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25 | On 10/20/2022, Licensing Program Analysts (LPAs) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20220914194759. LPA met with the administrator and explained the purpose of the visit.
During the course of the investigation, the allegation of resident sustained pressure injuries while in care was unsubstantiated, however, LPA observed resident #1 (R1) and resident #2 (R2) were in a hospital bed with 2 half bed rails up by the head of the bed and according to staff #1 (S1), this device is used to assist R1 and R2's mobility in bed. However, the facility was not able to provide a written physician's order for such device for R1 and R2.
Based on documents provided, the bed rails for R1 and R2 were not addressed in the appraisal /needs and service plans. Furthermore, the appraisal / needs and service plans for R1 and R2 were not signed by R1 and R2 and/or their responsible party(s) indicating that they reviewed and agreed with the service plans.
In addition, during the course of the complaint investigation, R1 expressed satisfaction with the services that was provided by the home health visiting nurse, however, R1 was pressured by facility staff to discontinue the services by this visiting nurse as R1 was told by the facility staff that the visiting nurse did not properly follow through with R1's physician on R1's medication but R1 disagreed.
Based on complaint investigation, deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the administrator.
A copy of this report and the Appeal Rights are provided. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
10/24/2022
Section Cited
HSC
1569.80(a)
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7 | ยง1569.80 Care and services decision making; meeting; written record a) A resident of a residential care facility for the elderly, or the resident's representative, or both, shall have the right to participate in decision making regarding the care and services to be provided to the resident. | 1
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7 | The administrator will meet with R1 and if R1 decides to resume the services from this visiting nurse, facility will assist and coordinate with R1 and R1's provider to do so. |
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14 | This requirement is not met as evidenced by: R1 is satisfied with services that was provided by the home health visiting nurse. However the facility pressured R1 discontinuing the services from this visting nurse which posed an immediately health risks to resident in care. | 8
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14 | The administrator will provide in-services to staff on this regulation.
The administrator will inform CCL in writing of R1's decision and will submit a copy of the in-service record to CCL by the plan of correction due date 10/24/22. |
Type B
11/03/2022
Section Cited
CCR87463(a)
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7 | 87463 Reappraisals(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement is not met as evidenced by: during the 10-day | 1
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7 | The administrator will review all residents appraisal /needs and services plans including and not limiting to R1 and R2 to ensure they are updated and accurate to the care that is provided to each resident. |
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14 | initial complaint visit, LPA observed R1 and R2 have half bed rails up by the head of their beds, however, the need of utilzing this device was not reflected in their appraisal needs which poses a potential health risk to residents in care | 8
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14 | The administrator will submit a copy of all the updated appraisal/ needs and services plan to CCL by the plan of correction due date of 11/3/2022. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
11/03/2022
Section Cited
CCR
87608(a)(3)
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7 | 87608 Postural Supports (a) Based on the individual's preadmission appraisal, Postural supports may be used under the following conditions.(3) A written order from a physician indicating the need for the postural support... | 1
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7 | The administrator will review the regulation pertaining to Postural Supports and provide in-services to facility staff.
The administrator and/or designee will obtain a written physician's order for R1 and R2's half bed rails. The administrator and/or designee will conduct an evaluation of all the resident's beds for
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14 | This requirement is not met as evidence by: R1 and R2 have half bed rails by the head of the bed and there was no written order from their physician which poses a potential health risks to residents in care. | 8
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14 | postural supports and if one is being used, the facility will obtain a physician's order indicating the need for the device that is being used.
The administrator will provide a copy of the in-service and a copy of all the physician's order obtained to CCL by the plan of correction due date 11/3/2022. |
Type B
11/03/2022
Section Cited
CCR87457(c)(3)
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7 | 87457 Pre-Admission Appraisal - General(c)Prior to admission a determination of the prospective resident's suitability for admission shall be completed..(3) The prospective resident, or his/her responsible person,...shall be involved in the development of the appraisal. | 1
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7 | The administrator and/or designee will review the appraisal needs/plans of R1, R2 and all other residents to ensure it has been reviewed, signed and agreed by the residents and/or responsible parties. The administrator will develop a plan to ensure this task is completed moving forward. |
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14 | This requirement is not met as evidenced by R1 and R2's appraisal needs/service plans were not signed indicating it's reviewed and agreed by the residents and/or their responsible parties which poses a potential health risk to residents in care. | 8
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14 | The administrator will provide a copy of all the completed residents appraisals and service plans and a copy of the above plan to CCL by the plan of correction due date 11/3/2022. |