Verdugo Valley Skilled Nursing & Wellness Centre
2635 Honolulu Avenue, Montrose, CA 91020
Citation Number: 920006159
Citation Date: 6/11/2009
Violation Date: 2/28/2009
Class: AA
Penalty: $ 100,000

CLASS AA CITATION --PATIENT CARE

72311 (a)(2) 72515(b)

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.

72515 (b) -Admission of Patients

The Licensee shall:

72515 (b) -Accept and retain only those patients for whom it can provide adequate care.

On March 2, 2009, at 5:05 p.m., an investigation was conducted for an entity reported complaint regarding a patient putting a fire extinguisher hose into his mouth and the fire extinguisher was discharged.

Based on interview and record review, the facility failed to ensure Patient 1, who had a history of self inflicting injury, suicidal ideation (Thinking about suicide or wanting to take one's own life) and attempts of hurting himself, was not accepted in the facility and retained without a plan that adequate care would be provided by failing to:

1. Ensure Patient 1, who was trying to hurt himself on February 3, 2009, by wheeling his wheelchair out of the facility in the middle of the street with a suicidal plan to be hit by a car, was provided with adequate care by developing a plan of care on how the patient would be supervised while in the facility

2. Ensure Patient 1, who had placed a fire extinguisher hose in his mouth and discharged the powder on February 11, 2009, and stated," I put the hose in my mouth to kill me" was adequately supervised to prevent hurting himself.

3. Implement the plan of care developed February 21, 2009, for the incident of the patient putting a fire extinguisher in his mouth and eating the powder. The approach included monitoring the patient's whereabouts frequently, however, there was no documented evidence how often the patient's whereabouts would be monitored and who would monitor the patient.

4. Ensure Patient 1, who had a second incident on February 22, 2009, of putting a fire extinguisher hose to his mouth and discharged the powder, was not accepted and retained in the facility without a plan to adequately care for the patient. Patient I had a third incident on February 28, 2009, of putting the hose of the fire extinguisher in his mouth and discharged the powder that resulted in asphyxiation (suffocation) and the death of the patient.

According to the admission record, Patient 1 was originally admitted to the facility on January 22, 2009, from a psychiatric hospital and was readmitted on February 27, 2009, with diagnoses that included mental retardation (Subnormal general intellectual development, originating during the developmental period, and associated with impairment of either learning and social adjustment or maturation), schizoaffective disorder (Mental illness characterized by mood swings and psychosis) and psychosis (Abnormal condition of the mind and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality").

The Minimum Data Set (MDS - a standardized comprehensive assessment of the resident's problems and conditions) assessment dated January 28, 2009, indicated the patient was moderately impaired in his cognitive skills for daily decision making and required extensive assistance from staff for transfer, ambulation and locomotion on and off the unit. The patient was also assessed with behavioral symptoms of wandering, which occurred daily, verbally abusive, and socially inappropriate/disruptive behavior, which occurred four to six days in last seven days, but less than daily and the behaviors were easily altered.

The acute care hospital admission note dated January 6, 2009, which was received by the facility on January 22, 2009, indicated the patient had suicidal ideation and had been placed on one to one sitter. The psychiatric evaluation note dated January 16, 2009, indicated the patient had a self-inflicting injury by picking his skin and making the skin bleed. Even though the facility was aware of the patient's behavior upon admission, the facility did not develop a plan of care on how the patient would be supervised.

On January 27, 2009, the facility received an individual program plan (Plan to address the needs of persons with developmental disabilities that outlines the services and supports of the patient) from the Regional Center (Agency that advocates, monitors, evaluates, coordinates and purchases the services to meet the individual plan of a patient with developmental disabilities), which indicated the patient had behaviors which required one to one supervision. The list of the behaviors indicated were the following:

1. Suicidal threats and or attempts where the patient ran and jumped in front of cars to commit suicide, which resulted in police intervention. 2. Behavior of temper tantrums, which included verbal and physical aggression, property destruction, hitting or pushing someone, and scratching and twisting the arm of an individual. 3. Blocking and barricading the door when the patient becomes frustrated, planning to escape from the facility and or suicidal attempts. The patient also had the behaviors, which included elopement, obsessive-compulsive behavior and habitual lying.

Even though the facility was aware of the patient's behaviors on January 27, 2009, the facility did not develop a plan of care or analyze the facility's ability to take care of the patient.

The licensed nurse's note dated February 3, 2009, at 6 p.m., indicated the patient tried to leave the facility and the patient was yelling at the staff. The patient was given Ativan (antiaxiety drug) two milligrams but the Ativan was not effective. The patient went out of the facility in a wheelchair and was trying to go in the street without regard for his own safety. The physician was notified and an order was obtained to transfer the patient to an acute care hospital.

The acute care hospital psychiatric evaluation dated February 4, 2009, indicated the patient wheeled himself outside of the facility in the middle of the street and the patient stated he wanted to kill himself. The patient was admitted to the psychiatric unit for evaluation and treatment and had diagnoses that included schizoaffective disorder, depressed type, with a suicidal plan and attempt, mild mental retardation and a global assessment functioning of 15>30 (The range is 15 to 30 out ofa possible 100 score maximum -Some danger of hurting self or others or occasionally fails to maintain minimal personal hygiene or gross impairment in communication).

The patient was readmitted to the facility on February 9, 2009, at 1:30 p.m. There was no documented evidence the facility had a plan of care addressing on how the patient, with a history of trying to hurt himself, would be cared for.

The licensed nurse's note dated February 11, 2009, at 7:45 p.m., indicated the patient was found in the basement of the facility on the floor with powder on his entire body from the fire extinguisher. The physician was notified on February 11, 2009, at 7:50 p.m., and an order was obtained to transfer the patient to an acute care hospital. The patient returned to the facility on February 12, 2009, at 2:45 am. This was the first incident of Patient 1 discharging a fire extinguisher.

There was a clinical evaluation from the acute care hospital dated February 12, 2009, which was sent to the facility when the patient returned on February 12, 2009. The evaluation indicated the patient stated, "I put the hose in my mouth to kill me". However, there was no documented evidence again that a plan of care was developed addressing the suicidal attempt of the patient and how the facility will protect the patient.

The licensed nurse's note dated February 21, 2009, at 10 p.m., indicated the patient complained that he was hungry and while waiting for the certified nursing assistant, who was getting a sandwich for the patient, the patient grabbed the fire extinguisher located close to the kitchen hallway and put the hose in his mouth and started eating the powder. The patient was noted with powder in his nose and mouth. The licensed nurse's note also indicated the patient had shortness of breath and the resident's oxygen saturation was 75 percent (Total amount of hemoglobin in the body that is filled with oxygen molecules. Range of 96 percent to 100 percent is generally considered normal). The paramedics were called and the patient was transferred to an acute care hospital on February 21, 2009, at 10:08 p.m. The patient came back to the facility on February 22, 2009, at 2:30 a.m. This was the second incident of Patient 1 discharging a fire extinguisher.

A care plan was initiated February 21, 2009, for the incident of the patient putting a fire extinguisher in his mouth and eating the powder. The approach included monitoring the patients whereabouts frequently. There was no documented evidence how often the patient's whereabouts would be monitored and who would monitor the patient. There was no evaluation done if the patient was able to be cared for in the facility since the patient already had three incidents of attempting to hurt himself.

On February 22, 2009, at 4 p.m., the patient was transferred to an acute care hospital due to diarrhea and was readmitted to the facility on February 27, 2009, at 3 p.m.

The licensed nurse's note dated February 28, 2009, with no specific time, indicated the patient was found in a wheelchair close to the kitchen hallway with the fire extinguisher in his mouth and the pin was pulled out. The patient was trying to inhale the contents of the fire extinguisher. The licensed nurse's note also indicated a yellow substance was coming out of the patient's mouth and the vital signs were as follows: blood pressure 140/80, pulse rate 100, respirations 20 and oxygen saturation 82 percent. The paramedics and the patient's physician were called with no specific time and an order was obtained to transfer the patient to an acute care hospital. The paramedics transferred the patient to an acute care hospital on February 28, 2009, at 2 a.m.

A review of the emergency room nursing assessment dated February 28, 2009, at 2:19 am., indicated the patient was non-responsive, lethargic, had an oxygen saturation of 79 percent at room air and yellowish secretions were coming out from the patient's mouth. The patient was placed on 100 percent non-rebreather mask (Device used to deliver higher concentrations of oxygen). On February 28, 2009, at 2:31 a.m., the patient was intubated (Placement of a flexible plastic tube into the trachea to protect the patient's airway and provide a means of mechanical ventilation). However, the patient's oxygen saturation stayed at 80 percent. The patient was reintubated (second time of intubation) at 3 a.m. At 3:04 a.m., the patient's heart monitor showed asystole (absence of heartbeat) and the patient had no palpable pulse. Cardiopulmonary resuscitation was started and the patient was pronounced dead at 3:30 a.m. The County of Los Angeles Department of Coroner, Case Number 200901560, indicated the patient's immediate cause of death was asphyxiation (suffocation) and full arrest (stop of heart function).

On March 2, 2009, at 6:20 p.m., during an interview with Employee A on why the facility accepted and retained the patient without a plan on how the facility would adequately care for the patient with suicidal ideation and three incidents of actual trying to hurt himself, Employee A had no explanation.

During an interview with Regional Center Staff Member A on March 12, 2009, at 9 a.m., she stated the patient was hard to be placed due to the patient's behavior.

The facility failed to ensure Patient 1 who had a history of self inflicting injury, suicidal ideation and attempts of hurting himself was not accepted in the facility and retained without a plan that adequate care would be provided by failing to:

1. Ensure Patient 1, who was trying to hurt himself on February 3, 2009, by wheeling his wheelchair out of the facility in the middle of the street with a suicidal plan to be hit by a car, was provided with adequate care by developing a plan of care on how the patient would be supervised while in the facility

2. Ensure Patient 1, who had placed a fire extinguisher hose in his mouth and discharged the powder on February 11, 2009, and stated, " I put the hose in my mouth to kill me" was adequately supervised to prevent hurting himself.

3. Implement the plan of care developed February 21, 2009, for the incident of the patient putting a fire extinguisher in his mouth and eating the powder. The approach included monitoring the patient's whereabouts frequently, however, there was no documented evidence how often the patient's whereabouts would be monitored and who would monitor the patient.

4. Ensure Patient 1, who had a second incident on February 22, 2009, of putting a fire extinguisher hose to his mouth and discharged the powder, was not accepted and retained in the facility without a plan to adequately care for the patient. Patient 1 had a third incident on February 28, 2009, of putting the hose of the fire extinguisher in his mouth and discharged the powder that resulted in asphyxiation (suffocation) and the death of the patient

The above violations either jointly, separately, or in any combination presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of Patient 1.

----