La Canada Care Center

Based on observation, clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that oxygen was administered per physician orders for one resident (#12). The sample size was 20.

Findings include:

The resident was admitted on December 18, 2019 with diagnosis including anxiety disorder, unspecified dementia, psychotic disturbance, mood disturbance , anxiety, depression, schizophrenia, acute respiratory failure with hypoxia, pleural effusion, other non specific findings of the lung field, pneumonia, chronic obstructive pulmonary disease and a wedge compression fracture.

A review of the MDS (minimum data set) dated December 07, 2023 revealed that the resident had a BIMS (brief interview of mental status) score of 14, indicating that the resident was cognitively intact. The MDS further noted that the resident was on oxygen therapy.

A review of the of the physician's orders dated January 2, 2024 for resident #12 revealed an order for 4 liters of oxygen per minute via nasal cannula. An update to the orders was made on January 30, 2024 at 2:00 PM noting oxygen via nasal cannula for chronic obstructive pulmonary disease and may citrate to keep oxygen saturation (SP02) levels at or above 90%

A review of the resident's care plan initiated on December 29, 2019 revealed a focus that resident #12 has emphysema, and chronic obstructive pulmonary disease and the included intervention that oxygen therapy is to be given as ordered by the physician. Furthermore, the care plan revealed that the resident has oxygen therapy and that the oxygen settings were noted to be at 5 liters per minute continuously via nasal cannula; however, oxygen was observed to be above the ordered liters per minute and above the documented care plan rate for resident #12.

An observation on January 30, 2024 at 9:52 AM revealed that resident #12 was observed to be on 6 liters of oxygen as observed on the oxygen concentrator setting.

An observation on January 30, 2024 at 12:26 PM revealed that resident #12 was still on 6 liters of oxygen.

An interview was conducted on January 30, 2024 at 12:26 P.M. with staff #70 LPN (Licensed Practical Nurse). Staff #70 stated that oxygen settings were as ordered by the physician. She further stated that oxygen settings are checked during rounding every 2 hours. She stated that oxygen setting for resident #12 should be at 4 liters per minute. She stated that the risk for settings outside of the parameters that the physician had established could impact the gas exchange and could impede the resident's breathing.

An interview was conducted with staff #13, DON (Director of Nursing) on January 30, 2024 at 12:40 PM Staff #13 stated that some patients, depending on the physician's order, may have settings designated on a range to maintain oxygen at a certain level. She stated that the nurse assigned to the resident, is required to sign off on the oxygen order every shift. Staff #13 reviewed the medical record for resident #12 and stated that the orders for this resident are at 4 liters per minute. She stated that the expectation is to ensure that the oxygen orders established by the physician are followed. Staff #13 stated that the risk could be that the resident may not get enough oxygen and that the resident's oxygenation could be impeded.

A review of the oxygen administration policy with a review date of May 2023 revealed that oxygen therapy is administered by a licensed nurse as ordered by the physician; however, the oxygen therapy settings observed on 2 separate occasions were not as ordered by the physician and noted to be 2 liters above the ordered setting. It was however observed that the facility did have the order changed on the same day the concern was brought to their attention.

Based on review of facility documentation and staff interview, the facility failed to ensure that nurse staffing information was posted on a daily basis that included the actual hours worked by licensed and unlicensed nursing staff and the resident census.

Findings include:

An interview was conducted on 2/2/2024 at 12:36 PM with the Staffing Coordinator (staff #18) who said daily staff postings should be accurate. She said that that she gets the numbers from the daily staff tracking form so staff must have left early or late that day. She reviewed the posting for 12/30/2023 and said that it was not accurate.

An interview was conducted on 2/2/2024 at 12:56 PM with the Director of Nursing (DON/staff#13) who said that daily staff postings should be accurate. She said that she'd have to assume that their numbers are accurate but she would have to double check.

An interview was conducted on 2/2/2024 at 1:31 PM with the Administrator (staff #115) who said that he did not know if there was a policy regarding the accuracy of staff postings and that he would check with the Director of Nursing.

A follow up interview conducted on 2/2/2024 at 1:56 PM with the DON included that the facility does not have a policy regarding the accuracy of staff postings.

Based on review of facility documentation and staff interview, the facility failed to ensure that nurse staffing information was posted on a daily basis that included the actual hours worked by licensed and unlicensed nursing staff and the resident census.

Findings include:

An interview was conducted on 2/2/2024 at 12:36 PM with the Staffing Coordinator (staff #18) who said daily staff postings should be accurate. She said that that she gets the numbers from the daily staff tracking form so staff must have left early or late that day. She reviewed the posting for 12/30/2023 and said that it was not accurate.

An interview was conducted on 2/2/2024 at 12:56 PM with the Director of Nursing (DON/staff#13) who said that daily staff postings should be accurate. She said that she'd have to assume that their numbers are accurate but she would have to double check.

An interview was conducted on 2/2/2024 at 1:31 PM with the Administrator (staff #115) who said that he did not know if there was a policy regarding the accuracy of staff postings and that he would check with the Director of Nursing.

A follow up interview conducted on 2/2/2024 at 1:56 PM with the DON included that the facility does not have a policy regarding the accuracy of staff postings.

Based on observation, clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that oxygen was administered per physician orders for one resident (#12). The sample size was 20.

Findings include:

The resident was admitted on December 18, 2019 with diagnosis including anxiety disorder, unspecified dementia, psychotic disturbance, mood disturbance , anxiety, depression, schizophrenia, acute respiratory failure with hypoxia, pleural effusion, other non specific findings of the lung field, pneumonia, chronic obstructive pulmonary disease and a wedge compression fracture.

A review of the MDS (minimum data set) dated December 07, 2023 revealed that the resident had a BIMS (brief interview of mental status) score of 14, indicating that the resident was cognitively intact. The MDS further noted that the resident was on oxygen therapy.

A review of the of the physician's orders dated January 2, 2024 for resident #12 revealed an order for 4 liters of oxygen per minute via nasal cannula. An update to the orders was made on January 30, 2024 at 2:00 PM noting oxygen via nasal cannula for chronic obstructive pulmonary disease and may citrate to keep oxygen saturation (SP02) levels at or above 90%

A review of the resident's care plan initiated on December 29, 2019 revealed a focus that resident #12 has emphysema, and chronic obstructive pulmonary disease and the included intervention that oxygen therapy is to be given as ordered by the physician. Furthermore, the care plan revealed that the resident has oxygen therapy and that the oxygen settings were noted to be at 5 liters per minute continuously via nasal cannula; however, oxygen was observed to be above the ordered liters per minute and above the documented care plan rate for resident #12.

An observation on January 30, 2024 at 9:52 AM revealed that resident #12 was observed to be on 6 liters of oxygen as observed on the oxygen concentrator setting.

An observation on January 30, 2024 at 12:26 PM revealed that resident #12 was still on 6 liters of oxygen.

An interview was conducted on January 30, 2024 at 12:26 P.M. with staff #70 LPN (Licensed Practical Nurse). Staff #70 stated that oxygen settings were as ordered by the physician. She further stated that oxygen settings are checked during rounding every 2 hours. She stated that oxygen setting for resident #12 should be at 4 liters per minute. She stated that the risk for settings outside of the parameters that the physician had established could impact the gas exchange and could impede the resident's breathing.

An interview was conducted with staff #13, DON (Director of Nursing) on January 30, 2024 at 12:40 PM Staff #13 stated that some patients, depending on the physician's order, may have settings designated on a range to maintain oxygen at a certain level. She stated that the nurse assigned to the resident, is required to sign off on the oxygen order every shift. Staff #13 reviewed the medical record for resident #12 and stated that the orders for this resident are at 4 liters per minute. She stated that the expectation is to ensure that the oxygen orders established by the physician are followed. Staff #13 stated that the risk could be that the resident may not get enough oxygen and that the resident's oxygenation could be impeded.

A review of the oxygen administration policy with a review date of May 2023 revealed that oxygen therapy is administered by a licensed nurse as ordered by the physician; however, the oxygen therapy settings observed on 2 separate occasions were not as ordered by the physician and noted to be 2 liters above the ordered setting. It was however observed that the facility did have the order changed on the same day the concern was brought to their attention.

Based on observation the facility failed to maintain several special locking exit doors located in the facility. Failing to ensure the correct amount of force needed to release of the exit doors could cause harm to patients and/or staff in an emergency

NFPA 101 Life Safety Court, 2012, Chapter 19, Section, 19.2.2.2.4 "Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side." Exception No. 2 "Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. Section 7.2.1.6.1 "Special Locking Arrangements" " (c) An irreversible process shall release the lock within 15 to 30 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbs nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only."

Findings include:

Observations made while on tour on April 25, 2023, revealed the following;

1) the 100 Hall delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed the door failed to open. Once power was disabled to the magnet the door opened freely
2) the 300 Hall delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and set off the irreversible process at 20 lbf

During the exit conference on April 25, 2023, the above findings were again acknowledged by the management team.

Based on observation the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff.

NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction."

Findings include:

Observations made while on tour on February 7, 2024, revealed the following;

1) room 104 door failed to latch secure
2) room 106 door had lower handle side damage, the door was delaminating
3) room 108 door had lower handle side damage, the door was delaminating
4) the door between the service hall and the kitchen had lower handle side damage, the door was delaminating

During the exit conference conducted on February 7, 2024, the above findings were again acknowledged by management team.

Based on observation, the facility failed to ensure patient safety by allowing an enteral feeding pump to be plugged into a non-UL rated power strip. The use of non-UL rated power strips for patient care related electrical equipment could malfunction and could cause injury or death to a patient.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2, "All Patient Care Areas," Sections 6.3.2.2.6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. NFPA 1 11.1.5. Multiplug Adapters 11.1.5.2 Multiplug adapters shall not be used as a substitute for permanent wiring or receptacles.

S&C: 14-46-LSC- Life Safety Code surveyors assess the use of power strips in healthcare facilities. However, the following guidance is provided as reference for healthcare surveyors as they survey physical environment along with other CoP requirements. Any observed power strip deficiencies should be conveyed to the LSC surveyors for citation.
If line-operated medical equipment is used in a patient care room/area, inside the patient care vicinity:
o UL power strips would have to be a permanent component of a rack-, table-, pedestal-, or cart-mounted & tested medical equipment assembly
o Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1
o Power strips cannot be used for non-medical equipment
If line-operated medical equipment is used in a patient care room/area, outside the patient care vicinity:
o UL power strips could be used for medical & non-medical equipment with precautions as described in the memo
o Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1
o Power strips providing power to non-medical equipment in a patient care room/area must be UL 1363
If line-operated medical equipment is not used in a patient care room/area, inside and outside the patient care vicinity:
o UL power strips could be used with precautions
Power strips providing power to non-medical equipment in a patient care room/area must be UL 1363. In non-patient care areas/rooms, other UL strips could be used with the general precautions.

Findings include:

Observations made while on tour on February 7, 2024, revealed the male resident in room 205 was attached to an enteral feeding pump. The enteral feeding pump was plugged into a power strip which did not have a UL rating. Staff plugged the enteral feeding pump directly into the wall receptacle.

During the exit conference on February 7, 2024, the above finding was again acknowledged by the management team.

Based on clinical record, staff interviews, facility records and facility policies, the facility failed to ensure that a resident was supervised to prevent urinating on another resident's room floor. This practice resulted in assault of a residents' dignity, infection control risks and disruptions of a resident's privacy.

Findings include:

Resident #4 was admitted to the facility on January 1, 2023 with diagnoses of COVID-19, malignant neoplasm of colon and rectum and need for assistance with personal care.

An Admission Minimum Data Set (MDS) dated January 7, 2023 included that this resident makes herself understood and understands others. This document included that a Brief Interview for Mental Status (BIMS) indicated that this resident was cognitively intact. This document also included that the resident required limited 2 person assistance for transfers and that the resident did not walk in the room or corridor during the lookback period.

A review of the resident's clinical record did not find any record of a resident urinating on this residents' floor.

-Resident #23 was admitted to the facility on December 31, 2021 with diagnoses of COVID-19, pneumonia, dementia and Alzheimer's disease.

A Discharge -return not anticipated MDS dated January 13, 2023 included that this resident makes herself understood and understands others. This document included that a Brief Interview for Mental Status (BIMS) indicated that this resident was moderately cognitively impaired. This document also included that the resident had wandered 4 to 6 days of the 7 day lookback, but less than daily.

An initial care plan did not include wandering.

A comprehensive care plan included to monitor for effects of psychiatric drugs which included wandering. However, no care plan or intervention were put in place to stop wandering.

A Tasks document included behavior monitoring. This document included that the resident had wandered on the 1st and 3rd of January 1, 2023.

The clinical record did not include that this resident had urinated in another resident's room.

A progress noted dated January 5, 2023 included that the resident was alert, "confused per usual", up out of bed at times restless walking into hall looking for the bathroom. This nurse included that she assisted him into the bathroom.

An interview was conducted on January 25, 2023 at 12:05 PM with a Nursing Assistant (staff #100) who said that one of the demented residents peed on resident #4's floor. She said that she had worked the next morning and that resident #4 had told her about it. She said that the she and other Nursing Assistants cleaned up the pee. She said that resident #23 was so hard to contain because he had dementia and would wander. She said that once she stopped him from urinating in a trash can in the hall.

An interview was conducted on January 26, 2023 at 3:37 PM with a Licensed Practical Nurse (LPN/staff #19) who said that she was not there that night but that she was informed by resident #4 that a man came in urinated on floor and that she put on the call light. She said that she thought he urinated near the resident's doorway. She said resident #23 was the one that was wandering, that he had dementia, and that he was in that end of the hall. She said that it was difficult to keep residents with dementia in the room. She said that resident #23 was a wanderer and that he seemed to stay in that area. She said that this resident was in the second or third room and that she thought he was attracted to the door to look outside and it makes sense that he would go to the room right next to that. She said that resident #4 was in the room next to the door.

An interview was conducted on January 26, 2023 at 2:46 PM with a nursing assistant (#103) who said that resident #23 was incontinent and that he was really confused. This nursing assistant said that resident #23 used to walk to the bathroom sometimes and he would have accidents or go over to the roommate and the roommate said, "He's right here staring at me". This staff said that he used to drip when he was walking, sometimes he would pee with a brief on but that the resident would stand up and the brief would fall and sometimes the resident would move the brief.

An interview was conducted on January 27, 2023 at 11:39 AM with a LPN (staff #99) who said that if a resident wanders, it has to be put in the care plan for the resident's safety. She said that a nurse can update the care plan but usually it is the MDS nurse.

An interview was conducted on January 27, 2022 at 12:18 PM with the Director of Nursing (DON/staff #52) who said that it is not abuse to have a resident peeing on another resident's floor if the resident is cognitively impaired. She said that care planning is an interdisciplinary process because it not one person caring for the resident. She said that because the outside doors were key coded and that because a charting area was nearby the room that a direct care plan for wandering was not needed.

A Facility Assessment included that this facility may accept residents with Alzheimer's Disease and Non-Alzheimer's dementia and other psychiatric/mood disorders except those residents who are deemed by the facility IDT to be a danger to self or others, or who have severe dementia and are continually exit
Seeking.

A policy titled Resident Safety revealed that it is the policy of this facility to create a safe environment for the resident.

A policy titled Care Planning revealed that It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The Care Plan will be revised as needed, and interventions will be implemented.

Based on clinical record, staff interviews, facility records and facility policies, the facility failed to ensure that a care plan for a resident included services to prevent the resident from urinating on another resident's room floor.

Findings include:

Resident #4 was admitted to the facility on January 1, 2023 with diagnoses of COVID-19, malignant neoplasm of colon and rectum and need for assistance with personal care.

An Admission Minimum Data Set (MDS) dated January 7, 2023 included that this resident makes herself understood and understands others. This document included that a Brief Interview for Mental Status (BIMS) indicated that this resident was cognitively intact. This document also included that the resident required limited 2 person assistance for transfers and that the resident did not walk in the room or corridor during the lookback period.

A review of the resident's clinical record did not find any record of a resident urinating on this residents' floor.

-Resident #23 was admitted to the facility on December 31, 2021 with diagnoses of COVID-19, pneumonia, dementia and Alzheimer's disease.

A Discharge -return not anticipated MDS dated January 13, 2023 included that this resident makes herself understood and understands others. This document included that a Brief Interview for Mental Status (BIMS) indicated that this resident was moderately cognitively impaired. This document also included that the resident had wandered 4 to 6 days of the 7 day lookback, but less than daily.

An initial care plan did not include wandering.

A comprehensive care plan included to monitor for effects of psychiatric drugs which included wandering. However, no care plan or intervention were put in place to stop wandering.

A Tasks document included behavior monitoring. This document included that the resident had wandered on the 1st and 3rd of January 1, 2023.

The clinical record did not include that this resident had urinated in another resident's room.

A progress noted dated January 5, 2023 included that the resident was alert, "confused per usual", up out of bed at times restless walking into hall looking for the bathroom. This nurse included that she assisted him into the bathroom.

An interview was conducted on January 25, 2023 at 12:05 PM with a Nursing Assistant (staff #100) who said that one of the demented residents peed on resident #4's floor. She said that she had worked the next morning and that resident #4 had told her about it. She said that the she and other Nursing Assistants cleaned up the pee. She said that resident #23 was so hard to contain because he had dementia and would wander. She said that once she stopped him from urinating in a trash can in the hall.

An interview was conducted on January 26, 2023 at 3:37 PM with a Licensed Practical Nurse (LPN/staff #19) who said that she was not there that night but that she was informed by resident #4 that a man came in urinated on floor and that she put on the call light. She said that she thought he urinated near the resident's doorway. She said resident #23 was the one that was wandering, that he had dementia, and that he was in that end of the hall. She said that it was difficult to keep residents with dementia in the room. She said that resident #23 was a wanderer and that he seemed to stay in that area. She said that this resident was in the second or third room and that she thought he was attracted to the door to look outside and it makes sense that he would go to the room right next to that. She said that resident #4 was in the room next to the door.

An interview was conducted on January 26, 2023 at 2:46 PM with a nursing assistant (#103) who said that resident #23 was incontinent and that he was really confused. This nursing assistant said that resident #23 used to walk to the bathroom sometimes and he would have accidents or go over to the roommate and the roommate said, "He's right here staring at me". This staff said that he used to drip when he was walking, sometimes he would pee with a brief on but that the resident would stand up and the brief would fall and sometimes the resident would move the brief.

An interview was conducted on January 27, 2023 at 11:39 AM with a LPN (staff #99) who said that if a resident wanders, it has to be put in the care plan for the resident's safety. She said that a nurse can update the care plan but usually it is the MDS nurse.

An interview was conducted on January 27, 2022 at 12:18 PM with the Director of Nursing (DON/staff #52) who said that it is not abuse to have a resident peeing on another resident's floor if the resident is cognitively impaired. She said that care planning is an interdisciplinary process because it not one person caring for the resident. She said that because the outside doors were key coded and that because a charting area was nearby the room that a direct care plan for wandering was not needed.

A Facility Assessment included that this facility may accept residents with Alzheimer's Disease and Non-Alzheimer's dementia and other psychiatric/mood disorders except those residents who are deemed by the facility IDT to be a danger to self or others, or who have severe dementia and are continually exit
Seeking.

A policy titled Resident Safety revealed that it is the policy of this facility to create a safe environment for the resident.

A policy titled Care Planning revealed that It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The Care Plan will be revised as needed, and interventions will be implemented.