounds (4-pound weight loss in one month and 13 pound weight loss in three months). 4. On September 1, 2017, Resident 14 weighed 118 pounds (5-pound weight loss in one month and 18-pounds weight loss in four months and 13.23% in three months). A review of Resident 14's physician orders indicated the following: 1. Mechanical soft, no concentrated sweet finely chopped diet, with nectar thick liquids, dated April 24, 2017. 2. High calorie/protein smoothies with meals, dated July 7, 2017 3. Resource 2.0 (nourishment) 120 milliliters (ml) every evening, dated July 7, 2017. A review of Resident 14's Quarterly Nutritional Assessment completed by the Dietary Service Supervisor (DSS) dated July 28, 2017, indicated Resident 14 was able to feed herself independently. Resident 14 weighed 127 lbs. a 6% significant weight loss which was a desirable and Resident 14 was still above her ideal body weight range (99 to 121 pounds). Resident 14 was to be weighed weekly for one month. A review of Resident 14's Nourishment Percentage Intake Record for the months of August and September 2017 did not include the amount consumed. Resident 14's Meal Intake flow sheet, for the month of August 2017, did not include whether Resident 14 was offered a meal substitute, when eating less than 75% of a meal. Resident 14's Meal Intake flow sheet from September 1, 2017 to September 5, 2017, indicated Resident 14 consumed less than 75% three days for breakfast, four days for lunch, and five days for dinner. On September 6, 2017 at 7:37 a.m., Resident 14 was observed alone, sitting in bed eating breakfast independently. The breakfast tray did not have a high calorie/protein smoothie as ordered. During a concurrent interview, the DSS stated a Weight Variance meeting to address Resident 14's weight loss was not done. On September 6, 2017 at 11:35 a.m., during an interview, Certified Nursing Assistant 3 (CNA 3) stated she had been assigned to Resident 14 since the resident's admission and resident 14 was not receiving high calorie/protein smoothies with her meals. On September 6, 2017 at 12 p.m., during an interview, Licensed Vocational Nurse 7 (LVN 7) stated he reviewed Resident 14's meal intake from September 1, 2017 to September 5, 2017, and was unable to provide documented evidence a meal substitute was offered when the resident meal intake was less than 75%. On September 6, 2017 at 12:15 p.m., during a dining observation, Resident 14 was sitting at a table eating independently. There were no staff members to assist Resident 14 with her meal. After eating a cookie, Resident 14 did not eat her main meal. On September 6, 2017 at 1:11 p.m., during an interview, LVN 7 stated Resident 14 required a staff member's assistance with meals (as indicated in the MDS dated July 30, 2017). On September 6, 2017 at 2:30 p.m., during an interview, the Registered Dietitian (RD) stated he evaluated Resident 14's nutritional status on July 7, 2017, two days after the resident triggered for significant weight loss (6% weight loss in one month). The RD stated his recommendations were to add high calorie/protein smoothies with meals and 120 milliliters (ml) of Resource 2.0 at 8 p.m. The RD stated his procedure/ practice was to meet with the staff on a monthly basis to evaluate the effectiveness of the interventions. The RD stated he visited the facility on September 5, 2017, but did not re-evaluate Resident 14's interventions and was not aware Resident 14 had an additional weight loss of five pounds on September 1, 2017. On September 7, 2017 at 4:37 p.m., during an interview, the Health Information Director (HID) stated she reviewed Resident 14's care plans, but was unable to provide a care plan addressing Resident 14's weight loss. On September 8, 2017 at 3 p.m., during an interview, LVN 7 stated the facility's procedure was to re-weigh the resident if he/she had a five pounds or greater weight loss in one month, and notify the physician. LVN 7 stated the facility's policy and procedure was not followed, when Resident 14 lost 5 pounds from August 1, 2017 to September 1, 2017. LVN 7 also stated Resident 14's physician was not notified of the five pounds weight loss. On September 7, 2017, Resident 14 was transferred to the GACH due to a decreased appetite and generalized weakness. A review of the GACH clinical record indicated Resident 14's History and Physical (H&P) report dated September 7, 2017, indicated Resident 14 was admitted due to an acute (sudden, rapid) worsening condition, was dehydrated and the blood sugar was poorly controlled. Resident 14's diagnoses included cachexia (condition that causes extreme weight loss, as well as, muscle wasting) with failure to thrive (inability to perform or to function properly) and severe malnutrition (condition that develops when the body does not get the right amount of the vitamins, minerals, and other nutrients). A review of the facility's policy and procedure dated August 1996 and titled, "Recording Meal Percentages," indicated if any resident refuses a meal, or the food eaten is less than 75%, the charge nurse shall be notified, and a substitute food from the same food group is offered to the resident. If the substitute is refused, a nourishment or meal replacement will be offered. Nursing staff are to indicate whether the substitutes were consumed or rejected and are to document all substitutions. A review of the facility's policy and procedure dated August 1996 and titled "Weights, Care Plan" indicated individualized resident care plans are developed by the Interdisciplinary team (IDT), and implemented by the appropriate team members, based on a comprehensive resident assessment. The care plan identifies any problems with a resident's nutritional status/weight, appropriate interventions and realistic goals. A review of the facility's revised policy and procedure dated June 1, 2017 and titled "Assessment and Management of Resident Weights" indicated if the weight is less than or greater than five pounds from the previous weight, immediately re-weigh and have a licensed nurse verify the accuracy of the weight. The Director of Nursing Services (DNS) or licensed nurse will report weight changes in the medical record and on the 24-hour report, notify the physician and dietitian of significant weight changes, and document the notification in the nurses' notes. Residents with significant weight changes will be weighed at least weekly and discussed at the-resident-at-risk or other clinical meetings to determine the possible causes of the weight gain or loss including goals for care. The IDT care plan will be updated to reflect individualized goals and approaches for managing the weight changes. A review of the facility's revised policy and procedure dated June 1, 2017 and titled "Change of Condition Notification" indicated the licensed nurse would notify the resident's attending physician when there is a change in weight of five pounds or more within a 30-day period unless the patient's physician has stated a different stipulation in writing. The licensed nurse will notify the resident, the resident's responsible party, or the family/surrogate decision-makers of any changes in the resident's condition as soon as possible. A review of the facility's revised policy and procedure dated June 1, 2017 and titled "Nutrition and Weight Variance Committee" indicated the weight of residents will be monitored for variance and the nutrition & weight variance committee, made up by IDT members, will meet monthly to assess and review any residents identified as "at risk" for unplanned weight loss. Prior to each meeting, the Director of Nursing Services (DNS) or designee will compile a list of residents who are at risk for, or in need of, weight change. Residents that meet the following criteria may be included on the list for discussion: a persistent weight loss over a period of 3 months, two percent weight change in one week, five percent weight change in 3 months. A review of the facility's revised policy and procedure dated June 1, 2017 and titled "Nutrition/Hydration Management" indicated the concept of nutrition management is an interdisciplinary process. The key components of this system are developing an individual nutrition program based on individual assessed needs, identifying instances of unplanned weight loss or gain, and ongoing assessment, monitoring, and evaluation of the effectiveness of the nutrition/hydration management program. A comprehensive care plan is developed by the IDT that addresses nutrition/hydration and an individualized nutrition/hydration management program based on individualized assessed need. The facility failed to ensure its residents maintain usual body weight and failed to provide therapeutic diet when there was a nutritional problem, including, 1. Failure to ensure Resident 14, who had swallowing problem, poor oral intake (poor eating), and needed assistance with eating, was provided with the necessary assistance and the meal and nourishment intake was closely monitored at all meals, to ensure effectiveness of interventions and develop new interventions. 2. Failure to provide Resident 14 with high calorie/protein smoothies with meals as ordered by the physician. 3. Failure to develop a plan of care to include measurable goals and interventions to maintain Resident 14?s nutritional parameters based on individualized assessed needs of Resident 14 as indicated in the Nutritional/Hydration and Weights, Care Plan and Nutrition/Hydration Management policies and procedures. 4. Failure to implement the facility?s policy and procedures on Recording Meal Percentages by not providing food substitute when Resident 14 ate less than 75%. 5. Failure to implement the facility?s policy and procedures on Assessment and Management of Resident Weights by not re-weighing Resident 14 when there was more than five pounds weight loss from previous weight and by not reporting the weight loss to the physician and RD. 6. Failure to implement the facility?s policy and procedures on Change of Condition Notification by not notifying Resident 14?s attending physician when there was a change in weight of five pounds or more within a 30-day period. 7. Failure to implement the facility's policy and procedures on Nutrition and Weight Variance Committee by not meeting monthly to assess and review Resident 14?s persistent weight loss over a period of 3 months, two percent weight change in one week, five percent weight change in 3 months. As a result, Resident 14 had unplanned significant weight loss of 18 pounds (13.23% of body weight) in three months, was transferred to a GACH where Resident 14 diagnoses including cachexia and severe malnutrition. The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious harm would result to Resident 14.
060001591	OLIVE STREET NORTH HOME	060013649	B	30-Nov-17	PDUF11	11879	W331 - 483.460(c) The facility must provide clients with nursing services in accordance with their needs. On 09/26/17, the CDPH (California Department of Public Health), L&C (Licensing and Certification) Program received an ERI (Entity Reported Incident) related to the discoloration on Client 1's left great toe. On 9/29/17 at 0705 hours, an unannounced visit was conducted at the facility to investigate the ERI. Clients 1 and 2 were observed sitting in their wheelchairs in the living room watching TV while DCS (Direct Care Staff) 1 and 2 were assisting the other clients with their breakfast. DCS 1 stated there were six clients currently residing in the facility, two of which did not go to the day program. On 9/29/17 at 0710 hours, DCS 2 was asked if Client 1's feet could be checked. DCS 2 wore clean gloves and removed the clog shoes on Client 1's feet. Client 1 was observed wearing TED hose stockings (stockings used to prevent blood clots) on both lower legs. Upon inspection, it was observed there was a resolving bruise underneath Client 1's left big toe. Both of Client 1's feet were observed to be swollen during inspection. Client 1 was not observed to be showing any signs of distress or pain at this time. When asked regarding the bruise, DCS 2 stated she did not know what caused the bruise on Client 1's left great toe. DCS 2 added the client sometimes got some bruises on her arms since Client 1 was able to wheel herself on the wheelchair. On 9/29/17 at 0850 hours, DCS 1 was interviewed regarding the bruising on Client 1's left great toe. DCS 1 stated during her shift on 9/18/17, she noticed a discoloration around Client 1's left great toe after they had given her a shower. DCS 1 added she immediately informed the House Manager. DCS 1 stated either she or the House Manager informed the RN. DCS 1 verbalized she documented the finding on the computer because that was how they would document their body check findings. DCS 1 stated Client 1 did not look like she was in pain when she discovered the discoloration on the client's left great toe that day. When asked regarding the incident on 9/24/17, involving Client 1, DCS 1 stated she noticed Client 1's left great toe was still swollen. DCS 1 added she documented the finding on the body check form and informed the House Manager. DCS 1 stated the House Manager informed the RN (Registered Nurse) regarding the incident. The DCS added Client 1 did not look like she was in pain when they discovered the swollen left great toe. In addition, DCS 1 verbalized she did not know how Client 1 got the discoloration or bruising on her left great toe since Client 1 had always been prone to bruising. DCS 1 also added Client 1 was able to wheel herself when she was at home. Review of the facility's P&P (Policy and Procedure) titled Nursing Best Practice: Change of Condition (undated) showed in part: any change in a client's condition, including but not limited to musculoskeletal and skin condition changes, should be properly assessed, treated, and monitored; and that the physician should be notified of the change in condition. Review of Client 1's clinical record was initiated on 9/29/17. Client 1 was admitted to the facility on 10/20/98, with diagnoses, including severe intellectual disability, cerebral palsy, and seizure disorder. Client 1 used a wheelchair for ambulation and was dependent on the facility staff for her healthcare needs. Review of the Nurses' Notes dated 9/21/17, showed the RN was informed by the facility staff Client 1 had a discoloration on her left great toe. The documentation showed the RN assessed Client 1 for a fracture, but none was noted and the RN educated the staff regarding Client 1's movements around her foot rest. In addition, the RN wrote the entry on 9/21/17 was a late entry for 9/18/17. Further review failed to show documented evidence the RN noted the type of discoloration Client 1 had on her left great toe or if the physician was informed regarding Client 1's condition. Additional review of the Nurses' Notes showed on 9/24/17, the RN documented Client 1 was taken to the urgent care clinic and diagnosed with a dislocation on the left great toe. In addition, the RN documented Client 1 was brought to the acute care hospital for treatment and x-ray and was diagnosed with dislocation, but no fractures were noted. The RN documented Client 1 was given a blow-up booties to wear and to follow-up with the physician in one to two weeks. Further review failed to show documented evidence the RN had informed Client 1's physician regarding the client's recent emergency room visit or that a follow-up visit had been scheduled at this time. Review of the facility's body check form showed on 9/18/17, the DCS documented Client 1 was found with bruising under the right arm and left toe. Further document review showed on 9/23/17, during the night/morning shift, the DCS documented the old bruise on Client 1's left toe was darker. Review of the patient plan from Client 1's urgent care visit on 9/24/17, showed the physician ordered x-rays for Client 1. The urgent care physician assessed Client 1 had a closed dislocation on her left great toe and advised Client 1 be seen in the emergency room for further evaluation. The physician advised that Client 1 be seen by her primary physician for follow up in one to two weeks. Review of the emergency room visit summary dated 9/24/17, showed Client 1 was diagnosed with a closed dislocation of her left great toe. The emergency room physician advised Client 1 be seen by her primary physician for follow up within three to five days. However, review of the clinical record on 9/29/17, failed to show Client 1 had seen her primary physician after the emergency room visit on 9/24/17. Review of the facility investigation report conducted by the QIDP (Qualified Intellectual Disabilities Professional) on 9/26/17, showed the QIDP was unable to substantiate the cause of Client 1's dislocated left great toe. During an interview on 9/29/17 at 1000 hours, the RN was asked regarding Client 1's dislocated left great toe. The RN stated she was informed by the House Manager the morning of 9/18/17, regarding the bruising on Client 1's left great toe. The RN added she came to the facility on 9/19/17, to assess Client 1 for possible fracture. The RN said she did not find any signs of fracture on Client 1's left great toe, so she instructed the facility staff to do alternating hot and cold compress on the affected site and to monitor for pain. The RN verified the Nurses' Notes entry dated 9/21/17, was her late entry for 9/18/17. The RN also verified she never documented the interventions she had given to the facility staff. The RN added she did not inform the physician or the QIDP regarding the incident involving Client 1 that happened on 9/18/17. When asked what happened to Client 1 on 9/24/17, the RN stated she was informed by the House Manager Client 1's left great toe was swollen. The RN verified she was in the facility on 9/24/17, to follow up with Client 1. The RN added she also conducted an in-service training for the facility staff on 9/25/17, related to Client 1's diagnosis of dislocated left great toe. However, the RN stated she had not informed the physician of Client 1's emergency room visit on 9/24/17. The RN verbalized she thought Client 1 was to follow up with the physician in one to two weeks and added she was not aware the emergency room physician gave discharge instructions for Client 1 to follow up with her physician in three to five days. The RN added she would have to make an appointment to schedule Client 1's follow up with her physician. During an interview on 9/29/ 17 at 1040 hours, the QIDP stated she was not informed by the RN or facility staff regarding the incident that involved Client 1 on 9/18/17. The QIDP stated she was not made aware Client 1 had a discoloration on her left great toe. The QIDP added their P&P stated if any of the clients had an injury of unknown origin, that client should be brought to the emergency room or be evaluated by a physician immediately to rule out any potential fracture or major injury. The QIDP said she received a call from the House Manager the morning of 9/24/17, regarding the injury on Client 1's left great toe. The QIDP verbalized she immediately instructed the House Manager to bring Client 1 to the urgent care to get an x-ray done. The QIDP also stated she immediately conducted her investigation after she was made aware of Client 1's condition. The QIDP added she was unable to find the cause of Client 1's injury and added Client 1 had a history of bruising and would bump her feet on the table during meal time. During a telephone interview on 10/2/17 at 0855 hours, the House Manager was asked regarding the incident involving Client 1. The House Manager stated on 9/18/17, she was informed by DCS 1 that Client 1 had a discoloration on her left great toe. The House Manager added she informed the RN and was told to keep the client home that day. The House Manager said the RN came in to see Client 1 on 9/19/17, to assess the client and gave the facility staff instructions to monitor the site and do alternating heat and cold compress. The House Manager further added Client 1 did not look like she was in pain when they found the discoloration. The House Manager stated they did not inform the QIDP about the incident on 9/18/17. With regards to the 9/24/17 incident involving Client 1, the House Manager stated when she saw that Client 1's left great toe was still discolored and swollen she immediately informed the QIDP and RN. The House Manager further stated the QIDP gave her instructions to bring Client 1 to the urgent care to get evaluated. The House Manager added she had to bring Client 1 to the emergency room after the urgent care physician informed her Client 1 needed more evaluation. The House Manager stated the x-rays were taken in the emergency room and the client was diagnosed with a dislocated left great toe. The House Manager further said she was not sure how Client 1 got the injury since the client always wore shoes or clogs. During a telephone interview on 10/10/17 at 0957 hours, the QIDP was asked if they had a P&P regarding when the staff should conduct the body checks. The QIDP stated the staff should do daily body checks especially when giving a shower or when changing the clients' clothes. The QIDP further added the staff only used the body check forms when they found anything on the clients. The QIDP verified they do not have any specific P&P regarding doing body checks on the clients. On 10/26/17 at 1400 hours, a telephone interview with the ED (Executive Director) was conducted. The ED was informed the RN did not inform the physician when Client 1's left great toe was identified with bruising on 9/18/17, and led to Client 1 not being seen by a physician for an x-ray of her left great toe until 9/24/17. The ED was also informed of the RN's failure to inform the QIDP also delayed the investigation regarding how Client 1 obtained the injury as stated in the facility P&P. The ED acknowledged the findings. The facility failed to ensure the RN informed the primary care physician in a timely manner when the discoloration on Client 1's left great toe was identified on 9/8/17, and the x-ray of Client 1's foot was not conducted until 9/24/17, when the client's left foot was x-rayed during an emergency room visit. The RN did not inform the primary care physician of the x-ray results, which showed Client 1 had a dislocation involving the great toe on her left foot. This failure had a direct or immediate relationship to the health, safety, and security of Client 1.