Sylmar Health and Rehabilitation Center
12220 Foothill Blvd Sylmar, CA 91342
Citation Number: 920011839
Citation Date: 07/15/2016
Violation Date: 2/23/2013
Class: AA
Penalty:$75,000.00

CLASS AA CITATION -- PATIENT CARE F309 42 CFR 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to 'attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. F323 42 CFR 483.25(h) Accidents The facility must ensure that -

(1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents.

The facility staff failed to ensure the resident environment remained as free of accident hazards as possible. The facility staff failed to ensure Resident 1, who had a history of suicide attempt, was provided adequate supervision and services to prevent him from committing suicide, including failures to:

1. Revise his care plan after a first suicide attempt, to include specific interventions to ensure his safety as indicated in the facility's "Suicide Threat Policy;" and

2. Ensure his environment was free of dangerous items according to the facility's policies and procedures.

As a result, on February 23, 2013, Resident 1 hanged himself in his room.

The Department received an entity reported incident (ERi) on February 25, 2013, indicating Resident 1 had committed suicide by placing a rope around his neck and hanging himself on February 23, 2013.

During an unannounced visit on February 25, 2013, Resident 1 's admission record indicated he was a 40 year old male, admitted to the facility on January 15, 2013. The resident's diagnosis included schizophrenia paranoid type (mental disorder often characterized by abnormal social behavior and failure to recognize what is real), antisocial personality disorder (pattern of disregard for others' rights), and drug abuse.

A review of the Minimum Data Set (MOS), a standardized assessment and care screening tool, dated January 21, 2013, indicated Resident 1 had a potential for hallucinations and delusions (seeing and hearing things that were not real). He had difficulty focusing and was disorganized in his thinking.

Resident 1 had a care plan dated January 15, 2013, as follows:

a. Potential for negative symptoms such as depression, isolation, anxiety, agitation, mood swings, related to new living situation. The interventions included staff to encourage resident to discuss feelings, medications as ordered and notify the physician if ineffective, encourage group attendance; and

b. At risk for isolation related to antisocial personality. The goal was to not isolate himself. The interventions included participate in activities, listen attentively and attempt to resolve issues when appropriate, and encourage talking about feelings.

The facility had a generic blank "Plan of Care: Short Term", for the problem of voicing suicidal thoughts, had a goal to not harm self within the next 3 months. Interventions included to monitor the environment for possible hazards. This care plan was not completed for Resident 1, to be used for any resident having suicidal thoughts.

A review of the Psychosocial Assessment dated January 21, 2013, under general history indicated Resident 1 had a family history of mental illness and suicide. The notes indicated Resident 1 stated he didn't want to be "here."

The Nurses Notes dated February 17, 2013, at 5 p.m., indicated Resident 1 had attempted to kill himself in his room by putting the curtains around his neck. The documentation indicated there was slight redness observed around his neck, but no bruises or injury noted. Resident 1 was placed on 1:1 supervision (direct observation by one staff person at all times), due to suicidal ideations (thoughts to kill himself), for 72 hours. Staff were to monitor for 1:1 effectiveness.

The Physician's Orders dated February 17, 2013, at 5 p.m., indicated Resident 1 was placed on 1:1 supervision for suicidal ideations for 72 hours, noted and carried out.

On February 18, 2013, at 10:00 a.m., the Licensed Nurses Notes indicated staff and the sitter reported that Resident 1 was verbally threatening to hit them. Verbal redirection was given three times, but was ineffective. Ativan (used to treat anxiety disorders or anxiety associated with depression) PO (by mouth) was given and was effective after 30 minutes. Resident 1 stated he was all right.

A routine physician Assessment and Recommendation notes form dated February 18, 2013, (no time) indicated Resident 1 "was suicidal" and complained of shuffling gait. The recommendation was to observe Resident 1 for deterioration of mood, suicidal ideation or increased agitation.

The Physician's Orders dated February 18, 2013, at 11 a.m., 24 hours after the order for 72-hour 1: 1 supervision, indicated to discontinue 1: 1 supervision, and place resident on every 15 minute checks related to status-post suicidal ideations (thoughts) for 72 hours, noted and carried out.

The IDT (interdisciplinary team) notes dated February 18, 2013, (no time) indicated the psychiatrist met with Resident 1, who stated, "I play with curtains." He "contracted" not to harm himself. The recommendation was to discontinue the 1 :1 supervision, and place the resident to observation every 15 minutes.

The Nurses Notes dated February 18, 2013, at 11 a.m., referred to the IDT's recommendation because Resident 1 "contracted to safety." The physie:ian ordered at 11 a.m. to discontinue the 1 :1 supervision, and ordered observation by staff every 15 minutes, related to suicidal ideation (thoughts), for 72 hours.

On February 18, 2013, at 11:40 a.m., the Nurses Notes indicated Resident 1 was seen by a physician and the physician was informed of Resident 1 's attempted suicide. Resident 1 complained of shuffling gait and of being depressed. Medications were changed and Prozac (medication to treat depression) was ordered.

On February 20, 2013, at 4:40 p.m., the Nurses Notes indicated Resident 1 was evaluated by the physician. On February 21, 2013, at 11 a.m., the notes indicated Resident 1 completed the every (Q) 15 minute supervision. There were no Nurses Notes documented after this until Resident 1 's suicide on February 23, 2013 at 6:20 a.m.

During an interview with the Director of Nursing on February 25, 2013, while reviewing Resident 1 's medical record, he stated there was no documented nursing notes after February 21, 2013, until Resident 1 's suicide. He stated there was no plan of care for suicide prevention.

The Monthly Progress Notes dated February 22, 2013, indicated Resident 1 had frequent hallucinations, and was observed attending to internal stimuli on a daily basis, and pacing the courtyard and the facility halls throughout the day.

A review of the February 2013 medication record (MAR) for monitoring Resident 1 for thought disorder, indicated staff had documented Resident 1 had "negative behavior" on February 17, 18, 20, 21, and February 23, 2013, on the 11 p.m. to 7 a.m. shift. There was no documentation in the medical record to explain the nature of Resident 1 's "negative behavior''.

The February 2013 MAR on the 7 a.m. to 3 p.m. shift, indicated Resident 1 had "negative behavior" on February 21 and February 22, 2013; and on the 3 p.m. to 11 p.m. shift on February 21 and February 22, 2013. There was no documentation in the medical record to explain the nature of Resident 1 's "negative behavior''.

A review of the "1 to 1 Supervision" Reason for Close Supervision, Required Duties form dated February 17, 2013, indicated at the beginning of each shift, staff are to search the resident, the resident's belongings and room for dangerous items, such as sharp items, keys, belts, "etc".

A review of the completed "1:1 Supervision" forms indicated staff started 1 :1 monitoring on February 17, 2013, at 5 p.m., and completed the 1:1 on February 18, 2013, at 11 a.m. (18 hours). The "Q 15 Minutes Check Form" indicated the staff performed the duties (by initials) starting February 18, 2013, at 11 a.m., and completed February 21, 2013, at 11 a.m.

The facility's undated "Report of Investigation" indicated at 6:20 a.m., the resident's roommate (8) came out of their room and told the CNAs that his roommate was "hanging". The CNAs ran to the room and found Resident 1 with a string around his neck, hanging. Staff responded and found the resident's heels touching the floor prior to any action. The resident was assisted to the floor and CPR (cardiopulmonary resuscitation -life saving measures) was immediately performed and continued until the paramedics arrived and took over. The Maintenance Supervisor found the remaining "string" wrapped around six or seven privacy curtain hangers multiple times.

A review of the Nurses Notes dated February 23, 2013 at 6:20 a.m. indicated Resident 1 hanged himself with a string that looked like a shoe lace. The resident was taken down and CPR was initiated. The paramedics arrived and pronounced the resident dead at approximately 6:50 a.m.

During interviews with Resident 1 's roommates on February 25, 2013, between 10:50 a.m. and 11 a.m., Roommate B stated he didn't remember the time of the incident, but saw Resident 1 hanging from a curtain. He said he was scared, and pointed to the curtain stating Resident 1 stepped on the bed and hanged himself. Resident C stated he heard Resident B screaming and saw Resident 1 hanging from what he thought was a string. He stated the ambulance crew came and said Resident 1 was dead.

In an interview with the certified nursing assistant (CNA 1) on March 1, 2013, at 8:10 a.m., she stated she saw Resident 1 hanging from a "shoe lace" from the curtains. The string was wrapped around plastic, and hanging from on top of the curtain, dangling. She and CNA 2 were yelling for help. She "burned" the rope with a "lighter" to cut it, while CNA 2 held Resident 1 up. Then they lowered the resident to the floor. Other staff came and started CPR. CNA 1 cut the rest of the rope, which was tight around Resident 1's neck.

A review of Resident 1 's care plans on March 1, 2013, with Licensed Vocational Nurse (L VN) 1, revealed no revision to include Resident 1 's previous attempt to put the curtains around his neck on February 17, 2013. There were no specific interventions to prevent suicide. An affidavit dated March 1, 2013, written and signed by LVN 1, indicated during a review of Resident 1 's chart, a suicide intervention care plan was not completed for Resident 1. LVN 1 documented the facility did not provide staff training/in-services for prevention and 1 :1 supervision, suicide, or accidents.

On March 1, 2013, during an interview, an affidavit was received from Employee 2 who indicated she had not given an in-service on suicide prevention in the past year.

A review of the undated "Suicide Threats" Policy indicated the policy is to ensure the safety of all residents in the cases of suicidal attempts. An assessment of the resident's behavior will be made of such incidents to determine intervention that may be necessary to prevent recurrence. Licensed nursing staff will evaluate the need for PRN (as needed) medications. Revised care plans will be developed to reflect such intervention. Nursing and/or Rehabilitation staff will perform locker and body search for objects which may be used to harm self (i.e., sharp objects, pens/pencils, strings head phones, etc.). Suicidal clients are not allowed to use these articles unless nursing staff feels it is safe to do so with constant and ample supervision.

The facility staff failed to ensure the resident environment remained as free of accident hazards as possible. The facility staff failed to ensure Resident 1, who had a history of suicide attempt, was provided adequate supervision and services to prevent him from committing suicide, including failures to:

  1. Revise his care plan after a first suicide attempt, to include specific interventions to ensure his safety as indicated in the facility's "Suicide Threat Policy;" and
  2. Ensure his environment was free of dangerous items according to the facility's policies and procedures.

As a result, on February 23, 2013, Resident 1 hanged himself in his room.

The above violations presented imminent danger of death or serious harm, or a substantial probability of death or serious physical harm, and was a direct proximate cause of Resident 1's death.