State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page I of 5 CITATION NUI~IBER: 17-1731-0010493-F Date: 04t14/2014 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED State of CA Dept of Developmental Seryices 1600 9TH STREET 170000774 SACRAMENTO, CA 95814 Type of Ownership: State Agency CANYON SPRINGS Cathedral Ci{,y, CA 92234 69696 Ramon Rd (760) 770-6200 Intermediate Care Facility/Developmentally Disabled 170001776 CLASS AND NATURE OF VIOLATIONS CLASS B W104 W149 IncidenttComplaint No,(s) : CA00373620 Capacity: 63 PENALTY ASSESSMENT $1,000.00 DEADLINE FQR COMPLIANCE 4/24/14 12:00 a.m. CITATION-- PATIENT CARE 483.410 The governing body must exercise general policy, budget, and operating direction over the facility. 483.420 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. The following citation was written as a result of an investigation of Entity Reported Incident (ERI) CA00373620 that was conducted during a Full Rece~tification Survey on 1/28/14. The Department determined the facility failed to: 1. Properly supervise clients by failing to ensure bed checks included direct visual observation and/or accountability at all times. 2. implement their policy and procedure for "Missing Client Search Procedures" when the staff failed to notify the Office of Protective Service of the missing client after staff had been searching for over 15 minutes. An investigation of ERI CA00373620 was conducted during the survey on 1/28/14. Review of the ERI "Intake Detail" indicated that on 10/12/13, at approximately 1:30 AM, Client 1 approached staff and asked regarding the whereabouts of Client 2. Licensed Name of Evaluator: Helen Williams HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000001 State of California - Health and Human Services Agency Depar{ment of Public Health SECTI(~)N 1424 NOTICE Page 2 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1731-0010493-F Date: 04/14/2014 Time: CLASS AND NATURE OF VIOLATIONS Staff A immediately went to Client 2’s room to check on him. He was not in his bed. A search of the residence ensued. During the search, a law enforcement officer called the facility and indicated he had picked up Client 2 at a local hotel/casino. The client was escorted back to the facility by the law enforcement officer, and arrived back at the facility at approximately 2:25 a.m. Client 2 was 22 a year-old male with a diagnoses that included Mild Intellectual Disabilities and Impulse Control Disorder. His bevel of supervision at the time of the Absence Without Leave (AWOL) incident was general supervision (described as direct visual observation andtor accountability at all times) throughout the facility, with an escort ratio of 1:5 (one staff to five clients) in the community. Client 1 was a 23 year-old male with Mild Intellectual Disabilities, with a history of poor insight, impaired judgment, and poor impulse control. He had a history of making threats to AWOL from the facility, and an actual AWOL on 10/2/12. His behaviors included refusal to follow rules, and attempts to manipulate or "con" others for his own gain. He was on a general supervision throughout the facility at the time of the AWOL. A special team meeting (a meeting held by facility staff/Interdisciplinary Team Members to discuss unusual incidents)was held with Client 2on 10/14/13. The client told the team he planned his AWOL attempt for that evening of 10/11/13 and waited until approximately 11:30 p.m. to make his attempt. He stated his roommate had "Gold Access" (when clients have independent access to enter courtyard during leisure time). When his roommate fell asleep, he took his badge out of his roommate’s pocket and used the badge to exit from the B2 living room into the courtyard. He propped the door open with the doormat. Client 2 then knocked on his peer’s (Client l’s) window. That peer came out to the courtyard through the propped door. His peer then used his (peer’s) body to push open the gate leading out of the courtyard. Client 2 stated he took off running towards the hotel/casino. He stated that when he arrived at the hotel/casino, he informed them that he would like to live there, and wanted to know if they had a room for him. The hotel staff notified law enforcement and the sheriff responded. The sheriff ran the clients name, but the search did not yield any information, so he took the client to the local acute hospital. The acute hospital staff was able to provide information that Client 2 lived at the facility. He was returned to the facility at approximately 2:25 a.m. by a law enforcement officer. He was assessed for injuries and none were found. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000002 State of California - Health and Human Services Agency .. SEC’~I(~N 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health Page 3 of 5 17-1731-0010493-F Date: 0411412014 Time: CLASS AND NATURE OF VIOLATIONS On 10/12/13 at approximately 1:30 a.m., Client 1 made a commer~t to Licensed StaffA that he couldn’t find Client 2, and they were supposed to "hang out" together. The staff thought the comment was odd and went to check on Client 2. She called out his name, and when he did not answer she pulled the covers back and found a pile of clothes in the bed. Sl~e notified Licensed Staff B, and a search ensued. During the search, a call was received from a law enforcement officer stating he had Client 2 with him, and would return him to the facility. Client I was interviewed by OPS (Office of Protective Service) on 10/12/13 at approximately 3:05a.m. Client I stated that Client 2 knocked on his window at approximately 11:00 p.m, and told him to go to the B2 group room next door. He left his room and went to the group room door exit and found it propped open, Client 1 said he looked out the door for Client 2, and he was gone. Client 1 stated he did not help Client 2 get out of the gate. On 10tl 5113, Client 1 reported to the Clients Rights Advocate that he had assisted Client 2 in his AWQL from the facility and had accompanied him to the hotel/casino. He stated that his peer was approached by hoteltcasino staff and Client 1 became nervous and returned to the facility. He was assessed for injury, no injury was noted. During the initial visit made to the facility to investigate the incident, interview was conducted with the Special Investigator on 10/17/13 at 1:45 p.m. The investigator indicated that he walked to the hotel/casino and found it took him 41 minutes to walk there, and the distance was 2.2 miles Review of the approximate timeiine from the Special Investigator reviewing the case indicated that the client ]eft the facility to walk to the hotel/casino at approximately 11:20 p.m. to 11:30 p.m. The walk to the hoteltcasino took approximately 30 to 35 minutes. Client 2, was first noted by hotel staff to be at the hotel/casino at approximately 11:55 p.m. to 12:05 a.m. Client t contacted staff at the facility asking about Client 2% whereabouts at 1:20 am to1:23 a.m.. Review of the "Round Sheets" dated 10/11/13 and 10/12/13 completed by Licensed Staff A indicated that Client 2 was in bed from 11 p.m. to 1:20 a.m. Documentation further indicated Client 1 was in the hallway at 11:40 p.m. and in bed after that until 1:20 a,m. when he was noted to be in the hallway. An interview was conducted with Licensed Staff A on 1/28/14 at 2;50 p.m. She NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE "to CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000003 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-173I~0010493~F Date: 04t14t2014 Time: CLASS AND NATURE OF VIOLATIONS indicated that she had checked on Client 2 during the times documented, but she did not remove the covers to check to see if he was in bed. She stated that he normally slept with his covers over his head, and she did not suspect he was not in his bed. She stated that she became suspicious of Client 2’s whereabouts when Client 1 asked about his whereabouts. She stated she immediately went to check on him and found him missing. Licensed Staff A also indicated she thought Client 1 was in his bed during the checks she conducted. Review of the Administrative Policy # 324 titled "Client Supervision’.’ dated 9/29111was conducted on 1/29t14. The policy indicated, "Every staff member of (name of facility) is responsible for the safety and well-being of clients. Staff shall be constantly alert to ensure that the physical and emotional well-being of a client is not endangered in any way ........ General supervision is described as direct visual observation and/or accountability at all times." Review of the Administrative Policy dated 4/20/12, "Missing Client Search Procedures", conducted on 1/28t14, under "Missing Client Search" under "2.1.3.3 If the client is not found within 15 minutes from when noted to be missing, contact the OPS Officer in order to implement Phase II of the search.". Review of the Crimeflncident Report dated 10/I2/13 was conducted on 1/28/14. The report indicated that during the Special Investigator’s interview conducted with Licensed Staff B SPT (Senior Psychiatric Techni~cian) on 10!17/13, Licensed Staff B indicated the staff searched the residence for approximately 30 minutes before receiving the phone call from the law enforcement officer. During an interview conducted by the Special investigator with Licensed Staff B on 10/17t13, the staff member indicated he was aware of the policy that indicated to make proper notifications after 15 minutes, and he should have stopped the initial search after 15 minutes had lapsed. The facility staff failed to conduct thorough rounds, when staff failed to physically inspect the client’s individual bed to determine if Client 2 was in his bed sleeping, and the facility failed to implement their policy and procedure for "Missing Client Search Procedures" when the staff failed to notify the OPS officer of the missing client after staff had been searching for over 15 minutes The Department determined that the above violations had a direct or immediate NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000004 State of California - Health and Human Services Agency Department of Public Health SEnTI’ON ’1424 NOTICE Page 5 of 5 CITATION NUMBER’ SECTIONS VIOLATED I7-1731-0010493-F Dale: 04-/14/2014 Time: CLASS AND NATURE OF VIOLATIONS relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFT, EY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000005 State of California - Health and Human Services Agency Department of Public Health SECTION 1’424 NOTICE Page 1 of 5 CITATION NUMBER: 17-173t-0010494-F Date: 04/14/2014 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALl FORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND R£GULAT[ONS Licensee Name; Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED W149 lncident/ComDlaint No.(s) : CA00365327, CA00369839, CA00368604 State of CA Dept of Developmental Services. 1600 9TH STREET 170000774 SACRAMENTO, CA 95814 Type of Ownership: State Agency CANYON SPRINGS Caf.hedral City, CA 92234 69696 Ramon Rd (760) 770-6200 Intermediate Care Facility/Developmentally Disabled 170001776 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $1,ooo.0o CLASS B Capacity: 63 DEADLINE FOR COMPLIANCE 4/24t14 t2:00 a.m. CITATION -- PATIENT CARE 483.420 The following citation was written as a result of a review of facility incident reports conducted on 1/28/I4 at 10:15 a.m. as part of a Full Recertification Survey, and as a result ot~ an inves_tigation of Entity Reported Incidents (ERI).CA00365327 CA 00368604, 0A00369839 The facility failed to protect a conserved client, Client 1, from sexual abuse by not implementing their policy for enhanced supervision (line of sight) and by not implementing its abuse prevention, reporting and supervision policies. During review of facility incident reports on 1/28/14 at I0:15 a.m. for allegations of abuse, neglect, mistreatment and exploitation reported during the time parameter of 12t14/12 through 1/27ti4, it was revealed the facility reported and investigated six allegations of sexual abuse involving Client 1. Three of six incidents reported were substantiated due to Client 1 being on enhanced supervision and a conserved client at the time of occurrence. Review of the documentation from the Department of Development Disabilities dated 11/13/2008, indic&ted that powers and authority were outlined under "Limited Conservator of the Person" which also included, "full power to make decisions concerning the conservatee’s social and sexual contacts." Name of Evaluator: Helen W~lliams HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature ’ Name ’ .Evaluator Signature : Title ’ NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000006 State of California - Health and Human Services Agency Department of Public Heallh S .F,.CTION 1424 NOTICE Page 2 of 5 CITATION NUMBER: SECTIONS VIOLATED i 7-1731-00t0494-F Date: 04/14/2014 Time: CLASS AND NATURE OF VIOLATIONS On 8/’7/13 the facility reported an incident of sexual abuse wherein it was alleged by Client i that she and Client 2 performed oral copulation and sexual intercourse on a male peer (Client 3). She also reported that they were forced to perform the inappropriate sexual acts, Per GER (General Event Report) a Level I review was conducted on 8/12t13 at 12:45 p.m. It indicated that Client l’s level of.supervision at the time of the event was line of sight and will continue to be line of sight. The OPS (Office of Protective Services) investigative report with a completion date of 11101/13 was reviewed. Under "Summary of Findings and Investigation Conclusion", it stated that the .allegation of sexual abuse was substantiated. Client I and Client 2 performed oral sex on a male peer (Client 3) because they were scared. The allegation of client supervision was substantiated. The facility staff were ultimately responsible for the health and safety of all clients in Room 24t (vocational classroom), which included Client 1, the female peer [Client 2] and the male peer (Client 3). The staff failed to adequately monitor the courtyard where Client 1, and a female peer (Client 2) performed oral sex. An interview was conducted with the Standards Compliance Coordinator on 1/30/13 at 1:45 p.m. She confirmed that Client l’s level of supervision at the time of the incident was line of sight-as per GER. She .also confirmed that the OPSinvestigation report concluded that the allegation of sexual abuse and client supervisi~)n were substantiated. On 8t22/13, the facility reported an incident of sexual abuse wherein it was alleged by Client 1 that she had sexual relations with her roommate, Client 4. The allegation included oral sex, digital manipulation and "humping" each other. Per GER the incident was reported on 8t22t13 at 7:00 p.m. Review of the accompanying Special Investigations report narrative, it was documented that the event took place on 8/21tl 3 at 9 p.m. in the clients’ bedroom with the door locked. Under "Summary of Findings and Investigation Conclusions" the report indicated, "1 .Substantiated: [Client 1] engaged in sexual, activity/contact with [Client 4]. [Client 1] is unable to give consent to engage in sexual activity/contact [Client 4] violated [Facility’s name] Administrative Policy of abuse, 301; 2.4 - Sexual Abuse/’ On 9/15/13 the facility reported an incident of sexual abuse wherein it was alleged by Client 1 she engaged in sexual activity with Client 5, The incident took place in Room 466 at 3 p,m. Per the Office of Protective Service (OPS) report under "Narrative" it was documented both clients admitted to fondling each other and Client 1 inserted a marker NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000007 State of California ~ Health and Human Services Agency Department of Public Health S£CTION 1424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1731-0010494-F Date: 04t14t2014 Time: CLASS AND NATURE OF VIOLATIONS into Client 5’s vagina and a chap stick container into her own vagina. The report further stated "Client I is a conserved client. She cannot give any consent for sexual relations." Additionally, the report documented "One green cap less Crayola marker and one all white chap stick container" were placed in the "Evidence Locker." During an interview with the night Shift Lead/Senior Psychiatric Technician (SPT) on 1f28/14 at 4:25 p.m., he stated that Client 1 had poor boundaries and sexual behavior that was inappropriate. He also stated that she’s currently on line of sight supervision throughout the day. When he was asked to describe what line of sight was, he stated, "Visual contact, knowing her whereabouts the whole time." He also stated that Client 1 was on general supervision (direct visual observation andtor accountability at all times) and every fifteen minutes check when she’s in her room. The Shift Lead/SPT stated that Client l’s supervision level was line of sight when she was involved in multiple inappropriate sexual activities. When asked why it happened, he stated, "Somebody broke the chain", indicating that staff failed to implement the line of sight supervision, During an observation on 1/29/14 at 9:05 a:m. inthe Vocational Room (Room 401), Client 1 was observed sitting in the corner of the room by herself for four minutes. Three staff in the room were engaged with other clients inside the room. During an observation on the same day between 9:10 a.m. and 9:30 a.m., Client 1 was observed on two occasions being escorted by Psychiatric Technician H (PT H) and Psychiatric Technician I (PT i) in two different areas. Both staff were observed walking in front of Client 2 with their backs turned. During an observation on the same day at 9:40 a.m. in the Vocational Room (Room 401), one staff (PT I) was observed with seven clients (two males and five females including Client 1). Afemale client suddenly became agitated and attempted to attack another female client. PT 1 positioned himself in between the two clients to prevent a physical altercation. PT I continued to calm the agitated client by talking to her. Client 1 was observed without line of sight supervision for 15 minutes, while talking to two male clients in the room. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000008 State of California - Health and Human Services Agency Deparl.rnent of Public Health SECTIC~N ’1424 NOTICE Page 4 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1731-00104944= Date: 04t14t2014 Time: CLASS AND NATURE OF VIOLATIONS During an interview with the ,Vocational Supervisor on I129/14 at 9:55 a.m., he stated that Client 1 was on line of sight supervision because of her sexual behavior. He stated that Client 1 invites male clients in the bathroom with her. He also stated that the line of sight supervision was being able to see Client 1 at all times in the coed (male and female) area. The Vocational Supervisor stated that Client l’s level of supervision becomes general supervision when she’s in the unit,.because it was not a coed unit. When asked about how staff should be escorting Client 1, he stated, "If the staff is walking with her (Client 1), the client should be always visible to the staff. If the client was behind the staff and their backs were turned, that’s breaking it." During an interview with PT H on the same day at 10 a.m., she stated that Client 1 was on line of sight when there’s coed in the room. She also stated that staff should be keeping an eye on her within line of sight at all times, knowing her. whereabouts. She further stated, "She can’t be behind us, because we won’t be able to see her." During an interview with PT I on the same day at 10:15 a.m., he stated that Client 1 Was on line of sight because of her sexual behavior with male peers. He also stated, "1 have -to be able to see her at all times, under no circumstances that she’s out of my vision." He also stated that when the staff’s back was turned, there was no line of sight supervision. PT I acknowledged that the line of sight was not provided to Client 1 during an incident where he had to intervene, because his back was turned and he was all by himself. He also stated, "What could I have done differently?" During an interview with the Standards Compliance Coordinator (SCC) on the same day at 3:50 p.m.i she stated. "The staff should have pulled his alarm. Every staff was trained, on how to use their alarm," The SCC acknowledged that the line of sight supervision was breached when staff (PT 1) attended to the incident between clients, The clinical record for Client 1 was reviewed on 1t30/14. The Individual Program Plan (IPP) Narrative dated 2t6/13 indicated that she was a 24 year old female admitted in the facility on 315108, with diagnoses that included mild intellectual disability, schizoaffective disorder (psychiatric disorder), and impulse control disorder. The IPP Narrative also indicated that she had an open behavioral plan, "B5-1 Sexually NOTE: IN ACCORDANCE WI’I’H CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000009 State of California - Health and Human Services Agency Department of Public Health SECTI(~N I424 NOTICE Page 5 of 5 CITATION NUI~IBER: SECTIONS VIOLATED 17-1731-0010494-F Date: 04/14/2014 Time: CLASS AND NATURE OF VIOLATIONS Inappropriate Behavior- ...defined as asking peers for sex, exposing herself, touching others, entering bathrooms while someone is using it, hugging and touching peers inappropriately." Client l’s Approaches and Strategies indicated that she was placed on line of sight supervision on 8/8t13, However. her Behavior Support Plan for sexually inappropriate behavior dated 8/29113 did not indicate and specify the level of supervision provided while she’s in the unit, bedroom, vocational room, and other areas where she could have contact with both male and female peers. The Special IPP Narrative dated 8/26/13, 10/7/13, and 10/28/13 indicated that recommendations were made to continue the line of sight supervision for Client 1 due to incidents of sexually inappropriate behavior, There was no documented evidence found indicating that the line of sight supervision would revert back to general supervision once Client 1 was in her unit or room. The Enhanced Supervision for Client Protection-Restrictive Plan with a review date of 1/28t14 indicated that the Interdisciplinary Team decided on 11t12/13 to change the level of suPervision for Client 1. It further indicated, "On 11119t13 [Client l’s] enhanced supervision was decreased from LOS (Line Of Sight) in all areas to all coed areasand activities." The Administrative Policy 324 titled, "Client Supervision." dated 1 ~ t25tl 3 was reviewed on 1t30/I4.. It indicated, "Staff working with clients will be responsible to ensure that active treatment services are delivered safely by maintaining the level of supervision determined by the interdisciplinary Team and documented in their Individual Program Plans, or when re-determined by changes in behavior as a Temporary Intervention Plan (TIP.)". Line of sight supervision was also identified requiring that "staff members place themselves in a vantage point approximately 4 to 25 feet determined by the IDT so they can view the client immediately and intervene when indicated as per the individual program plan. The facility failed to protect a conserved client, Client 1, from sexual abuse by not implementing their policy for enhanced supervision (line of sight) and by not implementing its abuse prevention, reporting and supervision policies. The above violations had a direct or immediate relationship to the health, safety, or security of Patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000010 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 ~ITATION NUMBER: 17-1731-0010615-F Date: 04t14/2014 Time: Type of Visit: Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VtOLATED State of CA Dept of Developmental Services 1600 9TH STREET 170000774 SACRAMENTO, CA 95814 Type of Ownership: State Agency CANYON SPRINGS Cathedral City, CA 92234 69696 Ramon Rd (760) 770-6200 Intermediate Care Facility/Developmentally Disabled 170001776 CLASS AND NATURE OF VIOLATI’ONS CLASS WI49 Incident/Complaint No.(s) : CA00328143 B Capacity: 63 PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 4/24/14 12:00 a.m. CITATION-- PATIENT CARE 483.420 (d) (1) The facility must develop and implement written policies and procediJres that prohibit mistreatment, neglect or abuse of the client. The following citation was written as a result of a visit to the facility on 4f30/13 to investigate Entity Reported Incident #CA00328143. The Department determined the facility failed to: Provide supervision of Client A, allowing him to gain access to a Staff member’s badge providing him with the ability to leave the facility not observed by staff on 10/02/12 at approximately 4 PM. While out of the facility, Client A was observed by an off-duty staff member walking down a busy road, and was observed being picked up by a vehicle driven by an unknown person. These failures resulted in Client A being placed in a dangerous situation when he was observed walking down a busy road and was picked up by an unknown motorist. A review of Client A’s medical record was conducted on 4/30/13. Client A was admitted to the facility on 9122t09 with diagnoses that included mild intellectual disability. His level of supervision at the time he left the facility without staff knowledge was general, which is defined as. direct visual observation and/or accountability at all times, per facility policy Name of Evaluator: Helen Williams HFEN Without admitting guilt, 1 hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR, LICENSE DPH POD 000011 State of California - Health and Human Services Agency Department of Public Health SECTION ’1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED t7-1731-00106,15-F Date: 04/14/2014 Time: CLASS AND NATURE OF VIOLATIONS dated 9/29/11. Record review indicated that on 10/02/12 at approximately 1600, following a basketball game in the facility gymnasium, staff noticed that Client A was no longer in the area. A search was conducted, and he could not be located. A search team was deployed, and the client was located and returned to the facility. There was no evidence of physical injury. Client A gave no insight into his leaving the facility, except to say that he was upset with his situation right now. Further: investigation on 4t30/13 revealed that on 10/02/12 at 1515, Staff 1 took 6 clients to the gymnasium to play basketball. There was one other staff present in the gymnasium on a 1 to 1 observation with a client. Client A, did not want to play basketball, andwanted to use the exercise machines instead. Staff 1 stated that at 1555, the gym activities concluded, and clients and staff returned to the unit. Upon reaching the unit, staff 1 noticed he did not have his badge, and went to the gym to look for it. At 1600 a headcount was done, and it was discovered Client A was missing. An interview was conducted with the Special Investigator on 6119t13 at 10 AM. He indicated that Staff 1 did not notice his badge was missing or that Client A was missing from the time the basketball game st.arted until he returned-to the unit, a period of approximately one hour. An interview was conducted with the HPO (Hospital Police Officer) on 7/17/13 at 6:25 F’M. He stated he received a call at about t600 on 10/02/12 from an off duty staff member (PT 2) asking if there was a missing client. She was on her way home from work at the facility, and observed Client A on the road. At the same time, PT 1 called to report his missing badge. During interview conducted with PT 2 on 4t04/14, she indicated she had left the facility at 1630, and observed someone she thought was a client hitchhiking a few miles north of the facility. She turned her car around to see if he was, in fact, a client. She called the HPO and asked if Client A was missing. She observed a silver colored SUV stop in the middle of the road, engage the client in conversation, and Client A then got into the vehicle. PT 2 reported the license plate of the vehicle to the HPO, and proceeded to follow the vehicle, flashing her lights, honking, and using emergency flashers. The driver proceeded to "flip her off’ and sped up to "75 miles per hour". They finally had to stop due to road construction and she was able to tell the driver the client was a patient from a state facility. The driver said, l don’t want any trouble, and told Client A to get out of the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000012 State of California - Health and Human Services Agency Department of Public Health SEOTIQN 1424 NOTICE Page 3 of 3 ITATION NUMBER: SECTIONS VIOLATED 17-1731-0010615-F Date: 0411412014 Time: CLASS AND NATURE OF VIOLATIONS car. PT 2 said that when Client A saw her, he crossed the road and began to approach her car. He appeared dazed and somewhat confused, yet agitated. She threw a bottle of water out the window to him and encouraged him to drink the water. He then lay down on the sand and exhibited "seizureqike movements". He then suddenly got up and ran into the desert hills in the surrounding area. She maintained visual contact until staff arrived. Client A was returned to Canyon Springs. He was calm and cooperative with staff direction. His face was slightly red, but no physical distress or injury was noted. The client was gone for approximately 45-60 minutes from facility. Review of the facility policy titled "Client Supervision" dated 9/29/11 conducted on 4t30tl 3, indicated the following: "Every staff member of (name of facility) is responsible for the safety and well-being of clients, Staff shall be constantly alert to ensure that the physical and emotional well-being of a client is not endangered in any way. This includes when clients participate in facility activities, receive services from other agencies and participate in activities in neighboring communities." ¯ The Department.determined that the .facility failed to: Provide supervision of Client A, allowing him to gain access to a staff members badge providing him with the ability to leave the facility not observed by staff. While out of the facility, Client A was observed by an off-duty staff member walking down a busy road, and observed him being picked up by a vehicle driven by an unknown person. The above violations had a direct or immediate relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WiTH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000013 State of California - Health and Human Services Agency Department of Public Health SECTI(~N 1424 NOTICE Page 1 of 3 CITATION NUMBER: 17~2220-0010492-F Date: 04t10t2014 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE IncidenttComplaint No,(s) ¯ CA00374239 FEDERAL STATUTES AND REGULATIONS State of CA Dept of Developmental Services Licensee Name: Address: 1600 9TH STREET SACRAMENTO, CA 95814 170000774 License Number: Facility Name: Type of Ownership: State Agency CANYON SPRINGS Address: Telephone: Cathedral City, CA 92234 69696 Ramon Rd (760) 770-6200 intermediate Care FacilitytDevelopmentally Disabled 170001776 Facility Type: Facility ID: SECTIONS VIOLATED CLASS AND NATURE OF VIOLATIONS Capacity: 63 PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 4123/14 12;00 a.m. CLASS B CITATION-- PATIENT CARE W149 W150 W153 483.420(d)(1) The facility must develop and implement policies and procedures that prohibit mistreatment, neglect or abuse of the client. 483.420 (d)(1)(i) Staffof the facility mustn0t use physical, verbal, sexual or psychological abuse or punishment. 483,420(d)(2) The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State faw through,established procedures. The facility failed to ensure physical abuse by a staff member did not occur to Client 1. The facility staff also failed to report a witnessed abuse incident by a staff member to a client immediately to the Facility Director/ Administrator on Duty ( AOD ) / Designee and resulted in the delay of the reporting to the California Department of Public Health (CDPH) within 24 hours. On 10/22/’13, the facility reported to the Department an allegation of physical abuse to Client 1. It was alleged by an eyewitness staff member, Psychiatric Technician A (PT A), that Psychiatric Technician B (PT B) choked Client 1 while in a facility observation room on 10tl 9/13. Name of Evaluator: Without admitting guilt, ] hereby acknowledge receipt of this SECTION 1424 NOTICE Suzette Valdehueza HFEN Signature : Name: Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000014 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 cIrATION NUMBER: SECTIONS VIOLATED 17-2220-0010492-F Date: ~)4110t2014 Time:’ CLASS AND NATURE OF VIOLATIONS Facility investigation determined and substantiated the eyewitness did not immediately report the incident when it actually occurred two days prior on 10/t9t13. Review of the General Event Report (GER), dated !0/21t13, verified on 1/28t14, notifications to the Facility Administrator and Office of Protective Services (OPS) occurred on 10/21/13 and subsequently the California Department of Public Health was not notified until 10/22tl 3. An eyewitness Psychiatric Technician A (PT A) and the alleged assaultive staff member, Psychiatric Technician (PT B); were present in the room at the time of the incident; Client 1 hit PT B causing a scratch to his arm; PT B grabbed Client "1 by the neck very forcefully and pushed her backwards; Client 1 was assessed by the PT A who noted superficial scratches to the Ctient l’s upper right cheek - 4 cm (centimeter) X 0.1 cm and .5 cm x 0.1 cm and 2 cm x 2 cm to the left cheek; a 3 cm x 1.5 cm and 1 cm x 0.2 cm bruise to the upper left chest area noted. Review of the facility’s Administrative Policy 304 (dated 7/16!13) entitled "Incident Reporting/Unusual Occurrences" conducted on 1/28/14, identified events that were expected to be reported. Guidelines for alleged or suspected abuse and/or neglect incidents were-articulated under "Notification to-Facility Director (AOD)/Designee" and required "1) immediate notification (as soon as possible, after ensuring the safety of involved residents)." Review of the Office of Protective Services (OPS) report conducted on 1/29/14, revealed additional findings from the eyewitness PT A. In the report, PT A stated that PT B "put his hands around Client l’s neck and choked her." PT A also stated she was in shock and froze. PT A became emotional and started crying. She became afraid because of what she had just witnessed. PT A stated she that she waited to report the event because she felt intimidated by PT B and afraid he might do something to her. OPS interview of Client t confirmed Client 1 was sent to the observation room on 10/19/13 after being confronted about having cigarettes by PT B. PT B directed her to the observation room where she took off her clothes and attempted.to dislodge a baseboard from the walt using a necklace. In the process, Client 1 stated she hit PT B’s arm. PT B’s reaction was to get on top of her and use his knee causing her to pass out. Client 1 stated she thought she had passed out and when she came to, she felt cold. Review of The Investigation Disposition Report on 1/29/14, included details from the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000015 Stale of California - Health and Human Services Agency . SECTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health Page 3 of 3 17-2220-0010492-F Date: 04/10/2014 Time: CLASS AND NATURE OF VIOLATIONS eyewitness, PT A, who observed PT B putting both hands on Client l’s neck. The Investigation Disposition Report also included that PT A left the room to obtain restraints and returned 2-3 minutes later, leaving Client 1 alone in the room with PT B. PT A also stated in this report that after Client 1 was placed in restraints PT A was told by PT B, "You didn’t see anything." Another staff, PT C, verified that she was asked to help out with restraint, and heard Client I stated she was choked by the PT B, but initially did not think an allegation was being made. PT C also heard the statement made by the PT B to the eyewitness PT A, "You didn’t see anything." In an interview with the Standards Compliance Coordinator (scc) on 1/29/14 at 7:30 a.m., the SCC discussed some of the action taken bythe facility in response to the event. The SCC explained and verified administrative action had been taken with the eyewitness and second witness for late reporting and administrative action with the alleged perpetrator was pending. The SCC stated that the eyewitnesses’ late reporting may have been due to fear of intimidation by the alleged perpetrat6r, The facility failed to implement their policies and procedures related to Abuse, Neglect ¯and Exploitation Prevention and Reporting and IncidentReportinglUnusual Occurrences and failed to ensure physica~ abuse by a staff member did not occur to Client 1. The facility staff also failed to report a witnessed abuse incident by a staff member to a client immediately to the Facility Director/Administrator on Duty ( AOD ) ! Designee and to the California Department of Public Health (CDPH) within 24 hours. The above violations had a direct or immediate relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000016 State of California - Health and Human Services Agency Department of Public Health ,-SECTION 1424 NOTICE CITATION NUMBER: Page 1 of 3 17-1324-0009363-S Date: 01t24t2014 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORN IA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) Incident/Complaint No.(s) ¯ CA00294260 State of CA Dept of Developmental Services 1600 9TH STREET 170000774 SACRAMENTO, CA 95814 Type of Ownership: State Agency CANYON SPRINGS Cathedral City, CA 92234 69696 Ramon Rd (760) 770-6200 Intermediate Care FacilitytDevelopmentallyDisabled Capacity: 63 170001776 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 12/7/14 12:00 a.m. CITATION -- PATIENT RIGHTS Title 22 76525 (a) (20) Clients’ Rights Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. failed to comply with the above regulation by failir~g to ensui’e that Client A was not subjected to sexual abuse when Client A performed an inappropriate sexual activity to a friend during a visit to the facility. Review of facility documentation dated 12tl 9tl 1, revealed that on 12tl 8/11, Staff 1 asked Client A about his visit with Friend 1 on 12t17111. Client A responded, "1 s.... d my [Friend 1]’s d-k". Client A stated that his friend brought him a Big Mac, large fries, and a large coke. The lights were off in the room, and his friend was sitting by the door. Friend 1 then asked me, "do you want to s-k my d-k?. Client A said yes, then Friend 1 said go for it. Client A was asked if the friend wore a condom. Client A responded yes, Friend 1 Name of Evaluator: Elna Ramos HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE . Signature : Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000017 State of California - Health and Human Services Agency Department of Public Health SEO’TI(~N 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1324-0009363-S Date: 01t24t2014 Time: CLASS AND NATURE OF VIOLATIONS took it from a package in his pocket. Client A stated that Friend 1 said thank you and not to tell anyone. Facility documentation indicated as of 12/12111, Friend 1 was Client A’s Volunteer Advocate for approximately one year and had left the advocacy services in 11/2011. He was visiting Client A as a friend not as a volunteer advocate. Client A was admitted to the facility on 2t28/03, with diagnosis of mild intellectual disability. The Standard Compliance Coordinator stated during the interview on 4/30/12 at 2:45 p.m., that the facility does not have a specific visiting time. The visitor checks in with the hospital police officers (HPO), and requests to see a specific client. The HPO would call the unit to have the client brought, into the visiting area. She further stated that there are no visitor requirements unless specifically indicated by the client or conservator. Client A is not conserved. Client A stated during an interview on 5/8/13 at 12:30 p.m. that he has a new volunteer advocate. His former volunteer advocate [Friend 1] was inappropriate. He was asked how was Friend 1-inappropriate~ he.said, "[Friend 1] showed me.his penis, not good." He was asked if he touched it Client A shook his head no. Client A stated that Friend 1 gave him a McDonald burger, large fries, and large diet coke. Client A was asked about the last visit with Friend 1. Client A stated that they were in the visiting room watching a TV movie called Mrs. Santa Claus. At this point, Client A terminated the interview. Friend 1 was unavailable for interview after several attempts by phone. Review of the facility’s investigative report dated 9/5/13 reviewed on 9/9/13 revealed that CIient A was visited by Friend 1 on 12/17tl 1, between 5:15 p.m. and 6:55 p.m. During the visit, Client A alleged that Friend 1 had asked Client A if he would orally copulate his penis. Client A agreed and orally copulated Friend l’s penis. In the report an interview conducted by the Office of Protective Services, Special Investigation Unit (OPStSIU) with Staff 1; Staff 1 reported that Client A’s initial disclosure of the incident was spontaneous. Staff 1 further stated that Client A had never made allegations of this sort in the past. Client A appeared calm and stated the incident as simple as having a conversation with Staff 1 about the visit. The facility had two criminalists obtain samples from the room occupied by Client A and Friend 1 during the above visit. All areas of the room, including Client A’s clothing NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND 8AFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000018 State of California ~ Health and Human Services Agency ,SECTICiN 1424 NOTICE CITATION NUMBER: SE,CTIONS VIOLATED Department of Public Health Page 3 of 3 17-1324-0009363-S Date: 01t24t2014 Time: CLASS AND NATURE OF VIOLATIONS screened negative for acid phosphatase (a component of semen that may have been left behind after the above incident.) Review of the Administrative Policy 307 - Clinical Services dated 10/22tl 2 indicated there is no procedure in place to ensure staff’s accountability in conducting safety rounds/check in the visiting area during visiting hours. Client.A, on 12/17tl 1 from 5:15 p.m. to 6:55 p.m. during a visit, was subjected to inappropriate sexual activity (oral copulation) to a visitor. The failure of the facility to )rotect Client A from harm caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000019 State of California - Health and Human Services Agency Department of Public Health SECT]’oN 1424 NOTICE Page 1 of 4 CITATION NUMBER: 17-1458-0008980-F Date: 04t29/2014 Time: Type of Visit ¯ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED State" of CA Dept of Developmental Services t600 9TH STREET, RM 340 t70000771 SACRAMENTO, CA Type of Ownership: 95814 State Agency FAIRVIEW DEVELOPMENTAL CENTER D/P SNF 2501 Harbor Blvd Costa Mesa, CA 92626 Skilled Nursing Facility 170001770 Capacity: 396 CLASS’AND NATURE OF VIOLATIONS CLASS A F323 Incident/Complaint No.(s) : CA00285809 PENALTY ASSESSMENT $20,000.00 DEADLINE FOR COMPLIANCE 5/14/14 12:00 a.m. CITATION-- PATIENT CARE 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 an~] assistance devices to prevent accident& An investigation was conducted on 10/27/11 as the result of a facility self-reported incident. The results showed that the facility: 1. Failed to investigate, for causal factors, a previous fall on 7/15111, during which Resident 1 hit her head on the floor; 2. Failed to review and revise the plan of care following that fall and develop new interventions to prevent further falls; 3. Failed to implement the written care plan so that Resident 1 received adequate supervision to prevent falls; and 4. Failed to identify possible or likely causes of Resident l’s 9t28tl 1, as specified by facility policy and procedure. Name of Evaluator: Alicia Lamarand HFEN Without admitting guilt, I herei~y acknowledge receipt of this SECTION 1424 NOTICE S ig nature -: Name: Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000020 State of California - Health and Human Services Agency Department of Public Health 8,ECTI’ON 1424 NOTICE Page 4 of 4 CITATION NUI~IBER: SECTIONS VIOLATED 17-1458-0008980-F Date: 04/29/2014 Time: CLASS AND NATURE OF VIOLATIONS Resident 1 was admitted to the intensive care unit on 9/30/11 and died on 10f3/11. The autopsy report listed the cause of death as blunt head trauma with skull fractures and bleeding in the brain. Staff Member C confirmed that no investigation of the fall was initiated until after Resident 1 had a change of condition on 9/30/11. During an interview on 2/6/12 at 11:25 AM, Staff Member A, who was responsible for the care of Resident 1 at the time of the incident on 9/28111, stated she was standing near the resident at the time Residen{ 1 attempted to transfer from her wheelchair to a padded chair in the classroom. Staff Member A stated Residentl got out of her wheelchair, took a couple of steps toward the padded chair which was about five feet away, turned, and fell straight backwards, hitting the back of her head on the floor. Staff Member A stated she was not touching or holding on to any part of Resident 1 during the attempted transfer from her wheelchair to the padded chair. During an interview on 2t7/12 at 8:50 AM, supervising Staff Member B confirmed that one-person physical assist and hand-holding during transfers and ambulation were interventions specified in Resident l’s plan of.care.to prevent, falls.. Staff Member B further stated that all staff involved in the care of Resident 1, including Staff Member A was aware of the interventions required in the plan of care. The facility’s failure to investigate the causal factors, review and revise Resident l’s plan of care, develop new interventions to prevent further falls after Resident 1 ’s 7fl 5/11 fall, in which Resident 1 hit her head on the floor, then failed to provide adequate supervision to prevent falls by failing to implement the written care plan in effect and the facility’s failure to begin efforts to identify possible or likely causes of the 9/28/11 fall as specified by the facility’ policy and procedures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000021 State of.,Catifornia - Health and Human, Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 ClTATIQN NUMBER: 17-1473-0010359-F Date: 04t0712014 Time: Type of Visit " Complaint Inveslig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE Incident/Complaint No,(s) ¯ CA00366907 CALIFORNIA STATUTES AND R~GULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 170000771 Type of Ownership: State Agency FAIRVIEW DEVELOPMENTAL CENTER DIP SNF 2501 Harbor Blvd Costa Mesa, CA 92626 Skilled Nursing Facility 170001770 Capacity: 396 CLASS AND NATURE OF VIOLATIONS CLASS B F323 SACRAMENTO, CA 95814 PENALTY ASS ESSM ENT $2,OOO.OO DEADLINE FOR COMPLIANCE 4/20/14 12:00 a.m. CITATION -- PATIENT CARE F323 483.25 (h) 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 facility failed to: 1. Ensure that Resident 1 was provided the correct assistive devices to prevent accidents when the resident, while being transported via a mechanized transfer lift instead of a wheelchair, fell from the sling, which gave way, resulting in a head laceration that required several staples to close the head wound. 2. Follow the plan of care for Resident 1 as stated in his assessment plan which indicated that the resident ~equired a minimum of 2 plus staff to physically assist during t ra n sfe rs. On 11/13/13 at 8 AM, during a recertification survey, Resident 1 was observed in his room receiving medication via gastrostomy tube. Further observation of the resident Name of Evaluator: Robed Ussher HFEN Without admitting guilt. I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name: Evaluator Sfgnature ’ Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUND8 FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000022 State of,California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER; SECTIONS VIOLATED 17-1473-0010359-F Date: 04t0-~t2014 Time: CLASS AND NATURE OF VIOLATIONS revealed a scar on top of his head in the frontal area. Review of the clinical record for Resident 1 on the same day revealed that Resident 1 was admitted to the facility with diagnoses including seizure disorder and abnormal gait. On 8t16/13 at approximately 6:50 AM, the resident was transported by one staff from his bed room through the residence hallway to the bathroom by means of a mechanized transfer lift on a sling. Per the Manufacturer’s recommendations, the mechanized lift was designed only for stationary transfer from bed to wheelchair, wheelchair to bath, etc. and not to be used for translocation. Resident 1 fell in the hallway from the mechanized lift to the floor on his right shoulder when the sling gave way from the lift. The top of his head hit the metal chassis of the mechanized lift. Resident 1 sustained a 2.0 cm (centimeters) by 0.2 cm laceration on top of his head with some bleeding. Resident 1 also sustained ~njury with a bruise measuring 12 cm by 15 cm on his right shoulder, redness to the left collar bone measuring 1 cm by 0.2 cm and redness to neck area measuring 0.1 cm by 0.2 cm. The clinical record also revealed that while being assessed in the hallway of the unit after the fall, Resident 1 vomited a small amount of bile. Vomiting is a symptom of concussion. Resident 1 was transferred to the acute hospital for fu. rther evaluation and treatment. The resident received four staples to the laceration on his head. During interview on 11t14/13 at 10:15 AM, licensed staff stated that on the morning of 8f16/I3 he was assisting Resident 1 with his personal grooming when he transported him by means of the mechanized lift from his bedroom to the bathroom. When asked the number of staff required to transfer Resident 1 licensed staff stated that he was not sure. He usually transferred him alone. A review of the Minimal Data Set (MDS- an assessment tool) on 11/13/13 and dated January 17, 2013, was conducted. It indicated Resident 1 required 2 plus persons to physically assist during transfer. When asked how residents requiring assistance with transfers are transported from one location on the unit to another, licensed staff stated it was by wheelchair and not on a mechanized lift with a sling. Licensed staff further acknowledged that the mechanized lift was only utilized in transferring residents from bed to wheelchair and vice versa. During interview on 11tl 5/13 with the Unit Supervisor, (US) she acknowledged that mechanized lifts are only used for transferring residents from bed to wheelchair or from wheelchair to bath. The US also acknowledged that the resident should not have been moved from the bed through the hallway to the bathroom in the mechanized lift. This was confirmed by review, on 11t15113, of the manufacturer’s recommendations that NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000023 State of,California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 17-1473-0010359-F Date: 04!07/2014 Time: CLASS AND NATURE OF VIOILATIONS indicated that the mechanized lift must only be used for transfers from bed to wheelchair, wheelchair to bath, etc. and not used for translocation. The facility failed to ensure that Resident 1 was provided the correct assistive devices to prevent accidents when the resident, while being transported via a mechanized transfer lift instead of a wheelchair, fell from the sling, which gave way, resulting in a head laceration that required several staples to close the head wound. The facility failed to follow the plan of care for Resident rl as stated in his assessment plan which indicated that the resident required a minimum of 2 plus staff to physically assist during transfers, The above violations had a direct or immediate relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000024 State of California - Health and Human Services Agency Department of Public Heallh .~ECTION 1424 NOTICE Page 1 of 2 CITATION NUN1BER: 17~1458-0009189-S Dale: 04,’07/2014 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(8)(7) Incident/Complaint No.(s) ’ CA00301989 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 170000771 SACRAMENTO, CA 95814 Type of Ownership: State Agency FAIRVIEW DEVELOPMENTAL CENTER DIP ICFDD 2501 Harbor Blvd Costa Mesa, CA 92626 7149575O0O intermediate Care Facility/Developmentally Disabled CapacitY: 792 170001769 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $2,000,00 DEADLINE FOR COMPLIANCE 4120114 12:00 a.m. CLASS A CITATION-- PATIENT RIGHTS 76525 (a)(7) Free from physical harm An investigation was initiated on 3/9/12 as a result of a facility self-reported incident, The facility failed to protect Client 2 from harm when Client 1 beat Client 2 to the point Client 2 required hospitalization for skull and facial fracture and bleeding in the brain. Client l’s Interdisciplinapj (ID) notes contain documentation of three client to staff aggressive acts over the preceding 6 months and two aggressive acts against peers. These aggressive acts included hitting and kicking. On 2/14/12, staff documented in the ID Notes that Client 1 pulled another client to the ground and kicked him in the face. Qn 2/26/12, staff documented in the ID Notes that Client 1 had an altercation with another client and the other client was unable to bear weigh:~ on his leg following the incident. The Individual Program Plan (IPP) "Desired Outcome and Milestone" behavior plan B2-2 for kicking others was initiated on 10/31/10. Client l’s medical record failed to contain documentation that Client l’s behavior plan had been either reviewed or revised since 10/31110. Name of Evaluat6r: Alicia Lamarand HFEN Wilhout admitting guitt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name: Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS. IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000025 Slate of California - Health and Human Services Agency Department of Public Health SEC~rlON 1424 NOTICE Page 2 of 2 CITATION NUN1BER: SECTIONS VIOLATED 17-1458-0009189-S Date: 04107/2014 Time: CLASS AND NATURE OF VIOLATIONS The facility was unable to provide documentation that Client 1 ’s behavior plans have been reviewed and/or revised following these violent aggressive acts. On 3/3/12 at 12:30 PM, Staff Member 2 observed Client 2 face up on the floor with Client 1 stomping on him. Medical record review revealed that Client 2 required cardiopulmonary resuscitation to restore breathing and heart action. He was taken to an emergency room with two skull fractures, a nasal fracture, and subdural/subarachnoid hematomas [bleeding in the brain.] Statistically, this type of bleeding into the brain can cause a 60-80% mortality rate if left untreated. During an interview on 3/28t13 at 10:20 AM, Staff Member 2 stated that he was mopping in the hallway near the dining room, looked down a side hall, and was about 6 or 7 feet away from the two clients. He stated when Client 1 saw him, Client 1 backed away. Staff Member 2 then called for Staff Member 1. During an interview on 3/22/13 at 10:30 AM, Staff Member 1 stated that on 3/3/12 at 12:30 PM, he was in the station chart room when he heard someone calling his name. When he ran out, Staff Member 2 told him that Client 1 was "beating up" Client 2. No other staff members were in the area. Staff Member 1 observed Client 2 face up on the floor in the ha!l.way with his face full .of.blood, unresponsive with no breathing, no heart rate, and his eyes rolled back in his head. Staff Member 1 stated that emergency measures were initiated and Client 2 was taken to a .hospital. He stated that he observed Client 1 in his room, still agitated, with blood on the bottom and inner side of his shoe. He stated Client 1 was assigned a one-to-one staff member to supervise him. Therefore, the facility: I. failed to ensure Client 2 was free from harm; 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. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000026 State of California - Health and Human Services Agency Departmenl of Public Health S~ECTION’1424 NOTICE Page 1 of 2 CITATION NUMBER: 17-145"~-0010289-S Date: 04107/2014 Time: Type of Visit ¯ Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS ’OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility 1D; SECTIONS VIOLATED 76525(a)(20) Incident/Complaint No.(s) " CA00317411 State of CA Dept of DevelopmentaI Services 1600 9TH STREET, RM 340 170000771 SACRAMENTO, CA 95814 Type of Ownership: State Agency FAIRVlEW DEVELOPMENTAL CENTER DIP ICFDD 2501 Harbor Blvd Costa Mesa, CA 92626 7149575000 Intermediate Care Facility/Developmentally Disabled 170001769 CLASS AND NATURE OF VIOLATIONS CLASS B Capacity: 792 PENALTY ASSESSMENT $1,000.00 t DEADLINE FOR COMPLIANCE 4/20/14 12:00 a.m. CITATION-- PATIENT RIGHTS 76525 (a) (20) Right to be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. . The facility’s neglect of Client 1 to prevent Client 1 from swallowing inedible items )laced Client 1 at risk of serious injury or death from unnecessary surgery to remove the inedible items Client l’s swaf]owed from Client l’s gastrointestinal tract. Review of Client l’s clinical record revealed that Client 1 had an extensive history of swallowing inedible objects (PICA). Foreign objects she had swallowed in the past included key rings, batteries, screws, paperctips, soda can tops, metal bicycle parts, tacks and zippers. Many of these incidents required that Client 1 be hospitalized for EGD procedures (esophagogastroduodenoscopy) for the removal of the foreign objects. This procedure consisted of inserting a long flexible tube with a camera and a retrieving device into the GI tract to remove objects lodged in the esophagus, stomach or duodenum. This procedure is performed when a foreign object is unable to pass through the GI tract or is likely to perforate the GI tract. Client 1 was on an enhanced supervision which required an assigned staff member to be in constant line of sight of the client during all waking hours. During the night, 15 minute checks were to be performed by staff when she was in bed. Client 1 had a strong Name of Eva]uator: Lloyd Biggs HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature ’ Name ’ Evaluator Signature Title ¯ NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000027 State of California - Health and Human Services Agency Department of Public Health SECTI,ON 1424 NO-JICE Page 2 of 2 CITATION NUMBER: SECTIONS VIOLATED 17-1457-0010289-S Date: 04t07t2014 Time: CLASS AND NATURE OF VIOLATIONS history of hiding objects on her person, in her bed linens or near her bed and would swallow them after she was in bed. Periodically, a denial of rights was put in place that consisted of AM and PM shift, rooms searches for items she could swallow. A body search would be performed on the AM and PM shifts if required. Client 1 did not have a denial of rights in place on 717/12. On 7t7/12, Client 1 reported to staffthat she had swallowed batteries and a zipper. An x-ray examination performed that day, revealed the presence of multiple foreign bodies in her GI (gastrointestinal) tract. Subsequent x-ray exam on 7/8t12 and 7/11/12 showed the foreign objects were not moving along her GI tract. The radiologist made the opinion that the objects were not likely to pass on their own. On 7/17/12 at an outside acute care hospital, EGD removal of Client l’s GI foreign objects was unsuccessful. Consequently, an exploratory laparotomy was performed. Six batteries and two paperclips were surgically removed from her stomach, small bowel and colon. Her surgical wound required 43 surgical staples for closure. The above violations had a direct or immediate relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000028 State of California - Health and Human Services Agency Department of Public Health ~’ECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 17-1458-0010290-F Date; 04/02/2014 Time: Type of Visit: Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORN}A STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGU LATIONS Licensee ;qame: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID; SECTIONS VIOLATED State of CA Dep1 of Developmental Services 1600 9TH STREET, RM 340 170000771 SACRAMENTO, CA 95814 Type of Ownership: State Agency FAIRVIEW DEVELOPMENTAL CENTER DIP ICFDD 250t Harbor Blvd Costa Mesa, CA 92626 7149575000 Intermediate Care FacilitytDevelctpmentally Disabled 170001769 CLASS AND NATURE OF VIOLATIONS CLASS B W249 Incident/Complaint No.(s) ’ CA00312436 Capacity: 792 PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 4/16/14 12:00 a.m. CITATION -- PATIENT CARE 483.440(d)(1) Facility Practices (1) As soon as the interdisciplinary team has formulated a client’s individual program plan, each. client must receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan. An investigation was begun on 2/27113 as a result of a facility reported incident. The investigation showed the facility failed to: 1. ensure that Client 1 received continuous active treatment consisting of needed interventions for safety awareness and 2. failed to implement recommendations for safety awareness training. The clinical record for Client 1 indicated that he had a history of chronic compression fractures of his back. The Individual Program Plan (IPP), dated 4/18t12, indicated that Client 1 walked with a steady gait with good balance The IPP documented that Client 1 was able to participate in conversational speech. The Safety Awareness section documented that the client did everything in a hurry, including walking and, "He does not always know how Name of Evaluator: Alicia Lamarand HFEN Without admitting guilt, f hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000029 State of California - Health and Human Services Agency Department of Public Health ,$ECTIOI~ 1424 NOTICIE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1458-0010290-F Date: 04/02/2014 Time: . CLASS AND NATURE OF VIOLATIONS to avoid environmental hazards such as wet floors, spills ..." The Interdisciplinary Team (IDT) recommended implementing training to enhance the client’s safety awareness skills. The Approaches and Strategies, dated 4/18/12, documented that Client 1 "walks with his head down and needs to be encouraged to keep his head up and watch where he is going." The Approaches and Strategies further specified, "Optimal techniques for skill acquisition include verbal instruction..." Facility documentation indicated that, on 5/24t12, Client 1 was in the dining room on his residence. The housekeeper had mopped up spilled liquid from the floor and had placed warning signs around the wet area of the floor at the exit of the dining room. At 7:50 AM, Client 1 was leaving the dining room. Staff Member 1, the dining room coordinator, noted the wet floor and "walked with caution" past the area. She then looked back to see Client 1 slip and fall in the wet section of the floor. Client 1 was transferred to the emergency room at an acute care hospital where he was treated for a fracture of the twelfth thoracic vertebra (broken lower+ back). Upon return from the hospital, Client 1 required pain medication 42 times during the next month. He still .complained of pain of a severity of 9 on a scale of 1 to I0. on 6/11t12, two and a half weeks after the injury. Client 1 was also required to wear a back brace at all times for several months. During an interview on 6t13/13 at 9:00 PM, Client 1 stated that he remembered the fall and that it hurt. During an interview on 6/13/13 at 3:15 PM, Staff Member 1 stated the client was exiting the dining room and she was going to give him mouey for the day. The housekeeper had mopped and placed warning signs on the floor. When asked, Staff Member 1 stated no one warned Client 1 or provided safety training about the wet floor before he slipped and fell. During an interview on 6t13/13 at 3:30 PM, more than a year after the injury, Staff member 2 stated, "1 don’t think he’s [Client 1] back to the level he was before." Therefore, the facility failed to provide continuous active treatment consisting of needed interventions for safety awareness to a client with poor safety awareness and failed to implement recommendations by the IDT for training to enhance the client’s safety awareness skills. The client suffered a fall and fracture. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000030 State of California - Health and Human Services Agency Department of Public Health S£CTiO~I Page 3 of 3 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED 17-1458-0010290-F Date: 04/02/2014 Time: CLASS AND NATURE OF VIOLATIONS The above had a direct or immediate relationship to the health, safety, or security of clients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000031 State of California - Health and Hu.man Services Agency De’partment of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 17-1457-0009179-S Date: 02t27t2014 Time: Type of Visit: Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE IncidentfComplaint No.(s) ’ CA0029t 174, CA00293476 FEDERAL STATUTES AND REGULATIONS Licensee Name: Address; License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525( a )(20) State of CA Dept of Developmental Services 1600.9TH STREET, RM 340 170000.771 SACRAMENTO, CA 95814 Type of Ownership: State Agency FAIRVlEW DEVELOPMENTAL CENTER DIP ICFDD 2501 Harbor Blvd Costa Mesa, CA 92626 7t 49575000 intermediate Care Facility/Developmentally Disabled 170001769 CLASS AND NATURE OF VIOLATIONS CLASS B Capacity: 792 PENALTY ASSESSMENT DEADLINE FOR $1 ,oo0.oo COMPLIANCE 3/11114 12:00 a.m. CITATION -- PATIENT RIGHTS 76525 (a) (20) right to be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. During the investigation of an unusual occurrence the following was revealed: The facility did not comply with the above regulation when it neglected to provide adequate supervision to prevent Client 2 from kicking Client I in the ribs resulting in harm, fractures to right 10th and 1 lth ribs. Clinical record review for Client 1 revealed that he had diagnoses that included anxiety and impulse control disorder. He had a history of aggressive harm to others, was intrusive and would make derogatory comments about and use profanity with others. Clinical record review for Client 2 revealed that he also had an impulse control disorder, psychosis not otherwise specified and a history of aggressive harm to others. He had open Individual program objectives to reduce the behaviors of hitting and kicking others. During August of 2011 he had kicked others seven times. He had hit others 13 times in August of 2011, two times in September 2011 and four times during November 2011. Client 1 had been complaining of pain to his right side. X-ray examination conducted on 11118/’11 at 10:40 AM, revealed that he had fractures of his t0th and 1 lth ribs on the Name of Evaluator: Lloyd Biggs HFEN Without admitti"n~] guilt, I hereby a’~knowled~e receipt of this SECTION 1424 NOTICE Signature : Name ¯ :_valuator Signature " Title ’ NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000032 State ifCalifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 17-1457-0009179-S Date: 02/27/2014 Time: CLASS AND NATURE OF VIOLATIONS right side. When asked about the origin of these injuries, Client 1 stated that on the prior Monday morning of 11t15tl 1, another client had kicked him while in the group area. He described the client only as tall and dark. Later that afternoon he pointed out Client 2 as the peer who had kicked him on his right side. He said he didn’t repod it sooner because he was afraid. It was documented that same afternoon that facility staff asked Client 2 if he had hit or kicked Client 1. He initially denied doing it, however he later came to staff and admitted that he did kicked Client 1 on the previous Monday. When asked where he kicked him, he said on the right side. He said Client 1 had called him a "nigger" and he got mad and kicked him. Review of an office of protective services investigation report dated 2t28/12 revealed that Client 2 stated he remembered physically assaulting Client 1 in the Group room R43. Client 2 said that Client 1 accused him of taking his soda. Client 2 stated he deniedtaking the soda and Client 1 called him a "nigger". Client 2 said he then kicked Client 1 on the legs and stomach area. He told the officer that no one saw him kick Client 1. On 4t2.9/12 during interview with a Supervisory Staff Member 1, she stated that Client 1 and 2 were assigned to different groups. She was not sure in which group the altercation took place. She acknowledged that there was two staff members assigned to each group.in response to being questioned as to why the assault had not been witnessed by staff, she stated that perhaps both staff.members were helping other clients. However, she stated that a staff member should have been in the group area. On 4118/12, Staff Member 2, who was the PM group leader on the day of the assault, was interviewed. She said that she didn’t hear any altercation that day. She said that afternoon Client 1 had come to her and said Client 2 had kicked him. She said she didn’t know if the attack had occurred in the morning or afternoon. She said one person usually stays with the group and that they are not supposed to leave the group unattended. On 5t5/12, Staff Member 3, who was the AM group leader on the day of the assault, was interviewed. He stated that usually one staff member will stay in the group area if the other staff member goes to help other cfients. He said that on the day in question, he didn’t remember where he was or why there was no staff member in the group area at the time of the incident. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000033 -. State 6f California - Health and Human Services Agency SECTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health Pag~ 3 of 3 17-1457-000917g-s Date: 02/27t2014 Time: CLASS AND NATURE OF VIOLATIONS Facility policy "5.5 CLIENT’S SAFETY 5.5.3 SUPERVISION OF CLIENTS" specified under Direct Care Staff Responsibilities, "Ensure that adequate supervision is provided whenever leaving clients, keeping in mind the health, physical and behavioral issues for each client". Therefore the facility neglected to provide adequate supervision for the clients in group room R43 resulting in Client 1 sustaioing fractures to his right 10th and 11th ribs after an unwitnessed physical assault by Client 2. The above violation had a direct or immediate relationship to the health, safety, or security of Clients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000034 State of California - Health and Human Services Agency Department of Public Health ,,~ECTI0’I~11424 NOTICE Page 1 of 3 CITATION NUMBER: 17q457-0009362-S Dale: 0212712014 Time: Type of Visit : YOU ARE HEREBY FOUND tN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525( a )(20) IncidentfComplaint No.(s) : CA00309848 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 170000771 SACRAMENTO, CA 95814 Type of Ownership: State Agency FAIRVIEW DEVELOPMENTAL CENTER DIP ICFDD 2501 Harbor Bird Oosla Mesa, CA 92626 7149575000 Intermediate Care FacilitylDevelopmentally Disabled Capacity: 792 170001769 CLASS AND NATURE OF VIOLATIONS CLASS El PENALTY ASSESSMENT $1,000,00 DEADLINE FOR COMPLIANCE 3/tt/14 12:00 a.m. CITATION -- PATIENT RIGHTS 76525 (a) (20) right to be free from harm, including unnecessary physical restraint or isolation, .excessive medication, abuse or neglect. During the investigation of an unusual occurrence initiated on 6t5tl 2, the following was revea led: The facility failed to comply with the above regulation when it neglected to provide adequate interventions to prevent Client 2 from hitting Client 1 in the face causing harm, right orbital (eye socket bones) and nasal bone fractures. Clinical record review for Client 1 revealed that he had diagnoses that included schizoaffective disorder and impulse control disorder with a history of aggressive harm to others. Clinical record review for Client 2 revealed he also had a diagnosis of impulse control disorder and a. history of aggressive harm to others. On 2f611.2, Client 1 entered Client 2’s room and proceeded to go through his property. Client 2 responded by wrapping an electrical cord around his fist and physically assaulting Client 1. Client 1 sustained abrasions to his head, face and neck. He also Name of Evaluator: Lloyd Biggs HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature : Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LlCENSE DPH POD 000035 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1457-0009362-S Date: 02t27/2014 Time: CLASS AND NATURE OF VIOLATIONS sustained 2 bites to his upper left arm. It was documented that following the incident, Client 2 said, "He won’t leave me alone and I am sick of it. He tried to take my stuff." Facility records indicated that Client 1 was known to have an unusual fascination with Client 2 and Client 2 had asked him to leave him alone on many occasions. Prior to this incident, Client 1 had grabbed Client 2 inappropriately with a defensive response by Client 2. Following the 2/6/12, a special conference was held on 2/9/12. The action plan included that staff were to ensure that there were no "chance" meetings between the clients, "until issue resolved by increasing visual checks for both clients". Facility record review revealed that on 4/28112, staff heard a commotion in the east wing of the residence where both clients’ bedrooms were located. Client 1 was found on the floor. He stated that Client 2 had hit him in the face. Client 1 complained of dizziness and began to vomit. He was transported to an outside acute care hospital where he was found to have a right orbital fracture and nasal fracture that required surgical intervention. Client 2 stated that Client I came into his bedroom and grabbed his genitals and that is when he hit Client 1. Client 1’s roommates confirmed that was what happened. On 6/’5/12 at 11:15 AM, the Unit Supervisor I who was in charge of the residence during the 2/6/t2 incident was interviewed. She said she that while she was still in charge of the unit the "issue" between the two clients was never resolved. When Unit Supervisor 1 was asked how the history of negative interactions between Client 1 and Client 2 was communicated to Unit Supervisor 2 wren she took over the unit, she stated that it was covered in their morning program management meetings. She was unsure if Unit Supervisor 2 was present in a meeting about Client 1 and 2. She stated that she did not have a face to face takeover meeting with Unit Supervisor 2. On 6/5/t2, supervisory staff for the Residence during the 4/28112 incident was interviewed. She stated that during the 2/6tl 2 incident she.was not on the residence and was not fully aware of the incident. When asked if there is ever a meeting between the oncoming and off going unit supervisors, supervisory staff stated she had never had such a take-over meeting. She said she wasn’t aware of the 2t9/12 special conference action plan that included that staff was to ensure there were no "6hance" meetings NOTE: tN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000036 State of California - Health and Human Services Agency Department of Public Hea~th SECTION 1424 NQTJCE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1457-0009362-S Date: 0212-7/2014 Time: CLASS AND NATURE OF VIOLATIONS between the clients, "until issue resolved by increasing visual checks for both clients". Therefore the facility neglected to implement adequate interventions to prevent Client 2 from physically assaulting Client 1 which resulted in harm to Client 1, a fractured right orbit and a fractured nasal bone. The above violation had a direct or immediate relationship to the health, safety, or security of Clients. NOTE: tN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTE¥ CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR RE~’OCATION OF YOUR LICENSE DPH POD 000037 State of California - Health and Human Services Agency Department of Public Health 8ECTIOI~ 1424 NOTICE Page 1 of 6 CITATION NUI~BER: 17-1457-0006840-S Date: 04f19t2012 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORN IA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Faciliiy Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) IncidenfJComp~aint No.(s) : CA00179998, CA00178929, CA00178891 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 170000771 SACRAMENTO, CA 95814 Type of Ownership: State Agency FAIRVIEW DEVELOPMENTAL CENTER DIP ICFDD 2501 Harbor Bird Costa Mesa, CA 92626 7149575000 Intermediate Care FacilitylDevelopmentally Disabled Capacity: 792 170001769 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $10,000.00 I DEADLINE FOR COMPLIANCE 5/1/12 12:00 p.m. CLASS A CITATION -- PATIENT RIGHTS T22 DIV5 CH8 ART4-76525(a)(20) Clients’ Rights (20) To be free from harm, including unnecessary physical restraint or.isolation, excessive medication, abuse or neglect. During the investigation of an unusual occurrence the .following was revealed: The facility did not comply with the above regulation when it neglected to provide sufficient supervision to protect Client 1 from homicide while residing in the facility’s locked Adolescent Residence 529. Clinical record review revealed Client 1 was a 16 year-old female admitted to the facility on 1t22/09 after numerous failed community placements. She had a history of aggression including threatening staff and private citizens with a knife. She had an unsteady gait and had been undergoing physical therapy three times a week to improve balance, strength, and endurance. Clinical record review for Client 2 revealed she was a 16 year-old female who had been original.ty admitted to the facility in 2006. She had experienced behavioral difficulties that required psychiatric hospitalizations since she was eight years old. tt was documented that she had episodes of intense anger and had attacked peers and staff. On 12/210& Name of Evaluator: Lloyd Biggs HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALII=ORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS tS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000038 State of California - Health and Human Services Agency Department of Public Health 8EC’I’ION 1424 NOTICE Page 2 of 6 CITATION NUMBER: SECTIONS VIOLATED 17-1457-0006840-S Date: 04t19t20t2 Time: CLASS AND NATURE OF VIOLATIONS while on an outing in the community with her court appointed special advocate she disappeared into the local community. She threw a brick through the window of a house to break in and steal a butcher knife. She then entered another house and threatened a female resident with the knife. She had good gross and fine motor skills. She ambulated with a steady gait, had full range of motion of all extremities, could manipulate objects without difficulty and was abfe to ride a two wheel bike. She had objective "’#1 Verbal/Written Threats to Harm Others will decrease to 1 time per month for any 6 months by 12/30/09." Staff Member-L was no longer employed by the facility however, she was interviewed by the Special Investigations unit with her interview was documented in the OPS Investigation Disposition Report. Staff Member L was the acting unit supervisor at the time of the incident. The report specified that Staff member-L reported, "....there are policies on the unit that require the clients are physically checked every 15 minutes. The checks are to be documented on the Q15 report. After the clients are put to bed there is to be a staff member positioned in the girls’ hallway to monitor the clients." She had also stated that it was common practice for staff members to leave the unit two or three minutes early if properly relieved, but not a futl 15 minutes prior to the end of the shift. She believed alf the staff members were aware of the shift expectations. "Nursing procedure: 7.11 Revised Date: 06/08," regarding shift change report specified that, "If residents are not ambulatory or in full view at the time of report, the on-coming Group Leader and the off-going Group Leader shall make rounds and observe all individuals in the group." The PM shift always ended at 11:00 PM and the Nocturnal (NOC) shift began at 10:45 allowing for a 15 minute overlap for shift change report. On 2t22/09, the census on Residence 529 was five clients and each of the three shifts had five’staff members assigned. Review of the Investigation Disposition Report conducted by the Office of Protective Services (OPS) revealed that on the evening of 2/22/09, Staff Member-A stated that she arrived at Residence 529 at approximately 2240 hours (10:40PM. She said at approximately 2250 hours (10:50PM), she went to assist Client 1 ’s roommate no one was monitoring the girl’s hallwa# and the door to the haflway was closed. When she reached their room she found Client 1 unresponsive and she ran to the nurse’s station to tell Staff Member-B to call in a medical emergency. The actual time recorded on the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR ’REVOCATION OF YOUR LICENSE DPH POD 000039 State of California - Health and Human Services Agency Department of Public Hea~th SECTION ~424 NOTICE Page 3 of 6 CITATION NUI~IBER: SECTIONS VIOLATED 174457-0006840-S Date: 04/19/2012 Time: CLASS AND NATURE OF VIOLATIONS code blue documentation sheet of the initial emergency call was 2257 (I 0:57 PM). The facility incident report specified that Client 1 was found unresponsive lying on her back on the floor of her bedroom. She had three blankets placed On her and appeared to be bfeeding from the mouth. There was a t-shirt partially inserted in her mouth and paper inserted in both nostrils. There was also what appeared to be hand lotion covering both eyes. When Staff Member-B entered Client l’s bedroom he began CPR (cardiopulmonary resuscitation) Client 1 was transferred to a local Emergency Room where she was treated and subsequently transferred to a hospital that specialized in pediatrics. It was there that Client 1 expired on 2/23/09 at 5:38 AM. The autopsy report listed the cause of death as anoxic encephalopathy (lack of oxygen to the brain) due to airway obstruction by foreign objects. The manner was listed as Homicide. The autopsy report also specified, "A collection of 7 to 8 superficial puncture wounds is noted on the right mid anterior thoracic wall/right upper medial breast region... Subsequent dissection and exploration reveals a 0.7 cm length of apparent pencil lead embedded within the fatty tissues of the right anterior thoracic wall/breast" When OPS Special investigator-D, working overtime as a patrol officer, responded to the residence on 2-22-09 at 2257 (10:57 PM), Client 2 told him that she had given a note to Staff Member-E allegedly written by Client 1 that said she, Client 1, wanted to commit suicide but Staff Member-E had torn it up. Staff Member-E subsequently told the OPS investigator that she never received such a note from Client 2. Client 2’s involvement in Client 1 ’s homicide was suspected by the facility and she was placed on constant one to one observation. On 2/26/09 Client 2 told a story of how another peer had assaulted Client 1. Then on 3t2t09 at "t2:00 PM, she had a conversation with a staff member that was documented in her interdisciplinary Notes. She stated, "1 don’t feel bad for what ~ did." When asked what she was talking about she said, "On Sunday night." Staff encouraged her to speak with her attorney about it. But she continued. She said she took her pi!low with her to Client l’s bedroom and asked if she could come in and Client 1 said yes. Client 2 said she looked down the hall and saw the hall door was closed and the staff member was knitting outside the door. She stated that she went onto Client l’s room and sat on her bed. She said I have a present for you then put the pillow on Client l’s face and held it NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000040 State of California - Health and Human Services Agency Department of Public Health ,~SECTiON 1424 NOTICE Page 4 of 6 CITATION NUMBER: SECTIONS VIOLATED 17-1457-0006840-S Date: 04/19/2012 Time: CLASS AND NATURE OF VIOLATIONS there for a long time. She then said she got Client t’s radio cord and put it around her neck and choked her with it. She said following that she went to her own room and got a plastic bag then returned and put over Client l’s face and made it really tight. She then said Client 1 wasn’t breathing. Client 2 said she again went to her room and this time got a pencil that she scratched and stabbed Client l’s chest with. She said she then put paper in Client 1 ’s nose and pushed it up with the pencil. She then put a shirt in Client l’s mouth and lotion on her eyes. Following this she covered Client I with blankets. Client l’s only roommate got up and asked if Client 1 w~s sleeping. Client 2 said she told her, "yes" Client 2 said she then heard someone open the door to the girls’ hallway. Client 2 said she hid in the room and when a staff member came in the room she began calling for help and left the room. Client 2 said at that time she went to her own room and then to the bathroom. On 3t4/09, Client 2 was taken into custody by the local police department. The court subsequently made a commitment order to send Client 2 to a secure treatment area of a developmental center when she was deemed incompetent to stand trial. Staff Member-F was no longer employed by the facility however, he was interviewed by the Special investigations unit with his interview was documented in the OPS investigation Disposition Report. He was the PM shift lead personon the 2/22/09, He had five staff members working the PM shift that day. The other working staff members were Staff Members-C, G, I and K. Staff Member-C had been assigned to monitor the girls’ hallway. Staff Member-I had left early at 9:30 PM because he had worked a double shift. When Staff Members-A and B arrived at approximately 10:40 PM, Staff Member-G asked if he could leave because he had worked a 16 hour shift the night before. Staff Member-F told him that he could and he did. When Staff Member-H arrived at around 10:45 PM, Staff Member-C asked if she could leave and Facility Staff Member-F told her she could and she did. Staff Member-F said he left at 10:47 PM, even though he falsified his time as staying until 11:00 PM. The OPS Investigation documented that Staff Member-F stated that,staff are always with the clients during the day so 15 minute rounds are not performed until the clients go to their rooms at 9:00 PM. He said it was at the time that staff members sat at the entrance of the boys’ and girls’ hallways to monitor the clients. He said if the hallway monitors have to do paperwork someone relieves them. When the 15 minute checks were done, the staff member was to get up and actually go look in the rooms. He said the hallway doors were to always remain open. Staff Member-F said rounds were not typically made with the relieving NOC (nocturnal) shift SPT (Senior Psychiatric Technician), because a NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR, SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000041 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 5 of 6 CITATION NUMBER: SECTIONS VIOLATED 17-1457-0006840-S Date: 04t19/2012 Time: CLASS AND NATURE OF VIOLATIONS verbal report was given. He stated that he did know it was policy for the PM shift SPT to complete change of shift rounds with the NOC shift SPT. He also stated that is was a common practice for the PM shift to leave I5 minutes prior to the end of the shift. Staff Member-C was no longer employed by the facility however she was interviewed by the Special Investigations unit and her interview was documented in the OPS Investigation Disposition Report. She said that on 2/22/09 after the girls went to bed, she positioned herself by the open door of the girls’ hallway and did. her charting. After she completed her charting she admitted that she was knitting. She stated that she checked the clients every 15 minutes from 9:00 PM until 10:30 PM. She said that at 10:30 PM, atl the girls were in their beds but were awake, The Q15 sheet indicated that she had checked the clients at 10:45 PM, but she admitted that she did not actually check the girls at 10:45 PM. It was documented that she could not provide a reason for falsifying the Q15 sheet on 2/22/09, and said "it was a mistake." She said she left the unit around 10:45 PM, even though she falsified her time as staying until 11:00 PM. Staff Member-B was interviewed on 7/19/11 at 4:30 PM. Hestate~i that he came to work at approximately 10:40 PM on 2/22/09. The door to the girls’ hallway was closed, which was not normal, and Staff Member-C was standing by the medication/chart room, waiting for.the oncoming shift. He stated that the girls’ ha!lway could not be visualized from Staff Member-C’s vantage point. He said he went to the nurses’ station to sign in and shortly thereafter Staff Member-A came in and said she needed help. Staff Member-A was interviewed on 9/29tl 1 at 11:24 PM. She said she arrived for the NOC shift on 2/22t09 at approximately 10:45 PM shortly after Staff Member-B had arrived. She stated that when she arrived she saw Staff Member-C was standing by the chart room. She said the girl’s hallway could not be visually monitored from that area. She also stated that the door to the girl’s hallway was closed. She said she went to the nurses’ station to sign in and read memos (memorandums). She stated that she did not conduct rounds with Staff Member-F as was facility policy. She said very often the PM shift members would leave early and she usually conducted rounds by hersetf. After she was done in the nurses’ station she said she went straight to Client t’s room to see if her roommate needed assistance. That is when she found Client 1 unresponsive on the floor of her bedroom. When Staff Member-A was asked how a closed hallway door impacted the ability to hear the clients down the hallway, she said, that to her, it was a very substantial noise reduction. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000042 State of California - Health and Human Services Agency Depart.merit of Public Health SECTiO~11424 NOTICE Page 6 of 6 CITATION NUI~BER: SECTIONS VIOLATED 17.1457-0006840-S [bate: 04t19/2012 Time: CLASS AND NATURE OF VIOLATIONS On 7/I2/11 at 11:50 AM, observation of the girls’ hallway door On Residence 529, revealed it was a solid two inches thick with a metal plate up to the door knob on the bedroom hallway .side. The upper portion of the door had wire reinforced glass which was also covered with a sheet of plexi-glass on both sides. It was also observed that while standing at the medication/chart room the girls’ hallway could not be visualized. Therefore the facility’s neglect to provide supervision to prevent or even be aware of Client 2% physical attack on Client 1 presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result or a substantial probability that death or serious physical harm to Client 1 would result. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR lICENSE DPH POD 000043 State of"California - Health and Human Services Agency Depadment of Public Health SECTION 1424 NOTICE Page CITATION NUMBER: 17-2004-0010361-F l of 3 Date: 08/1112014 Time: Type of Visit ’ Complaint lnvestig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Ucensee Name: Address: License Number: Facility Name: Address: Telephone: ¯ Facility Type: Facility ID: SECTIONS VIOLATED Incident/Complaint No.(s) : CA00345915 Department Of Developm#ntal Services 3530.POMONA BLVD 170000772 POMONA, CA 91766 Type of Ownership: State Agency LANTERMAN DEVELOPMENTAL CENTER DIP SNF 3530 Pomona Blvd Pomona, CA 91768 Skilled Nursing Facility 170001774 Capacity: 236 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $16,000,00 DEADLINE FOR COMPLIANCE 8125/14 12:00 a.m, CLASS A CITATION-- DIETARY F309 F309 - Each resident must receive and the facility must provide the necessary care and services tO attain or maintain the highest practicable physical, mental and psychological well-being, in accordance with the comprehensive assessment and plan of care. On 3/14/13 at 9:42 a.m., an unannounced complaint investigation visit was conducted at the facility. The Department determined that the facility failed to provide the necessary care and services required to Resident A when Psychiatric Technician (PT1) failed to provide required line of sight supervision on the morning of 9/2511.1, leaving Resident A unattended. The resident was found unresponsive on 9/25/11 at approximately 9:25 a.m. with bluishtgrey skin color and his tracheostomy tube dislodged. He was pronounced dead by the Medical Officer of the Day (MOD) on 9/25111 at 9:5t a.m. The clinical record for Resident A was reviewed on 3t14/13 at 10:55 a.m. The Individual Program Plan (IPP), dated 8/16!11, indicated that Resident A was a 59 year old male admitted to the facility on 8/17/62 with diggnoses that included profound mental retardation (intellectual disability), epilepsy (seizure), and unspecified chronic obstructive pulmonary disease (lung disease). The resident had a tracheostomy (a surgical opening to the front of the neck to help lhe person breath), performed on 1/12ti0 due to his acute respiratory distress and recurrent pneumonia (lung infection). Name of Evalualor: Manuel Dumangas HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000044 State o{ California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 17-2004-0010361-F Date: 08/11/2014 Time: CLASS AND NATURE OF VIOLATIONS He had no self-help skills, was very dependent and required staff assistance in all activities of daily living. The Summary of Psychological Evaluation conducted by the psychologist dated 7/t 1111, indicated that Resident A had a history of pulling his tracheostomy tube out. The evaluation indicated that Resident A would have line of sight observation (constant visual contact with Resident A) during the AM/PM (morning and afternoon) shift and 1:1 observation from HS (hour of sleep) to 0700 (morning). The Individual Program Plan ( IPP ~ treatment and plan of care of the resident) dated 816/11, under "Team Decision", indicated that the team discussed that the residence Physician discontinued the 1:1 supervision during the HS ( hour of sleep) on 8!11tl 1 and agreed to continue line of sight supervision during waking hours. The team agreed with the Psychologist’s recommendation. Review on 3114/14 of the "Death Review Summary", documented by the Resident Manager (RM) and dated 9/26/11, indicated that on 9/25!11. at approximately 9:25 a.m., PT 1 observed the resident in his room with bluish/gray skin color and his tracheostomy tube dislodged. The Medical Officer of the Day (MOD) pronounced Resident A dead on 9/25/11 at 9:51 a.m. due to cardiorespiratory failure. The Department of Coroner’s Supplemental Report dated 1/4/13 was reviewed on 3t14/13 at 4 p,m. The report indicated the cause of death as asphyxia (suffocation caused by insufficient intake of oxygen) due to dislodgment of indwelling tracheostomy tube. The manner of death was accidental. During an interview with the MOD on 10/12/13 at 2:10 p.m., he stated the line of sight failed during the time of the incident, because the staff left the resident without supervision. He stated, "The outcome could have changed if there’s someone there who could help at once." During interview on 10/17/13 at 10 a.m., the Health Services Specialist (HSS) 1 stated, "1 saw [Resident A] inside the room, hole in the neck, pale, unresponsive, and no pulse at 9:30 a.m,, basically already dead. She stated, "[Resident A] should had not been left by the group leader (referring to PT 1), because he was on line of sight supervision." The monthly Risk Assessment/Care Planning Meeting for Residence 54 was reviewed on 10t21/13 at 10:30 a.m. The monthly Risk Assessment/Care Planning Meeting dated 8t26/11 documented the following plans for Resident A: "...2. Line. of sight observation NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000045 State of’ California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS 17-2004-0010361-F Date: 08/11/2014 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED during the AM and PM shift..," During an interview on 10/24/13 at 2:27 p.m., PT 2 stated, "[Resident A’s] levet of supervision was fine of sight, meaning constant visual contact and unobstructed view of the patient." She stated PT 1 was assigned to conduct the line of sight supervision to Resident A on 9/25/11. She stated PT 1 was in the break room when the tracheostomy tube came out of Resident A. PT :~ stated, "To my knowledge, PT 1 did not let anyone know that she was going to the restroom." PT 2 acknowledged that by not notifying anyone before leaving Resident 1 unattended, PT 1violated the line of sight supervision. The facility’s Policy and Procedure (P&P) titled "Client Services - 226: Client Supervision and Personal Care" dated 6t6/08 indicated, "4. RESPONSIBILITY...4.5 Staff Assigned Responsibility For Any Client..4.5.6 Ensure that adequate supervision is provided whenever leaving clients, keeping in mind the health, physical, and behavioral issues for each client... The facility failed to provide the necessary care and services required when Resident 1, who had a tracheostomy tube, necessary for breathing, and with a known history of pulling out his tracheostomy tube, was left unattended by facility staff on the morning of 9/25/11. Resident 1 was found unresponsive on 9/25/11 at approximately 9:25 a.m. with bluish/grey skin color and his tracheostomy tube dislodged. He was pronounced dead by the Medical Officer of the Day (MOD) on 9125/11 at 9:51 a.m. 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. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000046 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NO’liCE Page 1 of 5 CITATION NUMBER: 17-2004-0010360-S Date: 04/04/2014 Time: Type of Visit ¯ YOU ARE HEREBY FOUND IN VI~3LATION OF APPLICABLE IncidenttCompfaint No.(s) : CA00332312 CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Addres.s: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525( a )(20) Department Of Developmenlal Services 3530 POMONA BLVD 170000772 POMONA, CA 91766 Type of Ownership: State Agency LANTERMAN DEVELOPMENTAL CENTER D!P ICFDD 3530 Pomona Blvd Pomona, CA 91768 (909). 595-1221 Intermediate Care FacilityfDevelopmentally Disabled 170001773 CLASS AND NATURE OF VIOLATIONS Capacity: 716 PENALTY ASSESSMENT $1 ,ooo.0b CLASS B DEADLINE FOR COMPLIANOE 4117/14 12:00 a.m. CITATION -. PATIF--NT RIGHTS 76525 - Clients’ Rights (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to ensure that Client 1 was free from harm by failing to protect Client 1 from sexual abuse when after examination by. the SART Nurse it was determined that Client l’s vaginal laceration was due to sexual assault. Name of Evaluator: Manuel Durnangas HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluater Signalure ’ J Title ¯ NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSI~ DPH POD 000047 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Pag~ 2 of 5 CITATION NUMBER; SECTIONS 17-2004-0010360-S Date: ,04/04/2014 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED The clinical record of Client 1 was reviewed on 11/20/12 at 10;50 a.m. The annual Individual Program Plan (IPP) Narrative dated 9/18/t2, indicated that Client 1 was a 75 year old female who had lived in the faciliiy since childhood. She was admitted with diagnoses that included severe mental retardation, dysphagia (difficulty swallowing), hypothyroidism (low thyroid hormone), paraplegia (paralysis of lower extremities), and cataracts. Client 1 was verbal with limited vocabulary, but able.to understand simple directions and could follow directions. She was able to alert staff of pain or illness with sounds such as moaning, whining, and grunting. She also enjoyed frequent social interactions with others and was able to recognize familiar staff members. She initialed social interaction with staff but disliked being approached by unknown peers. There was no information found in the IPP Narrative that indicated Client 1 would engage in selfqnjurious behaviors. On 11/7/12 at 2:20 p.m., an unannounced visit was made to investigate an entity reported incident of Client t, who was noted to have a genital injury of an unknown origin on 1116tl 2. During an interview with the Director of Quality Assurance (DQA) on 11t7112 at 2:20 p.m., she stated that the client resided in Residence 21. According to the DQA, the client had severe intellectual.disability, non-ambulatory, and used a diaper due to incontinence. During an observation on 11/7/12 at 3:20 p.m. in Residence 21, Client 1 was observed in her bed, located in room 50. Room 50 was shared by Client I and two other clients divided by a partial wall. Client l’s bed was located near the door entrance of the room, while the two other beds for clients were located behind a partial wall separating the space. During a concurrent interview with Client 1, she was unable to respond verbally when asked how she was feeling. Duringan interview with the Residence Manager (RM) of Residence 21on 11/7/12 at 3:40 p.m., he stated that Psychiatric Technician 3 (PT 3) discovered the laceration in the vaginal area of Client 1 while conducting per/heal care on the morning of 11/6/12. PT 3 immediately reported to the Health Service Specialist. Client 1 was examined by the residence physician and determined a possible sexual assault. Client 1 was transferred to the community hospital on 11/6t12, for a sexual assault examination. The RM stated four other female clients in the residence were examined by the residence physician for possible sexual assault and the 13 male clients would be NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000048 State of California - Heatth and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 5 CITATION NUNIBER: SECTIONS 17-2004-0010360-S Date: 04/04!2014 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED examined. The General Event Report dated 11/6/12 was reviewed on 11/20/12. The Level i review indicated, "On 11t6112 [Client l’s name] sustained a laceration to her vaginal felt labia area. The laceration is 1 cm (centimeter) in width and 2 mm (millimeter) deep... Upon changing [Client l’s name], observed dried blood surrounding [Client l’s name] rectal area with a small amount of BM (bowel movement) in her attends (diaper)...staff thought the dried blood was possibly contributed to her hemorrhoids condition...[Client l’s name] was assessed by the HSS and it was stilf determined that the blood was a result of her I~emorrhoids... "Staff commenced to clean the client’s perineal area and at that time it was discovered that the blood was not coming from her hemorrhoids or rectal area, but a cut located at the base of her vaginal left labia area. The residence physician was notified of the injury and through examination and nature of the injury he determined that a possible sexual assault might have occurred .... [Client l’s name] was escorted to [Community Hospital’s name] sexual assault response unit for further examination..." During an interview with the CliP Investigator on 12f20/12 at 1 0:02 a.m., he stated that the investigator at the facility was told by the SART Nurse that it was a sexual assault and they were notified by the facility investigator a day later after the incident. The Sexual Examination Report dated 11t6t12, conducted by the SART Nurse was received and reviewed on 2/7113. The review indicated that Client t had a red hymenal bruise located at a 9 o’clock (clock reference) position, one large laceration with bridging at 6 o’clock in the posterior fourchette (fork-shaped fold of skin at the bottom of the entrance to the vagina), and one purplish bruise to the posterior fourchette at 7 o’clock position. During an interview with the Standard Compliance Coordinator (SCC) on 8/6/13 at 10:15 a.m., she stated that PT 1 passed away in June 2013, due to his medical condition. During an interview with the CliP Investigator on 8/6/13 at 11:05 a.m., he stated that they finally concluded their investigation. The DNA test results came back negative and could nol be linked to any staff investigated. He also stated that even though the DNA test came back negative, it did not mean that Client 1 was not sexually assaulted. During an interview with the SART Nurse on 9/9113 at 2 p.m., she confirmed the findings NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000049 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 5 CITATION NUMBF_R: SECTIONS VIOLATED 17-2004-0010360-S Date: 04/04/2014 Time: CLASS AND NATURE OF VIOLATIONS on the Sexual Examination Report dated 11/6/12. She stated that the injury of Client 1 was consistent with sexual assault. She also stated that the injury was not .consistent with "cleaning her area" because there was a certain degree of force applied to the area. She further stated, "it was some type of blunt force trauma, but I cannot tell what." The Daily Time Record for the morning shift and night shift dated 11/5/t2 was reviewed on 9/9/13. The reviewed confirmed the assignments of staff on 11/5f12 during NOC shift. The review also indicated that PT 1 reported to work in Residence 21 at 2:30 p.m. on 11/5t12 and continued to work until 7 a.m. on 11/6112 for overtime. During another interview with the RM of Residence 21 on 9/9/13 at 12:30 p.m., he stated that Client 1 was on general supervision on 11/5/12 during NOC shift. PT 1 was assigned to Client 1 on the night of 11t5112 and had full access to the client. The CliP "ARREST- INVESTIGATION REPORT" dated 8/8/13, reviewed on 9/13/13 at 11:40 a.m., "Analysis and Qpinion:...Therefore, it is my opinion that the evidence and timeline of events proved that [PT 1] sexually assaulted [Client 1]. This opinion is based upon the fresh injuries sustained to [Client 1], the daily report listing that there were no injuries prior to [PT !] taking care of her, the interview conducted, reviewing the Sexual Assault Report, and reviewing the Forensic Reports. Recommendations: I recommend this report be forwarded to the Pomona District Attorney’s Office for review. Due to the demise of [PT 1], I do not recommend any charges against [PT 1]." PT 1 expired on 6/25113 due to septic shock as an immediate cause of death, according to the Certificate of Death. The facility policy and procedure.titled "Client Services - 227: Alleged Abuse, Neglect or Exploitation" dated 10!26/11, reviewed on 9/25/13 at 4:20 pro. indicated, "1. POLICY ...Any neglect, abuse, or exploitation by any’ person, whether staff, visitor, volunteer, student, family, or other clients, is prohibited .... Training: ...All staff shall receive training to assist in the prevention of abuse, neglect, mistreatment and misappropriation of property as well as client abuse reporting procedures..." The review also indicated, "2. DEFINITIONS - 2.3 Sexual Abuse - Sexual contact that results from threats, or fear, and involving range of activities, including, but not limited to, assault, rape, molestation sexual harassment." The facility failed to ensure that Client I was free from harm by failing to protect her from sexual abuse when after examination by the SART Nurse it was determined that Client l’s vaginal laceration was due to sexual assault. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000050 State o[ California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page ,~ of 5 CITATION NUI~IBER: SECTIONS VIOLATED 17-2004~00!0360~S Date: 04/04/2014 Time: CLASS AND NATURE OF VIOLATIONS These violations had a direct or immediate relationship to the health, safety, or security of patients, NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000051 State of ~alifomia - Health and Human Services Agency Department of Public Health ;~ECTION 1424 NOTICE CITATION NUMBER: Page l of 3 17-1731-0010187-S Date: 03/26/2014 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE lncidenl/Complaint No.(s) : CA00338925, CA00338571 CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type; Facility ID: SECTIONS VIOLATED 76525(a)(20) Department Of Developmental Services 3530 POMONA BLVD 170000772 POMONA, CA 91766 Type of Ownership: State Agency LANTERMAN DEVELOPMENTAL CENTER DIP ICFDD 3530 Pomona Blvd (909) 595-I221 . Pomona, CA 91768 Intermediate Care Facility/Developmentally Disabled Capacity: 716 170001773 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 4/9!14 12:00 a.m. CITATION .- PATIENT CARE 76525 - Clients’-Rights (a)Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The following citation was written as a result of an investigation of ERI #CA338925 and #CA00338571. The Department determined the facility failed to follow procedures listed in Client l’s Individual Program Plan (IPP) that indicated Client1 required an enhanced level of supervision on and off residence, defined as being in the presence of a staff member during waking hours. During record review conducted on 9t18t13 for Client1, it was revealed Client1 was a 51 Name of Evaluator: Helen Williams HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODEI FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000052 State of California - FEeallh and Human Services Agency Department of Public Health ~EOTION "1424 NOTICE Page 2 of 3 CITATION NUI~BER: SECTIONS 17-1731-0010187-S Date: 03/26/2014 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED year old male with diagnoses that included severe intellectual disability, epilepsy, and high cholesterol. He expired on 1/5/13 after being found unresponsive in bed at approximately 4:30 PM. Review of the Crime/Incident Report- Investigative Report completed 7/18tl 3, indicated on 1/5/13 Client 1 returned home and had a snack in the dining room. He finished his snack, and his group leader, Psychiatric Technician X (PTX), accompanied Client 1 to take a shower. At approximately 1630 the shift lead, Psychiatric Technician Y (PTY),entered the group room and saw PTX, but did not see Client 1. Client 1 was on enhanced supervision (defined as to be in presence of a staff member during all waking hours due to self-injurious behavior and elopement). PTX stated Client 1 was lying down in his room. PTY went immediately to Client l’s room and found him lying on his side, his face blue, and with blood and saliva on the pillowcase. Client 1 had no pulse and was moved to the floor where PTX began CPR. PTY called for help, Code Blue and 911 were called. Client 1 was pronounced dead at 5:06 PM. An interview was conducted with the Residence Manager (RM) on 1124/13 at IO:10.AM She staled that on 1/5/13, she was notified of the death of Client 1 and came to the residence. She was informed by PTY, who was the relief charge that day, that when Client 1 returned from a walk, he wanted to lie down. When PTX returned to the to the dayroom after assisting Client I to lie down, PTY informed him that Client 1 wason "enhancement" and was to be monitored at all times. Staff went to the room to check on the client and found him not breathing. Review of statements made to the law enforcement agents who conducted the investigation, indicated PTY was interviewed on 315113. She indicated she was the team leader for the unit on 115!13, and she assigned PTX to care for Client 1. PTY indicated she was aware that Client 1 was on enhanced supervision, and she explained to PTX that Client 1 was not to be out of PTX’s sight. The Office of Protective Services (OPS) investigative Report dated 8/5/13, included documentation of an autopsy completed by the [County Coroner’s office] on 1116113. The autopsy reported the immediate cause of death was listed as Idiopathic Cardiomyopathy and the manner of death was natural. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000053 State of California - Health and Human Services Agency Department of Public Health .~EG’~ION 1424 NOTICE Page 3 of 3 CITATION NU~IBER: SECTIONS 17-1731-0010187-S Date: 03/26/2014 Time: CLASS AND NATUR£ OF VIOLATIONS VIOLATED The OPS investigative Report also documented and concluded: the client’s IPP required enhanced supervision on and off the residence (in the presence of staff during waking hours; PTX did not confirm Client 1 was asleep prior to Ieaving Client 1 unsupervised. PTX admitted that leaving a client alone who was on one to one supervision was neglect. Client 1 was left unsupervised for at least 10 minutes. During this period he became non-responsive and was subsequently pronounced dead. Client 1 would have been undiscovered in this condition if anolher PT [PTY] had not intervened. Review of Approaches and Strategies dated 61"14/12 for Client "1 was conducted on 9;18113. The plan indicated the following: under "Alert/RiskslSafety ]ssues.~Supervision Level: enhanced supervision on and off residence, defined as: to be in the presence of a staff member during all waking hours due to SIB ( Self-Injurious Behavior) and elopement." The facility failed to ensure the supervision level for Client 1 was at an enhanced level during waking hours, resulting in Client I not receiving immediate needed medical attention. This failure had a direct or immediate relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000054 State of C.,alifornia - Health and Human Services Agency Department of Public Health S~ECTION "~424 NOTICE Page.1 of 4 CITATION N UI~1BER: 17-1893-0010153-S Date: 0~/31/2014 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: T61~Sh-on e: Facility Type: Facility ID: SECTIONS¯ Incident/Complaint No.(s) ¯ CA00357474 California Department Of Developmental Services 1600 9TH STREET 170000837 SACRAMENTO, CA 94244-2020 Type of Ownership: PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD 26501 Avenue 140 Portervil!e, CA 93257 Intermediate Care Facility/Developmentally Disabled ¯ 170001878 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $10,000.00 VIOLATED 76525(a)(20) State Agency Capacity: 512 DEADLINE FOR COMPLIANCE 8/14/14 12:00 a.m. CLASS A CITATION -- PATIENT RIGHTS Title 22 76525(a)(20) Clients¯’ Rights (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded tl~e following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. During the investigation of an entity reported event, the facility failed to ensure that clients were.protected from sexual abuse when a mildly intellectually disabled client, with a history of sexual crimes, was placed on a co-ed residence and committed a Sexual crime against a severely intellectually disabled client. The facility also failed to protect female clients on the co-ed residence when they remained on the residence with other male clients who had criminal sexual histories or sexually acting-out behaviors. Allowing the female clients to remain on the residence increased the potential that other incidents of a similar nature could Occur. On 6/11/13, an investigation of an entity reported incident (ERI) was initiated that documented an incident of sexual intercourse between two peers, witnessed by a third Name of Evaluator: Margaret Johnson HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature " Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000055 State of C.,a fornia - Health and Human Services Agency Department of Public Health S*ECTION 1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1893-0010153-S Date: 07/31/2014 Time: CLASS AND NATURE OF VIOLATIONS peer on 5/30/13. The witness did not report the incident until three days later, on 6/2/13, at which time the facility reported the incident to the Department. The initial police report done on 6/2/13, indicated that the sexual intercourse Was "consensual". Upon review of the clients’ medical recordS it was found that Client 1 is male and was diagnosed as being mildly intellectually disabled. He also had a history of previous sexual assault of a developmentally disabled female. Client 2 is female and has a history of having been sexually assaulted when she was a teenager, precipitating her psychosis, and is ’diagnosed as severely intellectually disabled and unable to give consent in any form. Client 1 had been transferred from the Secure Treatment Program of the facility to Unit 26 in the General Treatment Area of the facility on 8/23/12, because it was felt hewould benefit from a less restrictive living situation. At the time of the transfer and up until the incident, Unit 26 was aco-ed unit with three female clients, one of which was Client 1. A review of the Interdisciplinary Notes (IDN’s) for Client 1, dated 5/30/13 at 8:45 PM, indicated he was seen several times walking toward the short hall [where the female clients resided on Residence 26]. Staff redirected himand reminded him of unit rules and planned to continue to monitor him. IDN’s of 6/2/13 at 5:25 PM, indicated that . Client 3 had reported to staff that she had witnessed Client :1 having sex with Client 16 three nights ago. Staff spoke with Client 1 and he admitted to having sex with Client 2. The clients were immediately separated and Client 1 was "guested" on another Unit for the night. A review of Client 2’s Approaches and Strategies dated 11/28/12, indicated that "The client is developmentally incapable of responding appropriately in an emergency . situation and would willingly go with a stranger and would not be able to protect herself in an exploitive situation." A review of the IDN’s for 6/1/13 at 6:15 AM, indicated that that Client 2 was awake on and off throughout the night shift, pacing back and forth to the restroom. Client 2 was redirected back to her room each time. Client 2 has no signs of pain or discomfort noted by staff and that staff indicated they would continue to monitor her. After Client 3 reported the incident to staff on 6/2/13, Client 2 was examined by the Health Services Specialist (HSS) and the physician on duty and no physical Or emotional trauma was noted. In an interview with Client 1 on 6/12/13 at 12:35 PM, he stated that he went to Client 2’s room to check on her as she often wets her bed and he changes it for her. He stated that all the staff were down at the other end of the hall at that time dealing with another client’s behavior. He stated that Client 2 was naked at that timeand she. waved her hand at him to come into her room and told him that she wanted him to "do it to her, real NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000056 State of C, alifornia - Health and Human Services Agency Department of Public Health S~ECTION 1424 NOTICE Page 3 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1893-0010153-S Date: 07/3"~/2014 Time: CLASS AND NATURE OF VIOLATIONS fast". He stated that he then had sex with her. When asked to repeat what happened, he stated that he had sex with Client 2 but she did not say anything. He stated that he knew that he was not supposed to be in the short hall with the female clients. He also stated that he knew he was not ~upposed to have sex with any of the females. He stated that Client 3 saw him having sex with Client 2 and told him to get out of her room. In an interview with Client 2 on 6/12/13 at 1:05 PM, with a familiar staff to her acting as an interpreter, the surveyor attempted to speak with her. When asked if she remembered Client 1, she simply smiled and repeated his name. When she was asked if Client 1 was her friend, she giggled and repeated "friend". When asked if she had had sex with Client 1, she appeared upset and would not say anything more. In an interview with StaffA on 6/19/13 at 12:30 PM, he stated that he didn’t know Client 1 had a history of rape until the client had been on the residence for about 30 days He stated that over the past year most of the female clients had been moved off theresidence and the three who remained were felt to be able to protect themselves. They all required single rooms and there just was no other units available for them. He .stated, "We did the best that we could." He stated that the facility was merging programs atthe time and the other ICF residences were all full. He stated that Client.2 would bite:and scratch anyone who came too close to her so it was felt she could probably handle herself with the male clients. In an interview with Staff I on 6/19/13 at 4:20 PM, shestated that the Team was aware of the disparity of functioning levels on the unit and of the male clients’ sexual histories, but they felt that the female clients would be OK because they were verbal and would be able to yell or tell staff if someone was bothering them. She did acknowledge that it should be the facility’s responsibility to protect the clients, not the clients themselves. She stated that at first the facility police felt that the incident was one of consensual sex but she acknowledged that Client 2’s cognitive and social levels of functioning were s~ch that she could never consent to anything, let alone having sex with someone. She stated that the Team was aware of the disparity of functioning levels on Residence 26 and of the new male clients’ histories of sexual crimes or behaviors, but felt the other clients would be all right with them. In an interview with StaffL on 7/2/13 at 11:05 AM, she stated she was not immediately aware of Client l’s past history with sexual assault but as time went on, she became aware of his past history. She stated that during the time of his transfer, the residence was receiving a number of clients who had sexual behaviors and she had a "heightened NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000057 State ,.of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS VIOLATED 1.7-1893-0010153-S Date: 07/31/2014 Time: CLASS AND NATURE OF VIOLATIONS awareness" of all of the clients on the residence because of this. Client 1 has since been arrested and is in the county jail, awaiting trial. Therefore, the facility failed to ensure that clients were protected from sexual abuse when a mildly intellectually disabled client, with a history of sexual crimes, was placed on a co-ed residence and commi.tted a sexual crime against a severely intellectually disabled client. The facility also failed to protect female clients on the Co-ed residence -when4hey-remained-~n-the~r‘esidence-~w~ith-~ther-ma~e-c~ients-wh~had_cr~imina~sexua~ histories or sexually acting-out behaviors, Allowing the female clients to remain on the residence increased the potential that other incidents of a similar nature could occur. These facility failures presented eitherimminent danger that serious harm would result or a substantial probability that serious physical harm would result. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000058 State o~° California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 4 CITA’[10N NUMBER: 17-1893-0010248-F Date: 04/24/2014 Time: Type of Visit " complaint Investig. Incident/Complaint No.(s) " CA00395676 YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED California Department Of Developmental Services 1600 9TH STREET 170000837 Type of Ownership: State Agency PORTERVlLLE DEVELOPMENTAL CENTER D/P ICFDD 26501 Avenue 140 Porterville, CA 93257 Intermediate Care Facility/Developmentally Disabled Capacity: 512 170001878 CLASS AND NATURE OF VIOLATIONS CLASS .B W331 SACRAMENTO, CA 94244-2020 PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 5/8/14 12:00 a.m. CITATION -- PATIENT CARE 483.460( ) The facility must provide nursing services in accordance with their needs. The facility failed to comply with the above regulation to provide nursing services and supports for three clier~ts with Type 1 Diabetes. The facility failed to ensure insulin was administered in compliance with physician orders and failed to demonstrate competency in medication safety for the use of insulin when three licensed psychiatric technicians (LPT) incorrectly administered insulin to three clients who were hypoglycemic. Administering insulin when hypoglycemic placed Clients 1,2, and 3 at risk forseizures, coma, brain damage and death. The facility failed to ensure health care plans and objectives for daily monitoring of hypoglycemia related to diabetes were implemented for Clients 1 ,. 2 and 3. The facility failed to identify a pattern of insulin medications errors, provide health support services to Clients 1, 2, and 3 and education and training to the LPT’s resulting in a systemic failure of health services and supports for the client with diabetes. According to the National Institute of Diabetes, Diabetes is the condition in which the body does not properly process food for use as energy. Blood glucose .monitoring is a way of testing the concentration of glucose in the blood and allows for quick response to Name of Evaluator: W]thout admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Margaret Johnson HFEN Signature : Name : Evaluator Signature" Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000059 State Qf California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1893-0010248-F Date: 04/24/2014 Time: CLASS AND NATURE OF VIOLATIONS ". low blood sugar (hypoglycemia). In type 1 diabetes, the body does not produce insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. Insulin is administered by a syringe into body fat and used to lower high blood sugar levels in the blood. " Hypoglycemia, also called low blood glucose or low blood sugar, occurs when there is not enough sugar (glucose - food) in the body and blood glucose drops below normal levels, hypoglycemia can happen suddenly and cause confusion, clumsiness and or _fainting:_S.e.ver_e_hypog lycemia_ca nJead_to_seizu r_es,_co m a_a nd_death_Eor_people_with, diabetes, a blood glucose level below 70 mg/dl is considered hypoglycemia. Treatment for hypoglycemia can include consuming 15-20 grams of glucose or simple Carbohydrate foods. ¯ 1. Review of Client l’s record revealed a diagnosis of Type 1 Diabetes for which’the physician prescribed two different types of insulin, Humulin R and Lantus. Humulin R insulin is a short acting insulin and may promptly lower blood, sugars. Lantus is.a long acting insulin for the control of high blood sugars. The physician order indicated Client 1 was t~ receive Humulin R insulin 4 units, 15 minutes before breakfast and lunch, and 6 units 15 minutes before dinner. Lantus.insulin 12 units were ordered to be given at bedtime. Insulin was to be administered except if Client l’s blood sugar was less than 70, then the insulin was to be held or not given and the physician notified. Client l’s medication administration record revealed between 8/21/13 and 10/3/13 on six occasions Client t’s blood sugar was less than 70 (43, 45, 47, 60, 62, 66) and the LPT did not hold the insulin and call the physician. The LPT gave both types of insulin and placed Client 1 at risk for significant harm. Interview on 10/15/13 at 10 AM, with the LPT who administered the insulin incorrectly to Client 1, revealed she thought the physician order was to give the insulin for blood sugar less than 70 and then call the physician. The physician order was to hold or not give the insulin for blood sugar 70 or less and call the physician. Client l’s health care plan and objective for diabetes indicated thdt daily and as needed monitoring for hypoglycemia would be completed. The monitoring included observing, documenting and notifying the physician and registered nurse of symptoms including NOTE: IN ACCORDANCE WITH CALIP-ORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000060 State 04 California - Health dnd Human Services Agency ’ Page 3 of 4 SECTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of PuSlic Health 17-1893-0010248-F Date: 04/24/2014 Time:’ CLASS.AND NATURE OF VIOLATIONS sweating, tremors, pallor, rapid heartbeat, confusion and or nervousness. There was no documented evidence of daily monitoring for hypoglycemia. Interview with the registered nurse, "Health Services Specialist" on 10/17/13 at 1:30 PM confirmed there was no documentation of daily monitoring for symptoms of hypoglycemia for Client 1. There was no evidence of a comprehensive review by the registered nurse, physician or pharmacist of Client l’s prescribed insulin medication regime and medication errors were not identified. 2. Review of Client 2’s record revealed a diagnosis of Type 1 Diabetes for which the physician prescribed Lantus 55 units daily. Client 2’s medication records documented 21 hypoglycemic events from 8/21/13 to 10/14113, ranging from blood sugars of 43 to 68, where the LPT incorrectly administered insulin. On 10/15/13 at 10:59 AM, in an interview with the LPT administering Client 2’s insulin, she indicated incorrectly that Lantus insulin should always be given even with low blood sugar. Client 2’s health care plan and objective for diabetes indicated that daily and as needed monitoring for hypoglycemia would be completed. The monitoring included observing, documenting and notifying the.physician and registered nurse of symptoms including sweating, tremors, pallor, rapid heartbeat, confusion and or nervousness. There was no documented evidence of daily monitoring for hypoglycemia. Interview with the registered nurse, "Health Services Specialist" on 10/17/13 at 1:15 PM c,onfirmed there was no documentation.of daily monitoring for symptoms of hypoglycemia for Client 2. There was no evidence of a comprehensive review by the registered nurse, physician or pharmacist of Client 2’s prescribed insulin medication regime and the medication errors were not identified. ~ 3. Review of Client 3’s record revealed a diagnosis of Type 1 Diabetes for which the physician prescribed Lantus.45 units daily and a sliding scale based on the blood sugar results of Lispro insulin at 8 AM, 12 PM, 5 PM and 8 PM. Lispro is rapid-acting long lasting insulin used to lower high blood glucose. The physician order included instructions to call the physician if the blood sugar was less than 65 or greater than 400. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSlON OR REVOCATION OF YOUR LICENSE DPH POD 000061 State df California -Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1893:0010248-F Date: 04/24/2014 Time: CLASS AND NATURE OF VIOLATIONS Client 3’s medication record documented 36 hypoglycemic episodes from 8/19/13 thru 10/15/13 with blood sugar as low as 20 and several blood sugars in the 30’s ( 30, 32, 34, and 37)~ On average Client 3 was hypoglyc.emic once every 1.6 days (57 days divided by 36 hypoglycemic events). Client 3’s health care plan and objective for diabetes indicated that daily and as needed monitoring for hypoglycemia would be completed. The monitoring included o~serving, documenting and notifying the physician and registered nurse of symptoms including -sweating;-trem~rs~-pa~r~-ra~id~hea~t~eat~e~fusien-and~r-nePveusness~There~was-n~ documented evidence of daily monitoring for hypoglycemia. Interview with the registered nurse, Health Services Specialist A on 10/17/! 3 at 1:30 PM confirmed there was no documentation of daily monitoring for symptoms of hypoglycemia for Client 3. There was no evidence of a comprehensive review by the registered nurse, physician or pharmacistof Client 3’s prescribed insulin medication regime and the medication, errors were not identified. The facilities failure to provide Client 1, 2 and 3 nursing services in accordance with their Type 1 Diabetic needs resulted in a pattern of insulin medication errors placing them at significant risk for seizures, coma, brain damage and death. The facilities failure to identify the insulin medications errors, provide health support services to Clients 1, 2 and 3 and education and training to the licensed psychiatric technicians resulted in a systemic failure of the facility to assure nursing, service and supports were provided. ... These failures had a direct or immediate relationship to the health, safety, or security of clients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION .OR REVOCATION OF YOUR LICENSE DPH POD 000062 State;o~!’California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 4 17-156!-0009596-S CITATION NUMBER: Date: 04/10/2014 Time: Type of Visit : Complaint Investig. Incident/Complaint No.(s) " CA00329459 YOU ARE HEREBY FOUND. IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS California Department Of Developmental Services Licensee Name: Address: 1600 9TH STREET 170000837 License Number: Facility Name: Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER DIP ICFDD 26501 Avenue 140 Address: Telephone: Por:terville,. CA 93257 Intermediate Care Facility/Developmentally Disabled ’ Facility Type: Facility ID: Capacity: 512 170001878 CLASS AND NATURE OF VIOLATIONS SECTIONS VIOLATED 483.450(b)(2) SACRAMENTO, CA 94244-2020 CLASS B PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 4/23/14 12:00 a.m. CITATION-- PATIENT RIGHTS W285 z~83.450(b)(2) Interventions to manage inappropriate client behavior must be employed with sufficient safeguards and supervision to ensure that the safety, well,are, and civil rights of clients are adequately protected. The facility failed to ensure that Client A, a client with;pica (ingesting inedible items) had sufficient supervision to pre~)ent Client A from obtaining and swallowing several, inedible items. These inedible items had the potential to cause harm to Client A’s throat, esophagus (portion between the throat and stomach), stomach and intestines. Review of the clinical record on 10/25/12, noted that Client A, age 43, was admitted on 10/23/80. Current diagnoses include profound intellect disorder and pica. Review of the Interdisciplinary Notes indicated the following documentation: 10/12/2012; 7:00 a.m -7:30 a.m. The client appeared pale and lethargic. Possible x-ray of abdomen dueto PICA problem. 10/12/2012; 10:35 a.m. Per medical doctor, the x-ray of the abdomen was positive for 3 bolts, 1 nail and 1 needle. 10/12/2012; 5:30 p.m. Fecal matter had 3 foreign objects "inconsistent" with the Name of Evaluator: Marion Leatherwood HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name: Evaluator Signature ¯ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000063 State o~ California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1561-0009596-S Date: 04/10/2014 Time: CLASS AND NATURE OF VIOLATIONS consistency of the feces. 10/12/2012; 8:30 p.m. Staff obsewed during the shift that the client defecated (bowel movement)-2 yellowish crayons measuring 2 inches long coupled with folded paper material. 10/14/2012; 2:45 p.m. Client had small bowel movement with part of a crayon box. 4-0/-1.4/20-1-2;-6." O0-p, m._Client_h adJ ar-ge-bowel_mov_ement_with_a_g r_een cr~ayon,_3_cm (centimeters) long, tip oflatex glove and a hexagon nut about 1.5 cm.. 10/17/2012; 6:10 p.m. Client’s fecal matter had a .lip smackerlip gloss tube which measured 6cm long and what appeared like a jelly bean measuring Y2 cm. long. On each of the aforementioned days, it was noted that the client was on one to one supervision. Review of the X-ray relborts noted, the.following results:. 10/12/2012...0paque or metallic foreign bodies in the abdomen consisting of one long needle,approximately 4 cm; few nuts and one short nail and a nut. 10/15/2012...Previously described needle is actually a bobby pin. One of the nuts is actually a coin believed to be a nickel.. The small metallic screw remains. 10/25/2012. There were metallic foreign bodies in the abdomen consisting of a coin, small screw and a nut. The bobby pin had been passed. Review of the Physician Progress Notes dated between 10/12/2012 and 10/25/2012, noted that besides the orders of x-rays, staffs were to observe Client. A for signs of pain, fever and abdominal distention (enlargement of the stomact~). The day shift senior psychiatric technician (Sr. PT 1) stated during an interview on 10/26/1.2 at 8:15 a.m. that Client A had been on 1:1 supervision for a few years due to his severe pica behavior. He stated that he tried to assign consistent staff members to supervise the client. He stated that all staff assigned to the client denied having any knowledge that Client A ingested inedibleitems. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000064 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1561-0009596-S Date: 04/10/2014 Time: CLASS AND NATURE OF VIOLATIONS Sr. PT. 1 stated that the crayon usage was not a part of Client A’s active treatment plan. He stated that only one client, Client B, had access to crayons Which were her personal possessions. He stated that only two clients on the residence, Client C and Client D, who were high functioning clients, had lip gloss as a part of their personal possessions. He stated that Clients B, C, and D were assigned to the same group area as Client A, but were never at the same table with Client A or in the same area as Client A. The client’s room was observed on 10/28/2012 at 8:40 a.m., with Sr. PT1. One screw -was-observed-missing-in-the-flat-pl.ate-latching-area-ofthe-client;s-locker:-S r~-PT-1 stated that the screw had been missing for some time. Shortly thereafter, in the residence clinic room area, in the presence of Sr. PT 1, a plastic lip gloss shaped item with an attach label imprinted "lip smacker"with brownish affixed particles, was observed in a plastic see-through container. Review of the Approaches and Strategies dated 10/1/2012, noted a behavioral alert that Client A had a life-threatening behavior of ingesting non-edible items. It was also noted that Client A was on one to one supeHision during waking hours and on one to two supervision at night. Review of Policy, Facility Bulletin No. 48, Standards of Care, dated November 20.11, noted II. Standards, C. Client Supervison: "The safety and well-being of tt~e Clients is of primary importance. Sufficient staff shall be assigned on duty, and alert at all times to the clients’ needs, to provide client protection and safety". ¯ Review of Program 5 Staff Procedure, Section 1-30, Levels o~: Supervision, dated April 13, 2012: One to One/Constant Supervision are defined as close enough to protect the client and themselves .... The night shift senior psychiatric technician (Sr. PT 2) stated during an interview on 1/11/13 at 6:30 a.m. that prior to this incident, Client A had been on 1:2 supervision for some time. Sr. PT 2 stated that the assigned staff sat in the hallway, between Client A’s room and the room of another client (with pica behavior) which was located directly across the hallway from Client A’s room. Sr. PT 2 stated that none of the staff on the shift had seen Client A exhibit pica behavior.. The evening shift senior psychiatric technician Sr. PT 3, stated during an interview on 1114/13 at 10 p..m. that Client A had been on 1:1 supervision (within arm length reach of NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE . DPH POD 000065 State of.California - Health and Human Services Agency Page 4 of 4 ~ECTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health 17-1561-0009596-S Date: 04/10/2014 Time: CLASS AND NATURE OF VIOLATIONS staff) for a long time. Sr. PT 3 further stated that staff denied seeing the client ingest any inedible items. The facility’s failure to comply with the above requirements by failing to provide sufficient safeguards placed Client A in harm when Client A, a diagnosed pica client, obtained and ingested inedible items. This had the potential of causing harm to Client A’s throat, esophagus, stomach and intestines. -T~heseacti~ns~had-&direc~r~immed!ate~re~ati~nship~t~-the-hea~th~safety-~r~secudty-~f long term care facility patients or residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000066 .State of~California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 1 of 3 ¯ CITATION NUMBER: 17,1893-0009757-S Date: 04/10/2014 Time: Type of Visit" Complaint Invest.ig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Incident/Complaint No.(s) ¯ CA00341668 California Department Of Developmental Services 1600 9TH STREET 170000837 SACRAMENTO, CA 94244-2020 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD Add r_e_s_s :__2650_l_A~euue 1_4_0 Eorte~ville,_CA~.93257 Telephone: Intermediate Care Facility/Developmentally Disabled Facility Type: Facility ID: SECTIONS CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $1,000.00 VIOLATED 76525( a )(20) .Capacity: 512 170001878 CLASS B DEADLINE FOR COMPLIANCE .4/23/14 12:00 a.m. CITATION -- ABUSE/FACILITY NOT SELF REPORTED 76525(a)(20) Clients’ Rights (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and: implement written .policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. 76315(b) Developmental Program Services- Individual Program Plan (b) The individual program plan shall be implemented as written. During the investigation of a reported event the facility failed to: 1 ...Ensure that Client 1 was not neglected when staff failed to properly monitor him while he was using the restroom and the staff member was across the room, by the door. The lack of monitoring necessitated that the staff member used her foot to .try to prevent Client 1 from falling offthe toilet when he bent over to pull up his pants. 2. Ensure that Client l’s individual program plan was implemented when he was not placed on a shower/commode chair with a safety belt during toileting to help him maintain his balance and prevent falls. Client 1 is a 58 year old male who has diagnoses of profound inteilectual disability, right hemiplegia (paralysis of one.half of the body) and stereotypical movement disorder. Name of Ev~luator: Margaret Johnson HFEN Without admitting guilt, I herebyacknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature " Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT. VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000067 State, ofoCalifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1893-0009757-S Date: 04/10/2014 Time: CLASS AND NATURE OF VIOLATIONS According to his individual program plan (IPP) dated 9/4/12, he has profound hearing loss and staff are to use simple sign language and gestures in order to communicate with him. He also requires assistance to complete all of his hygiene and grooming tasks. Client 1 requires assistance with his toilet hygiene needs, washing his hands, ensuring privacy, flushing the toilet and wiping himself. The clien~ had an open health care plan for spastic hemiplegia that included steps for staffto observe for signs of instability, weakness, changes in balance, irritability,.agitation and pain. His activity level was as tolerated but he was to use a wheelchair for moving around the unit and -outside-and-a-shower-chair/commode~chair-with-a-safety-be t-for-bath ng-and4oileting~ A review of the General Event Report (GER) dated 1/29/13 indicated that Staff 1 went to assess Client 1 and found that he was in the restroom. Staff 1 entered the res;[room and observed the client seated on the toilet, trying to pull up his pants. Staff 1 observed Staff 2 kick the client on his right knee. Staff 1 twice told Staff 2 "You do not kick clients[" Staff2 apologized and informed Staff 1 that she thought the client was going to fall. Staff 1 then went out and notified facility staff of the.incident. in an interview with Staff 1 on 2/21/13 at 12:20 PM, he stated that went to Client l’s living area and staff there told him that the client was in the bathrotom. He knocked and:then entered the bathroom and saw that the.client was trying to get up off the toilet. He ¯ observed Staff 2 raise her foot and kick Client 1 on the right knee. He stated that he was shocked and upset and stated to her "You do not do that!" and he repeated this once more. He stated that Client 1 is known to have poor balance and ataxia .(defective muscular coordination) and requires assistance with his activities of daily living (ADL’s). He stated that Staff 2 was.standing by the door to the bathroom, about 4-5 feet away from the toilet; Staff 1 stated .that this would not be the place.to stand if one is concerned about the client’s balance or the client attempting to get off the toilet by himself. He stated, that there was no way that she could have reached him in time if Client "i had started to fall. He stated that he judged the kick to be of moderate intensity but not hard enough to have caused marks or bruising. He stated that Client 1 has a very high tolerance for pain and did not react. He also stated that the client is non-verbal and could not tell anyone what happened. He stated that kicking out with one’s leg is not in any way an acceptable method to prevent a client from getting up from a sitting position or to prevent a fall. In an interview with Staff 2 on 2/27/13 at 11:00 AM, she stated that she had taken care of Client 1 for many years and knew his IPP and health care plans. She stated that on that day Client 1 was not overly active in the group area where he was sitting in his NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000068 ,,State o["California - Health and Human Services Agency Page 3 of 3 SECTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health 17-1893-0009757-S Date: 04/10/2014 Time: CLASS AND NATURE OF VIOLATIONS wheelchair. She stated she took him out of the wheelchair and walked him to the bathroom and sat him on the toilet. She stated that he became more agitated while sitting there. She stated she was standing near the door to the bathroom, monitoring Client 1 but also monitoring what was.happening in the group area. She acknowledged that she was looking away from Client 1 while she was monitoring the group area and that it could take only seconds for someone to fall. She stated that she was about 3-4 feet away from Client 1 when she was standing near the door. She stated that Client 1 was rocking back and forth while on the toilet and suddenly lifted his buttocks offthe _toi_l_e_t,_r_o_ck_ed forward until his head was about one foot above the floor. She thought he was going to fall so she put her foot out to stop him from falling. She stated that when he saw her foot, he sat back up. It was at this time that Staff 1 came in and said something to her about not kicking the client. She acknowledged that she should have been using the shower chair with Client 1 due to his agitation and his high potential for falls but she did not use it on that day. Staff 2 denied that she kicked Client 1 ; however, when she demonstrated to the surveyor what she had done to prevent Client 1 from falling, she inadvertently kicked the surveyor in the shin and did not s4em to notice the kiok. She acknowledged that she had never been taught to prevent a fall by using her leg or foot.to "catch" a client from falling. Staff 2 could not explain why she used that method to try to stop the client from falling. Therefore, the facility failed to: 1. Ensure that Client 1 was not neglected whenstaff did not monitor him continuously while he was in the bathroom and was not in close proximity while he was in an agitated state. 2. Ensure that Client l’s IPPwas implemented when the proper safety equipment, i.e. a shower chair with a safety belt, was not used to help prevent him from getting up off the toilet and potential falls. He also was not closely monitored as stated in his care plans when in an agitated state when staff was standing near the door of the bathroom instead of right next to the client, where they could assist him and control his movements. These facility failures caused or occurred under .circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the client. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000069 Department of Public Health State of California - Health and Human Services Agency Page 1 of 4 "SECTION 1424 NOTICE CITATION NUMBER: 17-i 893-0010246-F Date: 04/10/2014 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 483.410(a)(1) Incident/Complaint No.(s) ¯ No complaints found California Department Of Developmental Services 1600 9TH STREET 170000837 SACRAMENTO, CA 94244-2020 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD 26501-Avenue 140--Po rte rville~-GA-93257 Intermediate Care Facility/Deyelopmentally Disabled Capacity: 512 170001878 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 4/23/14 12:00 a.m. CLASS B CITATION--ADMINISTRATION 483.410 (a).(1) Governing Body The governing must Exercise general policy, budget, and operating direction over the facility. The facility failed to-ensure the governing body exercised direction and developed a plan addressing the cockroach infestation and presence of rodents, met with plant operations, dietetics, housekeeping and infection control committees to develop an action plan consisting of surveillance, prevention, sanitation, trapping and chemical control. These failures meant that there was an effective pest control program was in place. Cockroach infestation and rodent droppings wei’e identified in the central kitchen and three residence satellite kitchens.. On i0/14/13 at 3:30 PM, evidence of cockroach infestation and rodent droppings were observed in the central kitchen. Live and dead cockroaches, cast skins, egg capsules and droppings are evidence of an infestation. A food mixer and a blue foam battery cover contained dark brown cockroach feces and decomposing bodies, resembling coffee grounds. A dead cockroach was found in a clean mixing bowl, three cockroaches were found on a food preparation counter, a dead cockroach was next to a cutting board. Under the food preparation counter, were nine Name of Evaluator: Margaret Johnson HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature " Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTE.Y CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000070 State o[ California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 4 ClTATIONNUMBERi SECTIONS VIOLATED 17-1893-0010246-F Date: 04/10/2014 Time: CLASS AND NATURE OF VIOLATIONS dead cockroaches, one of which had an egg case attached to its abdomen... The dish room and butcher shop walk-in refrigerator revealed more dead cockroaches. The cockroaches were identified as belonging to the German cockroach species. The German cockroach is brown to black with two parallel streaks running from the head to the base of the wings. The German cockroach is particularly associated with restaurants, food processing facilities and nursing homes. -I~lo~t~tSTi~ggl~it~hen brooms and~t~ff~lSttffing~-d~t-Td~6pp~ngs were over a quarter of the floor space. Through-out the central kitchen sanitation concerns were observed contributing to cockroach infestation; pooled standing water, broken floor tiles and unsealed grout around floor tiles were observed. Cockroaches favor hiding spots near food and water and nest in small tight places. On 10/14/t3 at 6 PM, evidence of cockroach infestation was Observed in three of five residence satellite kitchens, with rodent dropping in one. Interview on 10/15/13 at 10 AM with the facility Pest Control Technician (PCT) revealed use of a chemical pesticide (ULD BP300) to spray the kitchen. On 10/15/13 under the dish washing, machine on residence 26 satellite kitchen were ten dead roaches. Water was leaking from the dish washing machine. Food particles floating in the water into the floor drains provided food sources for cockroaches. Bait traps were placed in all residence satellite kitchens on 10115/13 and on 10/16/13; all bait traps showed presence of live and dead roaches. On 10/17/13 at 9AM, Residence 6’s satellite kitchen had a live cockroact~on a wall and three dead cockroaches on a bait trap. Residence 5’s satellite kitchen had live cockroach on a wall and crawling on the floor, three cockroaches were smashed in a door jam and one was in a bait trap. Interview with food service workers on 10/17/13 at 9 AM and 9:30 AM, indicated the. satellite kitchens were sprayed based on a schedule posted on the bulletin board. The posted schedule in each kitchen was dated September 2013 and the food service workers were unaware of the last time the kitchen was treated. Review of the log titled "Pest Control Spray at Main Kitchen and Stores," showed that the PCT "fogged" ( spr~aying insecticides into the air to form a fog) the central kitchen, NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000071 State of California - Health and. Human Services Agency Page 3 of 4 ,.SEC:I’ION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health 17-1893-0010246-F Date: 04/10/2014 Time: CLASS AND NATURE OF VIOLATIONS dietetics, warehouse and docking area in May 2013, July 2013, September 2013 and on 9/27/13, 10/2/13 and 10/9/13. Review of the log titled "Pest Control Trap Locations," showed traps had been placed in the central kitchen, dietetics, warehouse and docking area, although only one mouse trap was observed. On 10/16/13 at 1:30 PM, a review of the chemical pesticide in use by the facility was -eompleted~-The man ufaetu res-reeommendations-and-instructions-attaehed~o-the container, suggested use of the pesticide daily if re-treatment was necessary. The PCT indicated he did not read the. manufacture instructions and was unaware of the recommend frequency for successful abatement of the cockroaches. On 10/17/!,3 at 1 PM, the facility contracted with a (vendor) pest control management company for an inspection. The vendor toured the central kitchen and identified .three different species of cockroach involved in the infestation, and indicated cockroaches develop immunity to pesticides when not used correctly. Interviews conducted beginning. 10/14/13 with dietetic and plant operations, and review of facility documents revealed knowledge of cockroach infestation and presence of rodents for the previous two years. The facility "Vector Control" guideline dated April 2009 indicated, the facility will contract with an outside vendor to provide pest and vector services when necessary, but failed to do so. Review of "Effective Management of Cockroach Infestations" bythe County of Los Angles Vector Management Program, revealed the German cockroach is the most common and reproduces more rapidly than any Other of the cockroach species. The cockroach is believed to be capable of transmitting disease causing organisms such as Staphylococcus, Streptococcus, hepatitis, coliform bacteria, typhoid and dysentery. Center for Disease Control web site indicated that cockroaches transmit bacteria that cause food poisoning and carry salmonella and poliomyelitis virus. Cockroach saliva, feces and decomposing bodies trigger the severity of asthma symptoms. Rodents spread disease thru their urine, feces and fleas. Diseases associated with rodents include plague, typhus, leptospirosis, rickettsial pox and rat-bit fever. The facility’s governing body failed.to exercise direction and develop a plan addressing the cockroach infestation and presence of rodents, failed to meet with plant operations, NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000072 State of California - Health and Human Services Agency Page 4 of 4 ~’SEC~ION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health 17-1893-0010246-F Date: 04/10/2014 Time: CLASS AND NATURE OF VIOLATIONS dietetics, housekeeping and infection control committees to develop an action plan of surveillance, prevention, sanitation, trapping and chemical control. These failures led to an ineffective pest control program in that cockroach infestation and rodent dropping, were identified in the central kitchen and three residence satellite kitchens. These violations had a direct or immediate relationship to the health, safety.or security of individuals residing at the facility. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000073 State of ~alifornia - Health and Human Services Agency Department of Public Health gECTION 1424 NOTICE Page 1 of 5 CITATION NU~,IBER: 17-1040-0009188-S Date: 02/27/2014 Time: Type of Visit - YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR:APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: I el~pphone: Facility Type: Facility ID: SECTIONS VIOLATED 4502 4502( (h Incident/Complaint No.(s) ¯ CA00252924 California Department Of Developmental Services 1600 9TH STREET 170000837 SACRAMENTO, CA 94244z2020 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD 26501 Avenue 140 Portervitle, CA 93257 Intermediate Care Facility/Developmentally Disabled Capacity: 512 170001878 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $10,000.00 DEADLINE FOR COMPLIANCE 3/10/14 12:00 a;m, CLASS A CITATION -- PATIENT RIGHTS Welfare and Institutions Code 4502 (h) 4.502. 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 ~aving 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: 4502 (h) A right to be free from harm, including physical restraint, or isolation excessive medication, abuse, or neglect. 3-he facility did not comply with the above regulation by failing to ensure Client l’s right to be free from harm, abuse and physical restraint. Client 1 was PrOvoked into ar~ argument, pushed face first to the ground, kicked, and choked by Staff A resulting in a loss of consciousness, respiratory failure and cardiac arrest. Respiratory failure is a condition in which not enough oxygen passes from the lungs into blood, heart and brain, and can potentially cause coma and death. When the flow of blood to the heart stops, Name of Evaluator: Candice Bergseth HFEN Without admitting guilt, I hereby acknowledge ¯ receipt of this SECTION 1424 NOTICE Signature : ~ Name " Evaluator Signature ¯ Title " NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000074 State of California - Health and Human Services Agency Department of Public Health S]ECTION 1424 NOTICE Page 2 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1040-0009188-S ¯ Date: 02/27/2014 Time: CLASS AND NATURE OF VIOLATIONS the heart stops beating and Cardiac arrest occurs. Staff B, C, D, E, and F neglected to intervene and protect Client 1 from abuse. Client I required community emergency medical care in the intensive care unit on a ventilator (life support machine that supports breathing) for 11 days. On 12/23/2010, the ventilator was removed and Client 1 was transferred out of ICU, to a medical floor for¯ three days. On 12/26/10, Client 1 was discharged from the community hospital. -Review-ef-the-I ndividual-Prog ram-Plan-dated-3/23/201 ~)~-revealed-Glient 1-was-44-yearold individual with mild mental retardation and an intelligence quota of 61. An IQ of 61 is representative of a cognitive level equal of a 9 or 10 year old child. Client 1 was 5 feet8 inches tall, and weighed 218 pounds. An interdisciplinary note dated 12/8/10 described. Client 1 as polite to peers andstaff, using please and thank you when needed.He/she " had received a gold level (advanced) in the residence reward system and had no documented incidents of physical aggression for the previous six months:.. Review of facility incident reports revealed on the afternoon of 12/11/10, Staff A told. client 1 to stay in the group area located on the residence, however Client 1 went to his/her room and lay down on the bed. Between 3:45 PM and 4 PM, Staff A found Clieni 1 in his room, resting in bed. Staff A demanded he/she return to the group area, provoking an argument with Client 1. During interview on 6/24/2011 at 1 PM, Staff B indicated that while in the group area on 12~11/10, Client 2 and 3 observed StaffA push Client 1 face down to the ground and stated StaffA "stomped Client 1 on the chest and back," with his feet. Hearing screaming in the group area, Staff C, D; E and F ran to the group area and discovered Client 1 struggling on the ground face down with Staff A. Staff B, C, D and E got onto the ground and each held one of Client A’s limbs. StaffA knelt with his.knees onto Client l’s back. StaffA put his arm around Client l’s neck and pulled Client l’s head back. Client 1 screamed, he couldn’t breathe and lost consciousness, urinated, turned grayish blue, and his/her respirations and heart stopped. When Client 1 became unresponsive, Staff C, D, E and F "panicked" and left the group area. Staff B.pushed Staff A off Client 1 and rolled him/her over onto the back, assessed for NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOp, SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000075 State o,,f C~alifornia -Health and Human Services Agency Department of Public Health ~ECTION 1424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1040-0009188-S Date: 02/27/2014 Time: CLASS AND NATURE OF VIOLATIONS breathing and heart rate, finding none; began mouth to mouth resuscitations. Staff A complied with Staff B’s requestto help and did 10 chest compressions then abruptly stood up and said "Fuck Him" referring to Client 1 and refused to assist any further. An alarm had been sounded and other unit personnel began arriving to render emergency aide to Client 1 who was in respiratory and cardiac failure. The facility emergency team arrived and placed the client.on an automated external defibrillation (AED) device at which time he began breathing. An AED is a device that checks to -ensure~the-heart-is~beating. The community emergency medical service arrived at 4:27 PM and Client A was transported to the community hospital via ambulance, where he/she was intubated, and placed on a ventilator (tube into windpipe / throat attached to a machine to push air in and out of lungs). Client 1 was admitted to intensive care unit with diagnoses of acute (sudden) respiratory failure, cardiac arrest.(heart stopped), conjunctiva hemorrhage (ruptured blood; vessels in the eye from choking) and food / vomit pneumonitis, (gagging on vomit and breathing it into the lungs). The community hospital’s records dated 12/11/10 revealed Client I’S right eye was red and had ruptured capillaries in the white part of the eyes (due to choking), both eyelids were swo.llen, and there were abrasions to the right upper arm, right thigh and a bruise to the left upper arm. Facility investigations determined the bruising appeared to be shoe prints. Personnel record review revealed StaffA was a male in his 30’s, who weighed more than 400 pounds and stood 6 feet 3 inches tall, with a histo[y of employee misconduct related.to client abuse allegations occurring on: 11/26/2007, pushed a client tothe ground, 4/1/2008, twisted the arms of a client, 11/21/2009 hit a client on top of the head, 5/3~10 sexual assault of a client. After each of these allegations Staff A was cleared to return to work with developmentally disabled individuals as an unlicensed psychiatric technician / certified nurse assistant. After the assault of Client 1, StaffA immediately conspired with Staff B, Staff C, Staff D, Staff E and Staff F to report and falsify reports that Client 1 spit, struck out and was placed in an emergency wall containment, (holding a client while standing against the wall), lost consciousness because he/she was struggling and was then lowered tothe NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000076 State of C~ alifornia - Health and Human Services Agency Department of Public Health ~ECTION 1424 NOTICE Page 4 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1040-0009188-S Date: 02/27/2014 Time: CLASS AND NATURE OF VIOLATIONS floor. On 1/16/201 t, in an interview with the facility special investigator,. Staff B admitted Staff A assaulted Client 1 and pressured others to lie for him. Staff B indicated in interviews on 6/24/2011, Staff A’s family had called her at home, threatening her to "stick to the story." Client 2 and 3indicated in interview beginning on 7/18/2011 at 2:50 PM, that they were Jn4he-group-area-at-the4ime-of-the incident. Client 1-was-neverJn-a-wall-containment and they saw Client 1 face down on the ground, StaffA kicking him, StaffA’s knees on Client l’s back, and choking him/her. They indicated Client 1 said he/she couldn’t breathe, passed out and pissed on him/herself. Client 2 and 3 indicated Staff B was screaming to get off, get off of Client A. On 6/24/2011 at 12:50 PM in an interview with Client 1, he/she stated StaffA ’beat up on me." In an interview 0n 7/25/2011 at3 PM, with the Staff G, Program Director (manager) she confirmed Client l’s injuries should have not happened during wall containment, Staff A should have let Client 1 pace in the hallway, sounded his alarm and waited for more people. The Program Director indicated the facility Special Investigator either didn’t arrive soon enough or left too soon and "staff had opportunity to get together andwork it all out." On the afternoon of 12/11/2010, Client 1 wanted to smoke a cigarette and StaffA denied him/her a break, Client 1 asked to go to his/her room to lay down and StaffA refused to let him/her relax quietly. Staff A left the group area and Client 1 requested to use the restroom which Staff B granted, however Client i went to his/her room and laid down. Staff A found Client 1 resting quietly on his/her bed and demanded Client 1 return to the group area. Client 1 obeyed and went to the group area where an argument occurred. StaffA then assaulted Client 1; pushed Client 1 face down to the ground, kicked, put his knees onto Client l’s back, his arm around Client l’s neck and pulled his /her head back until Client 1 lost consciousness and went into respiratory and cardiac arrest. The facility failed to ensure Client l’s right to be free from harm,.abuse and physical restraint. Client 1 had been resting quietly on his bed when Staff A provoked him/her into an argument, pushed face first to the ground, kicked, and choked him/her, resulting in NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000077 State of ~alifornia - Health and Human Services Agency Department of Public Health ~ECTION 1424 NOTICE Page 5 of 5 CITATION NUMBER: SECTIONS VIO LATED 17.1040-0009188-S Date: 02/27/2014 Time: CLASS AND NATURE OF VIOLATIONS " Client 1 suffering a loss of consciousness, respiratory failure and cardiac arrest. Staff B, C, D, E, and F neglected to intervene and protect Client 1 from abuse. 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. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000078 State of ..Ca fornia - Health and Human Services Agency Department of Public Health ~ECTION 1424 NOTICE Page 1 of 4 CITATION NUMBER: Date: 03/25/2011 Time: 17-1893-0007180-S Type of Visit" Complaint Investig. Incident/Complaint No,(s) ¯ CA00221743 YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: A-ddress: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76315(b) 76329(a)(4) 76329(a)(6) state Of Calif. Dept. Of Developmental services P. O. BOX 2000 170000837 ~ PORTERVILLE, CA 93258-2000 ¯ Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER DIP ICFDD 26501-A~1-40--PS-rt~ille~C;A-93257 Intermediate Care Facility/Developmentally Disabled 170001878 CLASS AND NATURE OF VIOLATIONS ¯ Capacity~. 512 PENALTY ASSESSMENT $25 000.00 DEADLINE FOR COMPLIANCE 4/11/11 12:00 a.m. CLASS AA CITATION -- PATIENT CARE 76315(b) Developmental Program Services- Individu~! Program Plan (b) The individual program plan shall be implemented ’.as written. ; 76329(a)(4) Developmental Program Services -Application of Restraints (a) In the useof physical restraints, each of the following requirements shall be met: (4) A client placed in restraint shall be checked at least every 30 minutes by program staff to assure that the restraint is properly applied. A record shall be kept of these checks. 76329(a)(6) Developmental Program Services - Application of Restraints (a) In the use of physical restraints, each of the following requirements shall be met: (6) Clients shall be restrained only in an area that is under direct observation of staff and shall be afforded protection from other clients who may be in the area. During the investigation of a reported event it was determined that the facility failed to: 1. Ensure that the client’s individual program plan was implemented when Client 1 was ~laced .in a wheelchair restraint for reasons not documented, without the lap tray being ~laced on the wheelchair that resulted in Client 1 slipping down and strangling on the Name of Evaluator: Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Margaret Johnson HFEN Signature : Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000079 State of,California - Health and Human Services Agency Department of Public Health ~EECTION 1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1893-0007180-S Date: 03/25/2011 Time: CLASS AND NATURE OF VIOLATIONS seatbelt of the wheelchair. 2. Ensure that.Client 1 was checked at least every 30 minutes to assure that the restraint was properly applied. 3. Ensure that Client 1 was under direct supervision of staff while she was in the wheelchair restraint. Client 1 was a 62 year old female who was admitted to the facility with diagnoses of severe mental retardation and psychosis. ~ The client had a history of talking in a loud and shrill voice when she became agitated. She would also flop down on the floor and scream when she was agitated or reluctant to do something. Thesebehaviors also became apparent when she did not get a good night’s sleep orwhen she was bothered by her peers. A review of Client l’s IPP (Individual Program Plan) revealed that she had one behavior plan for reducing episodes of agitation that included the use of a wheelchair with seatbelt and lap tray. The lap tray would further secure the client and prevent the client from sliding down in the wheelchair. The client could be placed in the wheelchair restraint when all other causes of the agitation had been ruled out., the agitation was escalating and the client was a danger to herself. This intervention of a wheelchair restraint with seat belt and lap tray was listed on Client l’s IPP and dated 6/18/09. The Approaches and Strategies revealed that Client 1 .speaks in 1-2 word phrases, but at times speaks too softly to be understood. When the client is agitated, she speaks in a high pitched voice that is difficult to understand. A review of the Interdisciplinary Notes for 3/13/10 at 9:00 PM indicated that the physician’s order was noted for the wheelchair restraint with lap tray for agitation. The order was effective for 12 hours. The notes for 3/14/10 at 2:51 AM indicated that Staff A documented that he was informed by staff of an emergency in the female dorm area. The Client was found to have "slid down in chair, seatbelt was at the neck/chin area." Staff B had removed Client 1 from the chair, placed her on the floor and then informed Staff A: There was no documentation of why the client had been placed in the wheelchair restraint, when she had been placed there or that the client had been observed at any time while in the restraint. In addition, there was no documentation that Client 1 was assessedto determine that she was breathing or had a pulse when she was discovered unresponsive, in the wheelchair. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000080 State of,California - Health and Human Services Agency Department of Public Health ~I=CTION 1424 NOTICE Page 3 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1893-0007180-S Date: 03/25/2011 Time: CLASS AND NATURE OF VIOLATIONS A review ofNursing Procedure No. 2, Potentially Life Threatening Emergencies, dated 7/20/09, indicated that the "person discovering the emergency situation will immediately: Initiate emergency response (i.e.i "Dial 181", CPR...etc)". In an interview with Staff A on 3/19/10 at 1:45 PM, he stated that the client was agitated when he came on duty at i0:30 PM on 3/13/10. He assisted the evening shift staff to put her in the wheelchair restraint with the seat belt. He stated he did not place the lap tray on the wheelchair because he "did not think it was needed." He stated that he placed the client back in her room so "she wouldn’t wake up the rest of the unit." He stated that he then completed unit paperwork and was helping other clients with personal hygiene until about 1:30 AM, when Staff B came and told him about Client 1. (The time discrepancy is due tO the time change to Daylight Savings Time that weekend at 2:00 AM.) He stated that he saw Client 1 on the floor, went back to the tech station to call in the emergency, then returned to the client and started CPR. CPR was not successful. On 3/22/10 review of Facility Bulletin No. 104, Behavior Management, dated March, 2009, indicated that "individuals in restraint must be under continuous visual supervision by staff and must be released from restraint as soon as they are calm..." It also indicated that "nursing staff...will evaluate the efficacy of the procedure as well as health and safety concerns every 55 minutes the individual is in restraint and make a determination as to the apl~ropriateness of continuing the restraint..." In an interview with Staff B on 3/22/10 at 11:20 AM, she stated that she started her shift on 3/13/10 at 11:00 PM. She worked 0n client laundry and audits until about 12:30 AM on 3/14/10. She stated that she had not been told by Staff A that Client 1 was in restraints and she acknowledged that anyone in restraints should have 1:1 supervision. Then she started her rounds on the clients at about 1:30 AM. She provided personal care to two other clients and then entered Client l’s room. When she saw Client 1, she had slid down in the wheelchair, the wheelchair was tipped forward and Client 1 was hanging by the seatbelt around her neck. The lap tray was not on the chair. The client was limp and warm; she called her name and received no response, so she got the client out of the wheelchair and onto the floor. Then she went and got Staff A. An interview was conducted on 3/22/10 at 9:55 AM with Staff C - the physician on call on 3/14/10 and in charge of the resuscitation effort for the client. She stated that CPR was in progress when she arrived. Upon her arrival, Staff A told her that Client 1 was found with her wheelchair tipped forward and the client was caught by the seatbelt around her neck. She stated that the client’s left arm was flexed stiffly, her eyes were .wide open and the pupils were fixed and dilated. She stated that rigor mortis (the stiffness that NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000081 State,of~California - Health and Human Services Agency Department of Public Health ~ECTION 1424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1893-0007180-S Date: 03/25/2011 Time: CLASS AND NATURE OF VIOLATIONS occurs in dead bodies) was already occurring and that rigor mortis happens in about 3-4 hours after death. She stated that there were indentations exactly 4 inches apart on the client’s lower jaw; the measurement of the seatbelt buckle was exactly 4 inches. There were marks on the client’s neck 1 1/2 inches wide, which is the exact width of the seatbelt. Staff C believed the seatbelt and buckle around the client’s neck were ~he cause of the patient’s death. She stated that if the lap tray had been used the client probably would not have been able to slide down in the wheelchair and have the seatbelt up around her neck. A review of the final autopsy report, dated 4/1/10, indicated the cause of death to be positional asphyxia. Therefore, the facility failed to: 1. Ensure that the client’s individual program plan was implemented resulting in strangulation of the client by a wheelchair restraint. 2. Ensure that the client was under direct supervision while in restraints. 3. Ensure that staff checked that the restraints every 30 minutes and were applied properly, allowing the client to slide down in the wheelchair and strangle on the seatbelt and buckle. These facility failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and were a direct proximate cause of death to the client. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000082 State £~f California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 ClTATION.NUI!/1BER: 17-1893-0009453-S Date: 04/02/2014 Time: Type o~Visit Complaint Investig. Incident/Complaint No.(s) " CA00302932 YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES,AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 1424(f)(12) California Department Of Developmental Services 1600 9TH STREET 170000837 SACRAMENTO, CA 94244-2020 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTI~R D/P SNF 26501 Avenue 140 (55g) 782-2222 Skilled Nursing Facility 170001876 Porterville, CA 93257 Capacity: 201 PENALTY ASSESSMENT $2,500.00 CLASS AND NATURE OF VIOLATIONS DEADLINE FOR COMPLIANCE 4114/14 i2:00 a.m. CLASS WMF CITATION -- WMFMR Long-Term Care, Health, Safety and Security Act of i 973 Health and Safety Code 1424(0 (1) Any willful material falsification or willful material omission in the health record of a patient.of a long-term health care facility is a violation. Health and Safety Code 1424(9 (2) "Willful material falsification", as used in this section, means any entry in the patient health care record pertaining to the administration of medications, or treatments ordered for the patient, or pertaining to services for the prevention or treatment of decubitus ulcers or contractures, or pertaining to tests and measurements’ of vital Signs, or notations of input and output of fluids, that was made with the knowledge that the results falsely reflects the condition of the patient or the care or services provided. During .the investigation of a reported event the facility failed to ensure that staff did not willfully falsify a medical record when staff documented that medication had been given on days that the staff had not worked. Review of Resident l’s clinical record on 8/1/12 revealed that Resident I, a 55 year old male, was admitted to the facility with diagnoses of profound intellectual disability and required a gastrostomy tube (a tube implanted through the wall of the abdomen through which feedings may be introduced into the stomach, bypassing oral feedings). Resident Name of Evaluator: Margaret Johnson HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : EvalL~ator Signature " Title " NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000083 State q,f California - Health and Human Services Agency ,Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1893-0009453-S Date: 04/02/2014 Time: CLASS AND NA-iZURE OF VIOLATIONS 1 had chronic vomiting from other gastric problems and Promethazine syrup (a medication used to treat nausea and vomiting) 12..5 milligrams four times per day via gastrostomy tube, had been prescribed on 2/23/12. The medication was inadvertently discontinued on 2/27/12 .and the resident missed 13 doses before the error was discovered. When the error was discovered, the RN who originally received the order verified that the order was still in the computer system and re-transcribed the order onto the Medication Administration Record (MAR), back-dating the order to 2/23/12. Three staff then charted that all of the doses ordered had been given at the correct times, even ~houg h_the_staff_had_been_off d uty_d u rJ ng_som e_o.f_those_d osage_times._ Inan interview with Staff 1 on 8/1112 at 2:25 PM, she stated that she was giving medications on 2/27112 and noted that the Promethazine had been discontinued. She stated ihat she asked Staff 2, the nurse who received the original order, why the medication had been discontinued. Staff 2 checked to make sure the order was still active in the computer system and then re-wrote the order into the MAR.dating it 2/23/12. Staff 2 then asked Staff 1 to sign that she gave the doses on .the previous days. Staff 1 stated she did document a noon dose on a day that she knew she had been on duty and then filled in the other doses. She intended to go back and circle the doses, indicating that the doses had not been given, but forgot to do so. Staff 1 stated she heard Staff 2 tell Staff 3 to also sign for the missing doses. In an interview with Staff 2 on 8/8/12 at 6:45 pM, she stated that she had originally received the order for the Promethazine .for Resident 1 and he was responding very well to the drug. When the medication .was inadvertently discontinued she was very frustrated, checked io make sure that the order was still active in the system, then re-wrote the medication in the MAR and back-dated it to the original, order date. She stated thatshe did document the missing doses, but did not remember if she documented any doses as being given on days that she had not worked. She acknowledged that she had asked Staff 1 to fill in missing doses because she knew Staff 1 had been working on those days.On 8/14/12 at 0930, Staff 3 refused to be interviewed over the phone. In an interview and review of staffing records with Staff4 on 8/14/12 at 9:30 AM, she stated that staff had documented having given doses of Promethazine to Resident 1 on days that they had not been on duty. Staff 4 verified that the signatures and initials on the MAR were Staff 1, 2, and 3’s signatures. She stated that the medication had been discontinued on 2/23/12 but the MAR showed that Staff 1 documented the medication had been given at 12:00 PM on 2/25/12 and 12:00 PM and 6:00 PM on 2/26/12. She NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000084 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1893-0009453-S Date: 04/02/2014 Time: CLASS AND NATURE OF VIOLATIONS stated that Staff 1 was not on duty on those days or at those times, Staff 4 stated that Staff 2 documented that the Promethazine had been given at 12:00 PM and 6:00 PM on 2/24/12 but that she was not On duty o.n that day. Staff4 stated that Staff 3 had documented that she had administered the Promethazine at 6:00 PM on 2/25 but that she was not on duty at that time. A review of the facilities Personal Affidavit by Staff 1, dated 3/1/12, indicated that she did initial the MAR for doses given on 2/25/12and 2/26/12 but.she had not given the doses._A_r_e_v_ie_w o~f_tb_e_Pe(s_o~nal_A_ffid_av_it by-Staff 2 dated 2/28/12 indicated that the medication had been discontinued and she "took it upon myself to continue the order". A review of the Personal Affidavit of staff 3 dated 3/1/12, indicated that she did not give the Promethazine on.2/25/12 as the medication had been discontinued on 2/23/12. On 2/27/12, Staff 2 came to her and "brought me the medication page of client...with Promethazine order for 25th February and I initialed." Therefore, the facility failed to: 1. Ensure that staff only document medications as having been given On the dates and times that they are on duty and do not willfully falsify information on the resident’s medical record. The above facts indicate that there was a willful falsification in the medical record for the resident. NOTE: IN ACCORDANCE WITH CAL!FORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000085 State of California - Health and Human Services Agency Departm.ent of Public Health ~ECTION 1424 NOTICE Page 1 of 5 CITATION NUN1BER: 17-1893-0010955-S Date: 12/09/2014 Time: Type 6f visit : Incident/Complaint No.(s) CA00409095 YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS. Licensee Name: Address: License Number: ¯ Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED California Department Of Developmental Services !600 9TH STREET 170000837 SACRAMENTO, CA 94244-2020 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD (STP) 26501 Avenue 140 . Porterville, CA 93257 (559) 782-2876 Intermediate Care Facility/Developmentally Disabled Capacity: 469 170001877 PENALTY ASSESSMENT $1,000.00 CLASS AND NATURE OF VIOLATIONS DEADLINE FOR COMPLIANCE 12/16/14 12:00 a.m. 76525(a)(20) CLASS B CITATION -- PATIENT RIGHTS 76301(e) REGULATION VIOLATION: Title 22 76301 Required Services and 76525 Client’s: Rights 76301 (e) Client care provided by all team members shall be safe and considerate as ordered or indicated by the needs of the client and in accordance with acceptable standards of practice. AND 76525 (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld’except as provided in (c) of this section. Each facility shall establish and implement written.policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to: 1. Provide safe and effective care as indicated by Client A’s needs when the client was not supervised at a medical appointment by a direct care staff familiar with Client A’s IPP (Individual Program Plan: a written document describing training, supports and activities to be provided for the client as planned for the upcoming year). 2. Ensure that the client was free from harm by failing to ensure that a direct care staff Name of Evaluator: Margaret Johnson HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIEORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR .REVOCATION OF YOUR LICENSE DPH POD 000086 State of Qalifornia - Health and Human Services Agency Department of Publid Health ~ECTION 1424 NOTICE Page 2 of 5 17-1893-0010955-S CITATION NUMBER: SECTIONS VIOLATED " Date: 12/09/2014 Time: CLASS AND NATURE OF VIOLATIONS remained with Client A at his medical appointment. Client A was under the supervision of a facility police officer (a facility staff unfamiliar with the Client’s IPP) when Client A became agitated due to having to wait for his peer’s medical appointment to finish. The facility police officer took Client A down to the g’round when the client became agitated and attempted to leave the facility grounds. Client A sustained a commiriuted fracture (a fracture in which the bone is splintered or crushed) of the right distal (away from midline) clavicle (collar bone). ~Review-~f-~ienLA~s-medical-rec~r~dJndicated~he-has-diagn~ses-~f-mi~d-raenta~ retardation, post-concussion syndrome, bone/cartilage disorder and a comminuted fracture (a fracture in which the bone is splintered or crushed) of the right distal (away from midline) clavicle (collar bone). Complications due to having a fractured clavicle include, nerve trauma to the arm and shoulder, injury to the subclavian vein or artery from a .bony fragment and malunion (growth of fragments of a fractured bone in a faultY position, forming an imperfect.union)(Brunner and Suddarth, Textbook of Medical Surgical Nursing, 1992, p. 1381). Due to a past closed head injury, Client A has short-term memory impairment and has difficulty retaining information. A review of his Individual Program Plan (IPP) dated 6/12/14 indicdted that his supervision needs are 1:1 ratio of staff to client on campus.for medical appointments. The IPP also indicated that the client "has a high pain threshold." A nursing fracture risk assessment was completed on 5/6/14 with results showing that Client A has a moderate risk for fracture. The IPP also indicated that Client A does not like being bossed around and told what to do. He has an open behavior plan for harm to others that is defined as hitting, punching, kicking, pushing, etc.., that he will engage in when he is frustrated or staff is setting limits for him. Client A’s behavior plan indicated that staff are to counsel him if he is becoming agitated or demonstrating behaviors leading to assault. Staff can counsel him to use techniques he has learned in Anger Management classes, ask him what the problem is and help him resolve it. Staff can also instruct him "...about the consequences of acting out in anger... [and] discuss with him alternative ways to deal with his anger, frustration and/or disappointment.,, A review of the General Event’s Report (GER), dated 8/11/14 indicated that on 8/8/14 Client A had an appointment for a chest X-Ray to be done on the facility grounds. While waiting for another peel- and the direct care staff to return from the x-ray room Client A became upset. He left the building and attempted to leave the facility grounds. The Staff 4 who had accompanied him to the appointment attempted to redirect him but the NOTE: iN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000087 State of C, alifornia - Health and Human Services Agency Department of Public Health ,~ECTION 1424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1893-0010955-S Date: 12/09/2014 Time: CEASS AND NATURE OF VIOLATIONS client became upset and aggressive toward the police officer, stating he was going to fight with the police officer. In order to preventthe client from lea~ing the facility grounds and for thesafety of the police officer, the officer physically took Client A to the ground. A review of Client A’s medical record indicated that on 8/11/14, Client A was noted to have a large bruise his right shoulder by the Health Services Specialist RN at 9:10 AM. The bruise measured 1 lx14 centimeters (2.5 centimeters = 1 inch). Client A refused to allow physicians to examine him until 8/13114 at 11:40 AM, when a large bruise was noted, with no swelling to the right shoulder area and only mild pain. At 7:30 PM that same day the physician noted Client A to have bruising to the right shoulder and shoulderblade, with swelling to the area and limited ability to move his shoulder or extend his rigt~t arm in the upright position. The plan was to re-evaluate Client A and possibly order an X-Ray in the.morning. Client A Was seen by a physician on 8/14/14 at 10 AM and a X-ray of his right shoulder, arm and clavicle was ordered. A review of the X-ray report, dated 8/14/14 indicated that the chest X-ray done on 8/8114 was reviewed and "Tt~ere was no fracture i"nvolving either clavicle on the chest examination of 8/8/14. There is now100,000 COLONIES / ML OXACILL]N/METHICILLIN RESISTANT STAPHLOCOCCUS AUREUS’. However, antibiotics to combat this MRSA infection were not ordered on 6/21/07 and there were no documented physician progress related to Client 1 ’s condition on 6t20/07 or 6/21t07. During interview with Physician 1 on 11/8t07 at 11:45 AM he stated that even in light of the lab report he initialed on 6/21/07 that documented MRSA at greater than 100,000 colonies/ml and elevated body temperatures consistently almost without exception since 6116/07, he chose not to treat for MRSA infection at the time. He said he made this decision because the client was otherwise asymptomatic (not exhibiting abdominal pain, painful urination or urinary urgency). This was is spite of the .client’s severe retardation that made the conveyance of these symptoms difficult. Client 1 continued to exhibit elevated temperatures as follows: 6/21t07- 1PM 100.1 Ax (Axillary), 2:50 PM 101.5 Ax, 10:00 PM 99.4 Ax. 6122/07- 10.00 AM 101.6 Ax, 5:30 PM. On 6/22/07 Physician 1 wrote the following antibiotic orders for suspected UTI (urinary tract infection) at 4:38 PM and 4:49 PM respectively, "6/22/07 16:38 LEVOFLOXAClN TABLET TABLET 500 MG ORAL DAILY FOR 7 DAYS. 6/22/07 16:46) TIME(S): 0800 suspected UTI" and "6/22t07 16:38 LEVOFLOXACIN TABLET TABLET 500 MG ORAL DAILY FOR 7 DAYS. 6/22t07 I7:38) TIME(S): 1200 suspected UTI." There was no STAT order for a dose to be given at that time. Consequently, no antibiotics were administered to the client on 6/22/07 because the orders, as written, would start the next day. Additionally, the antibiotic ordered by the physician was not one of the medications listed on the tab results as sensitive (effective) in the treatment of this infection. The culture and sensitivity report initialed by Physician 1 on 6/21/07 clearly specified four different antibiotics that proved sensitive (effective) on this strain of MRSA. Levofloxacin was not one of them. In fact, Levofloxacin was one of three antibiotics that the lab report had listed as resistive (ineffective) to the client’s MRSA infection. On 6t22/07 at 1730 (5:30 PM) Client 1 was transferred from his residential unit to the facility’s hospital. He was subsequently transferred to an outside general acute care NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000271 Stat,e ef California - Health and Human Services Agency Department of’Public Health SECTION 1424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1457-0006835-S Date: 07f08/2010 Time: CLASS AND NATURE OF VIOLATIONS hospital early the next morning. The facility Interdisciplinary Notes documented that the client was admitted to an outside general acute care hospital on 6t23/07 at 0130 (1:30 AM),"for UTt". Client 1’s admitting diagnosis was Sepsis (blood infection) with MRSA. The client expired on 6/23/07 at 8:15AM in the Emergency Room. An autopsy was performed on 6/24/07. Cause of death was documented as "Sepsis with Fndocarditis". Therefore the facility failed to ensure Client 1 ’s right to prompt medical care and treatment when it failed to timely identify and communicate the laboratory results to the physician and promptly provide appropriate medical care for Client l’s urinary tract infection. These failures, jointly and separately, 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 death of the client. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTE¥ CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000272 State of C,alifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 5 CITATION NUI~1BER: 17-1235-0001744-S Date: 04/2412003 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE IncidenttComplaint No.(s) ¯ 170016649 FEDERAL STATUTES AND REGULATIONS State of CA Dept of Developmental Services Licensee Name: Address: 1600 9TH STREET, RM 340 170000771 License Number: Facil;ty Name: Type of Ownership: 2501 Harbor Blvd State Agency Costa Mesa, CA 92626 Skilled Nursing Facility FaciIity Type: Facility ID; Capacity: 396 170001770 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $80,00O.0O VIOLATED 72637(c) 95814 FAIRVIEW DEVELOPMENTAL CENTER D/P SNF Address: Telephone: SECTIONS SACRAMENTO, CA CLASS AA DEADLINE FOR COMPLIANCE 5/12/03 12:00 a,m. CITATION-- PHYSICAL ENVlRONNIENT 72637. General Maintenance. (c) All buildings, fixtures, equipment and spaces shall be maintained in operable condition. On July 8,. 2002, an unannounced visit to the facility was conducted to investigate a facility reported event. Subsequent visits were made to the facility to investigate the complaint further. During the investigation, it was determined that the facility failed to maintain bed rail equipment in operable condition. Patient A 30-year-old female with diagnoses, which include: 1. 2. 3. 4. Profound Mental Retardation, Abnormal Involuntary Movements, Disturbance of Salivary Secretions, and Dysphasia. Review of the facility’s incident report regarding Patient A dated, July 5, 2002, revealed that Staff 1 was making rounds Name of Evaluator: Rosie Soliz Evaluator Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000273 State of CaIifornia - Health and Human Services Agency Department of Public Health ~ECTION 1424 NOTICE Page 2 of 5 CITATION NUI~IBER: SECTIONS VIOLATED 17-1235-0001744-S Date: 0412412003 Time: CLASS AND NATUI~E OF VIOLATIONS at approximately 5:00 a.m. and found Patient A hanging through the space between the side rail and the bed with head on the floor and feet hanging on the bed. No pulse or respiration was detected Cardiopulmonary Resuscitation (CPR) was started. Patient A was pronounced dead at 5:41 a.m. Patient A’s, annual Minimum Data Set (MDS) dated, February 26, 2002, revealed that Patient A was totally dependent on staff for all activities of daily living. The MDS Focus Summary dated February 26, 2002, stated, "...[Patient A] sleeps in an adult bed (adult crib) with high side rails because she moves about freely in the bed. It is recommended to try [Patient A] on a regular bed for age appropriateness and staff will monitor her while on it. She lacks adequate protective reflexes and awareness of surrounding environment." Review of the Individual Program Plan (IPP) Narrative dated February 26, 2002, stated, "[Patient A]... continues to exhibit flailing movements of her upper extremities. She continues to flail her extremities, is able to turn side ways in bed [adult crib] and will reach for the blinds. She also tends to lift herself slightly but falls against the sides of her bed...to prevent her from falling, the bed rail would need to be extended higher. The Unit Supervisor will make arrangements to obtain the bed [regular bed] and initiate trial use of a regular bed." The interdisciplinary notes dated March t3, 2002, at 10:00 a.m. [approximately 2 weeks after the recommendation] documented "...[Patient A] has adjusted well to this bed and no reports of falls were noted." Interview with the Unit Supervisor on October 9, 2002, stated one side rail was adapted with extra railing on one side of the bed to prevent the client from falling out. The other side rail remained unchanged. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000274 State o,f California - Health and Human Seryices Agency Department of Public Health SECTION ’1424 NOTICE Page 3 of 5 C~TATION NUNIBER: SECTIONS VIOLATED 17-1235-000"1744-S Date: 04124f2003 Time: CI~ASS AND NATURE OF VIOLATIONS On November 4, 2002, an observation was conducted of a bed similar to Patient A’s. It was observed that when the head of the bed was raised the adaptive side rail would bend and crack and did not move with the bed. The non-adaptive side rail was observed to have large gaps when the head of the bed was raised. Review of the bed manufacture’s installation instructions for the placement of the side rails obtained by the bed manufacture on October 30, 2002, revealed that the side rails were not applied according to bed manufacture’s printed bed rail installation instructions and recommendations. Further review of the instructions for installation revealed the side rails were to be placed on the fixed portion of the bed frame. (Not the moveable portion of the bed frame.) fnterview with the Maintenance Staff 3 on October 30, 2002, at 11:00 a.m., revealed that he along with the Vendor had decided to apply the side rails in the fashion observed. Interview with Maintenance Staff 3 on October 30, 2002, stated,~’The side rails are constantly being broken and detached." Review of the. Maintenance Logs for Patient A’s unit (total of 32 patient beds) showed side rails were repaired 45 times in the last 12 months. Review of the facility’s Investigation Disposition Report dated, January 15, 2003, documented that Maintenance Staff 3 stated, "...the side rails could be dislodged from the bed frame, allowing the side rail to extend out from the frame of the bed, resulting in a gap measuring approximately four to six inches. (He further stated)...the slide mechanism is sensitive and can be dislodged by the staff pushing or pulling on the side rail to move the bed." The same report documented during an interview with Main{enance Staff 4 that, "there are issues with the side rails. (Maintenance Staff 4 said) when the head of the bed NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000275 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1235-0001744-S Date: O4/24/2003 Time: CLASS AND NATURE OF VIOLATIONS is elevated there is a gap between the bed and the side rails. (He also) said when the side rail is attached to the moveable portion of the bed frame, there is a potential to dislodge the side rail from the bed frame by applying force directly to the exterior of the bed frame..." Review of themaintenance work orders for Patient A’s bed revealed the following: 1. On May 2, 2002 revealed the side rail for Patient A needed to be repair. 2. On May 31,2002 the side rail needed extra guard and pad. 3. On June 2, 2002 side rail needed extra pad. On July 5, 2002, at 6:00 a.m. (approximately 5 months after Patient A was place on regular bed) the interdisciplinary notes documented, "1 went to the pt’s [Patient’s] room to do. pt [Patient] care and found her hanging through the space between the bed and the side-rail on the side next to the window. The head was on the floor and feet on the bed." Review of the Coroners Report dated, September 26, 2002, revealed the Patient A died of Positional Asphyxia [Absent exchange of carbon dioxide on a ventilatory basis]. Review of the pictures taken by the Police Officer on the scene July 5, 2002, showed that PatientA’s side rail attachment was dislodged at the head of the bed. This would allow a gap of approximately 6 inches. interview with Staff 1 regarding tl~e incident that occurred on July. 5, 2002, was conducted on October 9, 2002. During the interview Staff I stated, "f found the resident in the middle of the bed her feet were on the mattress in the middle of the bed and she was between the mattress and the side rail, The head of the bed was up at least thirty NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000276 State o,f California - Health and Human Services Agency Department of Pub}ic Health SECTION 1424 NOTICE Page 5 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1235-0001744-S Date: 04/24/2003 Time: CLASS AND NATURE OF VIOLATIONS degrees." She further stated that Staff 2entered room and detached the side rail at the foot of the bed. Review of the Special investigator Report documented Staff 2 was interviewed on July 8, 2002 and Staff 2 stated, when she removed the side rail from the foot of the bed there was a gap, measuring approximately six inches, between the side rail at the head of (Patient A’s) bed on the side nearest the wall. (she) said there is a spring-loaded mechanism set into the side rail and there was a "glitch" in the mechanism, allowing the side rail to extend away from the frame, leaving a gap. Therefore the facility failed: 1. To maintain side rails in operable condition at all times to ensure the safety of Patient A who was assessed as being at risk for falling out of bed due to spastic movements. The failure of the facility to maintain side rails in operable condition caused Patient A to get caught between the side rails and mattress and die of Positional Asphyxia. This 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 the death of the patient. NOTE: tN ACCORDANCE WiTH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000277 State of California - Health and Human Services Agency Department of Public Health SECTI@N "1424 NOTICE Page 1 of 5 CITATION NUMBER: 17-1242-0001852-S Date: 09108t2004 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Faci;ity Name: Add~/ess: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 72523(a) Incident/Complaint No.(s) : No complaints found State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 170000771 SACRAMENTO, CA 95814 Type of Ownership: State Agency FAIRVIEW DEVELOPMENTAL.CENTER D/P SNF 2501 Harbor Bird Costa Mesa, CA 92626 Skilled Nursing Facility Capacity: 396 170001770 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 9/22/04 12:00 a.m. CITATION -- ADMINISTRATION 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. Based on medical record review and review of the facility’s incident report, the facility failed to ensure that their P&P (policy and procedure) pertaining to supervision of clients was consistently implemented. This failure resulted in Client 1 ’s ingestion and subsequent removal of the foreign objects. On June 24-, 2004, an unannounced visit was conducted to follow-up on the facility reported incident. Client l’s medical record was reviewed. Client 1 was admitted to the facility on September 18, 1984, with diagnoses that included: 1. Profound Mental Retardation. Name of Evaluator: Susan Haupert HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000278 State of California - Health and Human Services Agency Depadment of Public Health SEC3"ION 14.24 NOTICE Page 2 of 5 CITATION NUi~IBER: SECTIONS VIOLATED 17-1242-0001852-S Date: 09/08/2004 Time: CLASS AND NATURE OF VIOLATIONS 2. Congestive Heart Failure. 3. Esophageal Reflux Disorder. 4. Epilepsy. On May 27, 2004, the facility reported an incident that occurred on May 21, 2004. The report indicated that on May 21, 2004, Client 1 underwent an EGD (esophagogastroduodenoscopy) for removal of a foreign body. The foreign body was identified as pieces of a plastic paper cups, measuring 2- cm (centimeter) in diameter and up to 4 X 3.5 cm. in diameter and 0.2-cm. in thickness, round to heart shaped, and triangular pieces of a foam material, ranging from 2-cm in diameter and 0.2 cm. in thickness and paper labels. The January 2004 IPP (individual program plan), referred to the client’s risk of choking and history of, "rule out intestinal obstruction" and aspiration pneumonia. Staff documented that as the client had a gastrostomy tube in place, secondary to weight loss, he would be better managed on a SNF unit on Program Ii. Therefore, Client 1 was transferred to the SNF section of the facility in February 2004. In addition, the IPP included information relating to the client’s behavior of consuming his feces. Staff documented that the client would be continued on "close supervision in the restroom; he is on a line of sight observation elsewhere on the residence and during waking hours." The March 18, 2004 IPP "narrative," listed a "desired outcome" of not ingesting feces or any non-edible objects." The folJowing was further noted, "keep the immediate NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000279 State of California - Health and Human Services Agency Department of Public Health SECTION .1424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1242-0001852-S Date: 09t08/2004 Time: CLASS AND NATURE OF VIOLATIONS environment free of objects/items which could be reached and ingested. Continually scan environment to detect and remove objects, which could be ingested. Observe hands for .presence of objects which could be ingested." Staff will remain within visual.contact during waking hours, during all activities, community outings and class activity..." The following documentation, prior to the client’s hospitalization, was noted. a.) On April 20, 2004 at 6:00 p.m., Client i regurgitated pieces of colored foam. Staff documented that Client 1 spat up 3 pieces of foam during lunch. Staff noted that this was a new problem for Client 1 ,’ as he had previously only ingested feces, not foreign objects. b.) On April 20, 2004 at 4:00 p.m., the physician was notified. A KUB (kidney, ureters, bladder) and abdominal xray were ordered and obtained. c.) On April 30, 2004, the physician documented that the xrays were negative for obstruction. No foam art objects were visualized. However, the physician further documented that during an examination of the client, a "dark brown circular 2 cm. object" was noted within the GT’s residual liquid. d.) On April 30, 2004, staff documented that the client would be monitored for PICA and the area would be kept free of small items that could easily be ingested. e.) On May 1, 2004, a repeat KUB was obtained; the findings were negative. No foreign objects were visualized. f.) On May 19, 2004, staff documented that the client received IV fluids and was kept "NPO," secondary to discovering "coffee ground" GT residuals on May 17, 18 and 19. NOTE: ]N ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS ~S GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000280 State of California - Health and Human Services Agency Department of Public Health SEG,rlON 1424 NOTICE Page 4 of 5 CITATION NUI~IBER: SECTIONS VIOLATED 17-1242-0001852-S Date: 09/08/2004 Time: CLASS AND NATURE OF VIOLATIONS g.) On May 19, the client’s physician documented an "impression" of "G.I. (gastrointestinal) bleed-high gastric residual." h.) On May 19, 2004 at 2:14 p.m., staff documented that the client was transported to the acute care hospital emergency room for evaluation of GI bleeding. An EGD was scheduled for May 2t, 2004. After recovering from the procedure to remove the foreign objects, Client 1 returned to the facility on May 25, 2004. The acute care hospital’s discharge summary, dated May 25, 2004, included the following diagnoses: "foreign body ingestion, large duodenal bulb ulcer, obstruction of the duodenal bulb, duodenal stenosis and severe grade 4. esophagitis." The physician’s discharge instructions included, "extra precautions should be taken so that all non-eatable items are keptout of his reach" On May 26, 2004, Staff 1 documented (on the incident report) that when the client’s foreign body ingestion was discussed with staff members on the client’s unit, the staff members reported that they had observed Client 1 seated next to the arts/craft drawer. The staff further related that Client 1 was noted with scattered pieces of plastic "all over his lap and the floor." Staff documented that Client 1 was then observed vomiting plastic colored art pieces. However, there was no documented evidence of the above observation in the medical record. The facility’s P&P (policy and procedure) pertaining to supervision of clients, described "line of sight supervision" in the following manner, "requires that a staff NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000281 State of Calif.omia - Health and Human Services Agency Department of Public Health SEC,TION 1424 NOTICE Page 5 of 5 CITATION NUMBER: SECTIONS V1OLATED 17~1242-0001852-S Date: 09108/2004 Time: CLASS AND NATURE OF VIOLATIONS member place themselves at a vantage point so they can view the client at all times." Therefore, the facility failed to consistently implement their P&P. This failure contributed to the client’s ingestion of foreign bodies and subsequent hospitalization for removal of the objects. Client 1 was subjected to unnecessary pain and suffering due to the facility staff’s failure to follow the facility’s P&P. The above violation had a direct relationship to patient health, safety, or security. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000282 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 5 CITATION NUMBER: 17-1705-0001873-S Date: 07/13/2005 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORN IA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 7231 l(a)(l)(A) 7231 l(a) (2) 7231 l(a) (3) (C) 72523(a) IncidenttComplaint No.(s) ’ No complaints found State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 170000771 SACRAMENTO, CA 95814 Type of Ownership: Stale Agency FAIRVIEW DEVELOPMENTAL CENTER D/P SNF 2501 Harbor Bird Costa Mesa, CA 92626 Skilled Nursing Facility Capacity: 396 t 7000177O CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 trebled to $3,000.00 DEADLINE FOR COMPLIANCE 7/26/05 12;00 a.m. CITATION -- PATIENT CARE 72311. Nursing Service--General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient’s needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (2) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. (3) Notifying the attending physician promptly of: Name of Evaluator: Linda Davies HFEN Wilhout admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name: Evaluator Signature ¯ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VlOLATfONS IS GROUNDS FQR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000283 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1705-0001873-S Date: 07113/2005 Time: CLASS AND NATURE OF VIOLATIONS (C) An unusual occurrence involving a patient, as defined in Section 72541. 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. On February 1, 2005, an investigation was conducted at this facility in response to a facility-reported event, The results revealed the facility failed: 1. To complete a thorough assessment of Patient A for two days after he sustained a fall with fracture and after the facility had identified he had a history of osteoporosis, 2. To follow policy and procedure, which is to report a fall to the physician in a timely manner, and 3. To follow their policy and procedure for change of condition including falls, which was to complete an investigation in a timely manner. Patient A was admitted to the facility on October 22, 1962. Diagnoses included Prenatal Encephalopathy and Osteoporosis. Review of interdisciplinary notes reveafed Patient A did not indicate pain or discomfort prior to a fall incident.on January 22, 2005. On January 24, 2005, Patient A was diagnosed with a fractured clavicle. Review of the medical record revealed the following documentation: 1. An Interdisciplinary (IDT) note, dated January 22, 2005, at 3:15 p.m., revealed Patient A was ambulating with his mother.in the hallway when he fell. His mother stated he tripped. The nurse documented the patient was found on the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000284 State of California - Health and Human Services Agency ¯ Departmenl of Public Health SECTION 1424 NOTICE Page 3 of 5 CITATION NUI~BER: SECTIONS VIOLATED 17-1705-0001873-S Date: 07/13/2005 Time: CLASS AND NATURE OF VIOLATIONS floor lying on his back. Further documentation .revealed Patient A was assisted to his feet and he walked on his own with no signs and symptoms of injury. Review of his care plan and interdisciplinary notes revealed that there was no evidence that a temporary care plan was initiated after the fall. There was no physical assessment, and no vital signs were obtained, nor was there documentation to show that the physician examined the patient on January 22, 2005, 2. Review of Patient A’s care plans revealed a care plan titled, "Will be free of injury or Fractures," dated July 28, 2004. One of the approaches was to ambulate with supervision. A second care plan dated January 11, 2005, revealed a care plan for swelling of the limb of the right foot. One of the approaches was to provide one to-two person assistance for transfers as needed, to provide supportlguidance and caution during ambulation. 3. Review of facility policy titled, "Documentation in Medical Emergency or Change of Condition," identified a change of condition may include, falls. When there is a change in an individual’s medical/physical condition; the Physician on duty (MOD), RN (registered nurse), HSS (Health Service Specialist), or ACNS (Assistance Coordinator Nursing Service) must be promptly notified by the licensed nursing staff. A full set of individual vitals must be taken. When notified of a change of condition, if the affected system is noL apparent, the RNtHSS/ACNS shall perform a full body system review. 4. Further review of the IDT notes revealed vital signs were taken at 10:00 a.m. on January 22, 2005, identified as related to the diagnosis of hypertension. Further review of the IDT notes revealed the 113-1- failed to document any reference to the fall from January 22, 2005, at 3:15 p.m. until January 24, 2005 at 8:15 a.m., when the nurse noted NOTE: IN ACCORDANCE wITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000285 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1705-0001873~S Date: 07113t2005 Time: CLASS AND NATURE OF VIOLATIONS PatientA had slight discoloration to the left knee 4 cm x 5 cm. The nurse documented the patient was able to ambulate without difficulty. The nurse notified the social worker, the program assistance and the information was placed on the doctors’ log to follow that morning. On January 24, 2005 at 1:30 p.m., a new care plan problem was opened for Unsteady Gait. A diagnosis of contusion to left knee was documented. On January 24, 2005 at 7:00 p.m., the supervisor documented the group leader reported swelling and a bruise to the entire right shoulder and clavicle area. Patient A was unable to raise his right arm. The physician was notified. This was the first time direct contact was made with the physician since his fall on January 22, 2005. The Supervisor documented the probable cause of bruising and swelling to the clavicle was due to the fall on January 22, 2005. Pain was noted; vital signs will be taken. At 8:00 p.m., the supervisor further documented the patient was in bed. He had purple and greenish discoloration on his right shoulder measuring 8 cm x 12 cmo He was exhibiting pain and discomfort with range of motion (ROM). She documented he fed himself using his right hand. He refused to be touched and showed guarding. She notified the MOD (medical on call physician). Documented goals were to do vital signs per protocol, monitor pain and manage, x-ray as .ordered and report to unit MD in the morning. Review of an incident report, dated January 24, 2005, two days after the injury, revealed that the PT (psychiatric technician) documented a body check that showed no visible signs of injury on January 22, 2005. This incident report assessment addressed the knee injury. A second incident report was generated that same day for the fractured clavicle discovered when the nurse was getting Patient A ready for a shower on January 24, 2005 at 7:00 p.m. Record review revealed that Patient A was not thoroughly assessed for injuries twice, once on January 22, 2005 after the initial fall and on January 24, 2005 at 10:00 a.m., when the NOTE: IN ACCORDANCE WITH CALIFORNIA ~IEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000286 State of California - Health and Human Services Agency Department of Public Health SE(~TION "1424 NOTICE Page 5 of 5 CtTATION NUtVlBER: SECTIONS VIOLATED 17-1705~0001873-S Date: 07/13/2005 Time: CLASS AND NATURE OF VIOLATIONS patient was identified with an injured knee. The MOD completed a thorough assessment on January 24, 2005 at 8:00 p.m., ordered an x-ray; Tylenol for pain; a shoulder immobilizer and an orthopedic consult. Final review of the medical record revealed the facility had identified Patient A had a fall on December 22, 2004, he was identified as having an unsteady gait, and the facility had identified he needed supervision or guidance with ambulation due to foot swelling. The facility identified the patient was also to have Osteoporosis. However, the faci]ity failed to ensure he was guided or supervised during ambulation. The facility failed to follow their policy and procedure and assess the Patient from head to toe after an unwitnessed fall. The facility failed to monitor the patient for injuries after a fall and after the facility had identified he had a history of Osteoporosis. Due to these failuresl Patient A sustained an injury and was subjected to unnecessary pain and suffering. The lack of a thorough assessment after the fall, the failure to implement their policy and procedure for investigation of falls, the failure in following their care plan which was to provide supervision with ambulation and the failure in notifying the physician of the fall to obtain diagnosis and treatment in a timelymanner, either jointly, separately, or in any combination had a direct or immediate relationship to Patient A’s health, safety, or security. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000287 State of California - Health and Human Services Agency Department of Public Health Page 1 of 3 ’ SECTION 1424 NOTICE CITATION NUMBER; 17-1324-0001877-S Date: 09t08t2005 Time: Type of Visit ¯ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 72319(g) IncidenttComplaint No,(s) : No complaints found State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 170000771 SACRAMENTO, CA 95814 Type of Ownership: State Agency FAIRVIEW DEVELOPMENTAL CENTER DIP SNF 2501 Harbor Bird Costa Mesa, CA 92626 Skilled Nursing Facility 170001770 Capacity: 396 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 9/t6/05 12:00 a.m. CLASS B CITATION -- PATIENT CARE 72319. Nursing Service--Restraints and Postural Supports. (g) Restraints shall be used in such a way as not to cause physical injury tO the patient and to insure the least possible discomfort to the patient. Based on record review and staff interview, the facility failed to ensure that the care for Resident A, provided by all team members shall be safe and considerate as ordered or indicated by the needs of Resident A and in accordance with acceptable standards of practice. Resident A is a 73-year old female, admitted to the facility on April 14, 1968. Alerts/Safety Issues documentation dated April 22, 2004, describes Resident A as non-verbal and communicates through facial expressions, vocalizations and body movements. The resident is also described with a history of fractures due to falls, abnormal gait, and history of seizures. Resident A sleeps in bed without side rails and utilized Name of Evaluator: Elna Ramos HFEN W]thout admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature ¯ Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000288 State of California - Health and Human Services Agency ’SECTION 1424 NOTICE CITATION NUNIBER: SECTIONS VIOLATED Department of Public Health Page 2 of 3 17-1324-0001877-S Date: 09/08/2005 Time: CLASS AND NATURE OF VIOLATIONS protective waist device per Behavioral Management Committee/Human Rights Committee (BMCtHRC) approval for fall prevention. She is independent with bed mobility, which she is able to turn from side to side freely, and can sit from lying down position even with the waist device on, as tong as the waist device is secured and applied properly to prevent her from falling. On May 24, 2005 at 6:45 a.m., documentation in the IDT notes read, "[Resident A] found on her back on the floor. [Resident A] was put back to bed with assistance from [Staff A review of an investigation report completed by the SPT (Senior Psychiatric Technician) dated May 26, 2005, revealed that the waist belt was incorrectly fastened. The plan of correction for this incident was to discuss to all staff during inter-shift report meeting how to correctly and securely apply the waist belt device to prevent this incident from happening again. The name and signature of Staff A was on the sign-in sheet indicating attendance of the in-service. Another facility investigation report dated June 1, 2005, revealed that on May 30, 2005, Resident A was put to bed at 1:05 p.m., and at 1:20 p.m., fifteen minutes later, she was found on the floor, face down (4 days after the first fall). The laceration on the forehead required four sutures to close it. Facility level I investigation report by SPT, dated June 1, 2005, stated that Staff A could not find a modified belt after washing the resident’s soiled belt. The investigation report further revealed, "[Resident A] wears a waist belt restraint whenever she is in bed. This belt is modified with an extra buckle to prevent her from undoing the waist belt." A health care objectives and plan initiated on April 30, 2005, on Abnormalities of Gait, revealed an objective that NOTE: 1N ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000289 State of California - Health and Human Services Agency Department of Public Health SE~’[ION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1324-0001877-S Date: 09/08t2005 Time: CLASS AND NATURE OF VIOLATIONS Resident A will remain free from injury due to falls. Interventions included the following: "1. [Resident A] sleeps in low bed position with no side rails. She wears a protective waist device. 2. When in bed [Resident A] wears a waist device (extra large) to prevent falls from unsteady gait." On July 15, 2005, during a telephone interview with Staff A, she indicated that at the time of the incident, the resident was using her modified belt. She was unable to explain the discrepancy between her statement and the documentation on the investigation report, which revealed that she (Staff A) had admitted using a regular belt after washing the soiled one, because she could not find a modified waist belt for the client. On the same day during the telePhone interview with SPT, she stated that she wrote what StaffA had said during her investigation. Resident A was subjected to unnecessary harm and pain due to a fall when the waist belt was incorrectly fastened and fell again when a non-modified waist belt was used again. She sustained a laceration to the forehead on the second fall. Four sutures were required to close the laceration. Resident A fell twice within six day period due to the waist belt incorrectly fastened and staffs use of a non-modified waist belt. The violation of these regulations either separately, jointly, or in any combination has a direct or immediate relationship to the health, safety, or security of Resident A. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS iS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000290 State of California - Health and Human Services Agency Department of Public Health Page 1 of 3 .... SECTIbN 1424 NOTICE CITATION NUMBER: 17-1705-0003099-S Date: 07/1312006 Time: Type of:Visit : Complaint Invesf.ig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facitity ID: SECTIONS VIOLATED 72311(a)(1) 72311(a)(2) 72319(c)(2) Incident/Complaint No.(s) ¯ CA00057426 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 170000771 SACRAMENTO, CA 95814 Type of Ownershib: State Agency FAIRVIEW DEVELOPMENTAL CENTER DIP SNF 2501 Harbor Blvd Costa Mesa, CA 92626 Skilled Nursing Facility 170001770 Capacity: 396 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $800.00 CLASS B DEADLINE FOR COMPLIANCE 7120/06 12:00 a.m. CITATION -- PATIENT CARE TITLE 22, 72311 (a)(1)(2) NURSING SERVICE-GENERAL (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least 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. TITLE 22, 72319(k)(2) NURSING SERVICE-Restraints and Postural Supports (k) Postural support means a method other than orthopedic braces used to assist patients to achieve proper body position and balance. Postural supports may only include soft ties, seat belts, spring release trays or cloth vests and shall only be used to improve a patients mobility and independent functioning, to prevent the patient from falling out of bed or chair, or for positioning rather than to restrict movement. (2) Postural supports shall be applied. During an onsite investigation of a self-reported fall the following was identified: Staff failed to follow Client A’s plan of care and. apply postural and safety supports when Client A was placed up in his wheelchair. Client A sustained a fail’with head injury when the wheelchair tipped over. Name of Evaluator: Linda Davies HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name: Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000291 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUI~BER: ¯ SECTIONS VIOLATED 17-1705-0003099-S Date: 07113/2006 Time: CLASS AND NATURE OF VIOLATIONS Client A was admitted to the facility on August 15, 1977. Diagnoses included Profound Mental Retardation, Osteoporosis and Congenital Quadriplegia. The Minimum Data Set (MDS), dated June 20, 2005, revealed Client A had no falls in 180 days. He required two persons to transfer. Review of a MDS, dated September 23, 2004, revealed Client A had no falls and the client was to be transferred with two persons. He was totally dependent for aiI care. A review of Client A’s plan of a care, dated September 23, 2004, titled, Congenital Quadriplegia-Free from Fails, revealed one of the approaches included a two person assist with transfer or mechanical lift used for all transfers between surfaces. Under a care plan titled, Osteoporosis, dated September23, 2004, the care plan identified a Quikie tilt wheelchair, space foam in place with seat belt, foot bucket and tray as tolerated. "Two person assist or use of mechanical lift for all transfers between surfaces. Provide caution and support during all transfers and repositioning." Review of an interdisciplinary note, dated August 2, 2005 at 7:15 a.m., revealed a Psychiatric Technician Assistant (PTA) staff person was transferring Client A from bed to wheelchair with a mechanical lift and after the client was positioned in his wheelchair, the mechanical lift got stuck. The staff member could not get the client out and when she tried to push the wheelchair away from the lift, the client tipped over on his side and sustained a 2 centimeter laceration to the right side of his forehead. Pressure was applied to stop the bleeding. The physician was notified, examined the patient and applied two sutures to close the laceration. Neurological checks were initiated and completed. Review of the facility Incident report (SIR), dated August 2, 2005, revealed Client A was unable to voice what happened. Review of the SIR revealed documentation that the staff member had not placed the seat belt on Client A after she transferred him to the wheelchair. The SIR further identified the seat belt and padded tray had not been placed on the client before the fall incident. The Nursing coordinator from the clients’ unit was interviewed at 9:15 a.m. on August 9, 2005. She stated that two person transfer was used only when staff were not using the mechanical lift. She further stated the PTA failed to apply the postural supports on Client A before she attempted to move him and that he and the wheelchair fell over. She stated the facility was using the ARJO mechanical lift. The facility failed to ensure their staff followed Client A’s care plan for application of NOTE: tN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000292 State of California - Health and Human Services Agency Deparlment of Public Health SECTION t424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1705-0003099-S Date: 07/13/2006 Time: CLASS AND NATURE OF VIOLATIONS safety devices for postural support after placing him in his wheelchair in order to protect Client A from injury. The failure of the facility to ensure Client A had his safety devices placed before he fell either jointly, separately, or in any combination had a direct or immediate relationship to the health, safety or security of Iong4erm facility patients or residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000293 State of’ California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE CITATION NUI~IBER: Page 1 of 4 17-1354-0001704-S Date: 08/15/2002 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL S-i-ATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone~ Facility Type: Facility ID: SECTIONS VIOLATED 76315(b) 76525(a)(20) tncidentJComplaint No.(s) " 170016451 Department Of Developmental Services 3530 POMONA BLVD 170000772 POMONA, CA 91766 State Agency Type of Ownership: LANTERMAN DEVELOPMENTAL CENTER DIP ICFDD 3530 Pomona Bird Pomona, CA 91768 (909) 595-1221 lntermed;ate Care FacilitytDevelopmentally Disabled 170001773 CLASS AND NATURE OF VIOLATIONS . Capacity: 716 PENALTY ASSESSMENT $10,000.00 trebled to $30,000,00 DEADLINE FOR COMPLIANCE 8t28/02 12:00 a.m. CLASS A CITATION -- PATIENT RIGHTS 76315. Developmental Program Services--Individual Program Plan. (b) The individual program plan shall be implemented as .written, 76525. Clients’ Rights. (a) Each client has the rights listed .in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. An unannounced investigation visit to the facility was conducted on March 18, 2002, in response to a special incident received on March 18, 2002. The results showed Name of Evatuator: Lea Ann Reseigne Evaluator Without admitting guilt, I hereby acknowledge receipt of this SECTION t424 NOTICE Signature : Name ; Evaluator Signature ¯ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000294 State of California - Health and Human Services Agency SECTION I424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health Page 2 of 4 I7-1354-0001704-S Date: 08f15/2002 Time: CLASS AND NATURE OF VIOLATIONS that the facility failed to implement the individual program plan as written and ensure that the clients are free from harm including abuse or neglect. Client A, a 4I year old male was admitted on October 16, 1979, with diagnoses of Profound Mental Retardation and Osteopetrosis, Review of Client A’s medical record revealed an "Approaches and Strategies" report dated October 23, 2001, the "Alerts" section stated "Prone to fractures due to Osteopetrosis, pressure sores, and harm to self: Never use soft ties as form of emergency restraint due to fracture risk. While in his wheelchair no safety awareness when off the residence (Will roll down ramps.)" The "Behavioral Considerations" section stated, "He requires direct visual supervision." On March 18, 2002, a review of the incident report dated March 13, 2002, at 9:35 a.m. stated "...while escorting to DTAC (DayTreatment Activity Center) out the patio door, the door was left open. [Client A] was at the door as the student approached the door with his assigned client. It was reported that [Client A] wheeled himself down the ramp and ran his chair into the bicycle. The chair and [Client A] tipped over..." The Individual Program Plan, dated October 23, 2001, stated "(Client A) has no safety awareness, his level of supervision is considered general at this time, unless otherwise warranted according to his needs and conditions." The Individual Program Plan described Client A as able to self propel a wheel chair and ambulate with assistance, utilizing a front wheel push walker. On April 4, 2002, an interview was conducted with Staff 1 who witnessed the incident. Staff 1 stated "1 was just approaching the patio door while pushing [Client B] in a wheel chair, when [Staff 2] offered to open the patio door NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000295 State of California - Health and Human Services Agency Department of Public Health SEC’I:ION 1424 NOTICE Pag6 3 of 4 CITATION NUt~RER: SECTIONS VIOLATED 17-1354-0001704-S Date: 08t15t2002 Time: CLASS AND NATURE OF VIOLATIONS for me. [CIient A] was near the door when [Staff 2] opened the door and propped it open with something, then [Staff 2] walked down the ramp to the bottom. [Client A] then wheeled himself out the door as [Staff 2’s] back was turned, he began down the ramp and ran into the tandem bikes and tipped over." An interview was conducted with Staff 2 on May 23, 2002. Staff 2 stated she was visiting Unit 317 to provide respiratory treatments to some clients..She stated she did not usually work on Unit 317 and was not familiar with Client A. Staff 2 stated ’1 was about to leave the unit when a young man [Staff 1], who was pushing a client in a wheel chair, asked me to ieave the door open for him because he did not have any keys." Staff 2 stated she ]eft the door open for him, and walked down the ramp toward the fence of the patio, to leave the patio area, when she heard a "terrible noise, like something heavy tumbling". She then turned and saw Client A on the ground in the wheel chair. Staff 2 stated Client A "looked startled and scared" and his "eyes were big". On April 4, 2002, an interview conducted with Staff 3, (supervisor on duty the day of the incident), revealed Client A had exhibited signs of agitation between 8:30 a.m. and 9:00 a.m. on March 13, 2002, (just prior to the fall " down the ramp). She indicated that Staff 2 was probably not aware of Client A’s agitation, and was not familiar with Unit 317’s escorting process. Staff 3 stated, "When clients are going to DTAC they [clients] are always escorted up and down the ramp, and when the patio door is open a staff person would stay at the door." An x-ray report dated March 13, 2002, revealed Client A’s left arm had sustained a "vertical (upright) fracture involving the proximal (closer to the point of attachment) ulna (the larger of the two bones in the forearm) 4 cm (centimeters) from its proximal extent. The fracture NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000296 State or California - Health and Human Services Agency ’ SECTION 1424 NOTICE CITATION NUh’IBER: SECTIONS VIOLATED Department of Public Health Page 4 of 4 17-1354-0001704-S Date: 08t15/2002 Time: CLASS AND NATURE OF VIOLATIONS extends into the ulnar articular (joint) surface." A referral was made to an orthopedic surgeon and a cast was applied. Client A was observed on April 4, 2002, with a cast to his left arm spanning from the middle of his upper arm to his wrist. During an interview with Staff 4 on April 4, 2002, at 11:38 a.m., she stated that since the cast was placed on Client A’s arm, he is not able to ambulate with his walker. Client A, who was identified with no safety awareness while in his wheel chair, and a history of roiling down ramps, sustained a fracture of the left proximal ulna, extending into the ulnar articular surface. Therefore, the facility failed to implement the individual program plan as written and failed to ensure Client A was free from harm. The failure of the facility to implement the individual program plan as written and ensure Client A was free from harm, caused Client A unnecessary pain and a loss of the use of his left arm, resulting in the inability of Client A to ambulate with his walker. The violation of the above regulation, either jointly, separately, or in any combination presented an imminent danger that death or serious physical harm would result. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS 1S GROUNDS FOR SUSPENSION OR REVOCATION OI= YOUR LICENSE DPH POD 000297 State of California - Health and Human Services Agency Department of Public Health SECTION t.424 NOTICE " Page t of 4 CITATION NUMBER: 17-1235-0001694-S Date: 04/03/2002 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility SECTIONS VIOLATED 76525(a)(20) lncidenttComplaint No.(s) : 170016329 Dep,~rtment Of Developmental Services 3530 POMONA BLVD 170000772 POMONA, CA 91766 State Agency Type of Ownership: LANTERMAN DEVELOPMENTAL CENTER DIP ICFDD 3530 Pomona Bird Pomona, CA 91768 (909) 595-1221 Intermediate Care Facility/Devefopmentally Disabled Capacity: 716 170001773 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $8oo.oo CLASS B DEADLINE FOR COM PLIANCE 1/23/02 12:00 a.m. CITATION .. PATIENT RIGHT8 76525. Clients’ Rights. (a) Each client has the rights listedin (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect, On November 11, 2001, an unannounced visit to the facility was conducted to investigate a facility reported event. Subsequent unannounced visits were made to the facility to further investigate the complaint. During the investigation, it was found that the facility staff failed to ensure Client "B" and all other clients to remain free from harm and abuse. Client "A", a female, 29 years of age, was admitted to the Name of Evaluator: Rosie Soliz Evaluator Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000298 State of California - Health and Human Services Agency Department of Public Health SEOrlON 1424 NOTICE Page 2 of 4 CITATION NUhlBER: SECTIONS VIOLATED t7-1235-0001694-S Date: 01/03/2002 Time: CLASS AND NATURE OF VIOLATIONS facility with diagnoses, which included, Profound Mental Retardation and Bipolar Disorder. The client was receiving the following medications: Olanzapine (antipsychotic. medication) for symptoms of mood disorder and Zoloft (antidepressant). Review of the Comprehensive Psychological Evaluation dated November 20,200:1, stated the client was ambulatory, has good gross and fine motor skills, and had self-injuries behavior and aggressive behaviors. Review of the Interdisciplinary (IDT) notes for the month of October revealed Client "A’s" self-abusive behaviors had decreased, however, there was an increase of aggressive behavior toward others. On October 18, 2001, a new behavioral plan for aggression was instituted. The plan would be to reduce physical aggression (grabbing others and pulls them down, or out of chairs, hits, kicks, pulis hair and bites others) to 15 times per month for 3 consecutive months. The training methods included: a) Staff to intervene to prevent injury; b) To redirect her and; c) Staff will continue to ensure that she does not injure herselfor others. Further review of Client "A’s", IDT notes, documented a late entry on October 27, 2001, "Aggressed upon Client "B" during escort to breakfast." On November 29, 2001, at 11:00 a.m., an interview with the Staff #1 caring for Client "B" on the day of the incident was conducted. Staff #1 stated, she was caring for Client "B" on October 26, 2001, and while assisting with Client "B’s" ambulation to the lunch area, Client ,A" came out of the lunch area unsupervised and pulled Client "B’s" hair, Client "B" fell to the ground landing on her right hand. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000299 State of California - Health and Human Services Agency Department of Public Health SE(~T~0N ’1424 NOTICE Page 3 of 4 CITATION NUI~IBER: SECTIONS VIOLATED 17-1235-0001694-S Date: 01t03t2002 Time: CLASS AND NATURE OF VIOLATIONS On October 27, 2001, an X-ray was taken of Client "B’s" hand and revealed an, "Undisplaced Fracture Proximal Phalanx 5th finger". Review of Client "B’s" Individual Program Plan dated, November, 27, 2001, documented, "On October 26, 2001, Client "B’s" ...injury occurred as a result of a fall to the floor when aggressed upon by a peer." Further review of Client "A’s" medical record revealed that the client had at least two more incidence of aggression toward others after the October incident. Review of the IDT notes revealed the following documentation: a) November 18, 2001, at 2:20 p.m., "Uncooperative this a.m. wants to sleep or be in wheelchair and pinching group leader (Staff #2) and hitting people with wheelchair." b) November 19, 2001, "Was in...classroom and pulled (Client C) down on the floor with client hitting I~er buttock." Client "A" was observed on December 13, 2001, at 12:20 p,m,, in the residence, wandering hallways unsupervised. Review of the medical record revealed no changes in behavioral plan. The data collection sheet for the month of November documented at least 100 incidence of physical aggression. Further review of the data collection sheet (for the month of December) documented the client had physical aggressive behavior 62 times in the last 11 days. Interview with the Individual Program Coordinator on December 13, 2001, confirmed there had been no changes in the client’s behavioral plan since October 2001. The continued aggressive behavior by Client "A" subjected Client "B" to sustain a fractured finger, and the failure of NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000300 State of California - Health and Human Services Agency . SECTION t424 NOTICE CITATION NUN1BER: SECTIONS VIOLATED Department of Pubtic Health Page 4 of 4 17-1235-0001694-S Date: 01/03/2002 Time; CLASS AND NATURE OF VIOLATIONS the facility to promptly act to prevent Client "A" from continued harm to others, exposed other clients to harm. Therefore the facility failed: To ensure that Client "B" and all other clients be free from harm and abuse. The above violation jointly, separately, or in any combination had a direct or immediate relation to patient health, safety, or security. NOTE: IN ACCORDANCE WITH CAL:IFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS iS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000301 State of California - Health and Human Services Agency Department of Public Health 3ECTION 1424 NOTICE Page 1 of 4 CITATION NUMBER: 17-1220-0001705-S Date: 09/09/2002 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORN IA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) IncidentfComplaint No.(s) " 170016598 Department Of Developmental Services 3530 POMONA BLVD POMONA, CA 91766 170000772 Type of Ownership: State Agency LANTERMAN DEVELOPMENTAL CENTER DIP ICFDD 3530 Pomona Bird Pomona, CA 91768 (909) 595~1221 Intermediate Care FacilitytDevelopmentally Disabled Capacity: 716 170001773 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $800.00 trebled to $2,400.00 DEADLINE FOR COMPLIANCE 9123102 12:00 a.m. CITATION -- PATIENT CARE 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. On June 17, 2002 an unannounced visit was made tothe facility to investigate a facility reported unusual occurrence. Subsequent unannounced visits were made to the facility on June 28, 2002; July 10, 2002, and July 17, 2002. The results showed that the facility failed to ensure that Client A was free from harm. Client "A", a male 47 years of age, was admitted to the Name of Evaluator: Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Naomi Russell HFEN Signature : Name : Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEAL’I’H AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000302 State of California - Hgalth and Human Services Agency DePartment of Public Health SECTION 1424 NOTICE Page 2 of 4 CITATION NUI~IBER: SECTIONS VIOLATED 17-1220-0001705-S Date: 09t09f2002 Time: CLASS AND NATURE OF VIOLATIONS facility on April 6, 1962, with a diagnosis of Profound Mental Retardation. He requires staff assistance to complete all activities of daily living and is incontinent, which requires wearing an adult diaper at all times. Review of the Interdisciplinary Notes (IDN) dated June 4, 2002, at 8:15 p.m., it was documented, "During showers staff note client had laceration around shaft of penis, laceration appeared to require sutures due to length and width. ACNS [Acute Nursing Services] notified @ 0815 [8:15 a.m.] area. cleaned with soap & water, client appeared to experience pain on scale of 2-3 touched. Sutures (15) applied." Review of the RN/HSS (Registered Nurse/Heath Support Services) report dated July 2, 2002, which stated, "On 6-5-02 1 observed a 3/4 [inches] semi-circular laceration on the shaft of [Client A’s] penis, there was also a 1t4 " laceration (between the larger laceration and the tip of the penis). The larger laceration had fourteen sutures intact, the smaller laceration had one suture intact. The wound appeared recent, with the wound edges being clean and dry and no evidence of healing at the wound ends." Review of the Physician’s progress notes dated June 4, 2002 at 9:30 p.m., documented "Called to see the resident because of laceration on his penis. Staff reports this laceration while giving shower; the resident is alert, not in any distress, nonverbal, no other signs/symptoms. There are 2 lacerations on penis. 1. Small laceration yery close to his gland that required 1 stitch. 2. A circumference laceration with minimum bleeding that required 14 stitches to ciose." On July 10, 2002, at approximately 10:00 a.m., an interview was held with Staff 3, who stated that he had Client "A’s" NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000303 State of California - Health and Human Services Agency Department of Public Health ,SECTION 1424 NOTICE Page 3 of 4 CITATION NUMBER: SECTIONS 17-1220-0001705-S Date: 09/09/2002 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED group on June 4, 2002, on a.m. shift. Staff 3 stated that he did not see any injuries to Client A’s penis during his shift. He had changed Client A’s diaper from behind, while Client A was standing with his hands on the wall to keep himself steady. Staff 3 further stated that he had changed the client’s diaper twice during his shift. When Staff 3 was asked if he would have noticed an injury to Client "A" from behind, he stated, "maybe not". On July 10, 2002, at approximately 10:40 a.m., an interview was held with Staff 4, who stated that Client "A’s diaper was routinely change from behind and that an injury could have happened during the day and not have been noticed. Staff 4 further stated she had investigated the environment that Client "A" had been in that day (June 4, 2002) and had not found what had caused his injury. On July 10, 2002, at approximately 1:00 p.m., an interview was held with Staff 1, who stated, "1 had not changed [Client A] that shift because he was dry. Yes, we change him from behind. [Client A] helps by trying to pull up his diaper in front. At around 8:15 p.m., I had [Client A] in the bathroom removing his clothes. When I started to remove his diaper, 1 saw dark red blood on it". Staff 1 further stated he looked at [Client A’s] penis and noted the cuts and a little bit of blood. "1 called for help at that time". On July I7, 2002, at approximately 10:00 a.m., an interview was held with Staff 5, who stated that he had finished his investigation. The results of the investigation Were that there was no evidence uncovered to determine how this injury was sustained, so the case was closed as inconclusive. Client A sustained two lacerations on his penis a semicircular laceration on the shaft and a laceration between the larger laceration and the tip of the penis. These lacerations needed 15 sutures to close them. The facility staff was unable to explain how the client sustained the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORREC’i" VIOLATIONS IS GROUNDS FOR SUSPENSION OR: REVOCATION OF YOUR LICENSE DPH POD 000304 State of California - Health and Human Services Agency Department of Public Health .SEC’I’!OrI~ ’1424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1220-0001705-S Dale: 09t09/2002 Time: CLASS AND NATURE OF VIOLATIONS injury. Therefore. the facility failed to ensure that Client A was protected from sustaining bodily harm, required medical care, sutures and the potential for infection, The above violation presents an imminent danger that serious physical harm would result. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000305 State of California - Health and Human Services Agency Department of Public Health SF__£;T’ION 1’424 NOTICE Page 1 of 3 CITATION NUMBER: 17~1220-0001706-S Date: 10/22/2002 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) IncidentlComplaint No.(s) ’ 170016666 Department Of Developmental Services 3530 POMONA BLVD 170000772 POMONA, CA 91766 Type of Ownership: State Agency LANTERMAN DEVELOPMENTAL CENTER D/P ICFDD 3530 Pomona Blvd Pomona, CA 91768 (909) 595-1221 Intermediate Care Facility/Developmentally Disabled 170001773 CLASS AND NATURE OF VIOLATIONS CLASS E} PENALTY ASSESSMENT $800,00 trebled to $2,400.00 Capacity: 716 DEADLINE FOR COMPLIANCE 1114/02 12:00 a.m. CITATION -- PATIENT RIGHTS 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excess ve medication, abuse or neglect. On July 11, 2002, an unannounced visit was made to the facility to investigate a facility reported event. Subsequent visits were made to the facility on July 17, 2002, July 25, 2002, August 6, 2002, August 12, 2002 and August 26, 2002. The facility failed to assure that each client was free from physical abuse. Name of Evaluator: Naomi Russell HFEN. Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name: Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000306 State of California - Hearth and Human Services Agency Department of Public Health SE.~TION 1’424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1220-0001706-S Date: 10/2212002 Time: CLASS AND NATURE OF VIOLATIONS Client "A", a female 37 years of age, was admitted to the facility on May 11, 1993, with a diagnosis of Severe Mental Retardation. The client communicates through gestures and vocalizations. She needs direct supervision while eating, on residence, and when off the residence. Review of the facility’s incident report dated July 10, 2002, at 8:30 A.M., Staff 1 described the incident, "While making rounds following breakfast, I knocked and entered living room #20, and found [Staff !’2"] hitting this resident with a white hair brush about her legs and trunk. The [Client A] was deep into a ’chair with her arms out stretched as if to block blows and her legs raised in the air. I asked [Staff 2] what she was doing. She turned and said that the client was hitting her ..... Body check completed by HSS [Health Support Services] who noted 1 cm [centimeters] abrasion (scrape) to right shoulder and 6 cm superficial (near the surface) scratch to left forearm; noted 4 by 6 cm red area to top of head." The physicians’ progress notes dated July 10, 2002, at 10:00 A.M., stated, "Skin-scalp: apex (highest point): no discoloration or swelling. Right shoulder: 2 cm superficial abrasion no bleeding. Left forearm: 6 cm. Erythematous linear excoriations [abnormal redness, narrow straight and layer of skin removed]" On July 11, 2002, at 11:00 A.M., an interview was held with Staff 3, who stated, " I was on the unit within 45 minutes of the incident and took pictures of the reddened scalp and the two other injuries." On July 17, 2002, at 10:00 A.M., an interview with Staff 1 was conducted.. She stated, "1 knocked before going into the room, I could not believe that she kept hitting her as I walked into the room." On review of the written declaration from Staff 1, dated NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000307 State of California - Health and Human Services Agency Department of Public Health SE~T]O’N "~424 NOTICE Page 3 of 3 CITATION NUNIBER: SECTIONS VIOLATED 17-1220-0001706-S Date: 10t22/2002 Time: CLASS AND NATURE OF VIOLATIONS July 17, 2002, it stated, "While making rounds following breakfast on Juty 10t02, I knocked and entered living room #20, and found... [Staff 2] hitting... [Client A] with a white hairbrush about her legs and trunk .... [Client A] was deep into a chair with her arms outstretched as if to block blows and her legs raised in the air. I asked... [Staff 2] what she was doing, she turned and said that "the client ( Client A) was hitting her." I said to... [Staff 2] "you know you can’t do that." Escorted... [Staff 2] to the Rm office; in route... [Staff 2] stated ’Please don’t turn me in for abuse". I replied or/and asked "what do you expect me to do".... [Client A] was escorted to the " clinic V.S. [vital signs] and body check were completed by the reed [medication] person for the day and the residence HSS [Health Support Services]." Client A, who is non-verbal, and needs staff supervision and assistance with her activities of daily living, was subjected to phYSical abuse from Staff 2, and sustained abrasions and erythematouslinear excoriations on left forearm and right shoulder. Therefore, thefacility failed to ensure that Client A was free from physical abuse from Staff 2. The violations of the above regulations jointly, separately or in any combination had a direct an immediate relationship to the health, safety, and security of all patients of the facility. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS 1S GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000308 State of California - Health and Human Services Agency Department of Public Health SE,~T[ON 1~424 NOTICE Page 1 of 4 CITATION NUMBER: 17-1235-0001747-S Date: 05t06t2003 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORN IA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(7) 76525(a)(14) IncidentlComptaint No.(s) : 170016755 Department Of Developmental Services 3530 POMONA ;3LVD 170000772 POMONA, CA 91766 Type of Ownership: State Agency LANTERMAN DEVELOPMENTAL CENTER D/P ICFDD 3530 Pomona Blvd Pomona, CA 91768 (909) 595-1221 Intermediate Care Facility/Developmentally Disabled 170001773 CLASS AND NATURE OF VIOLATIONS Capacity: 716 PENALTY ASSESSMENT $10,000.00 DEADLINE FOR COMPLIANCE 5!15/03 12:00 a.m. CLASS A CITATION-- PATIENT RIGHTS 76525. Clients’ Rights, (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section, Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. (14) To dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs. On August 12, 2002, an unannounced visit to the facility was conducted to investigate a facility reported event. Subsequent visits were made to the facility to further investigate the complaint. During the investigation, it was determined that the facility failed to: Name of Evaluator: Rosie Soliz Evaluator Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signat~Jre : Name ’ Evaluator Signature ¯ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000309 State of California - Health and Human Services Agency Department of Public Heatth S~CTION ’ 424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS VIOLATED t7-1235-0001747-S Date: 05/06t2003 Time: CLASS AND NATURE OF VIOLATIONS 1. Ensure that each client admitted is afforded rights to be free from physical abuse and, 2. Treat clients with dignity, respect and humane care. Client A was a 26-year-old male with diagnoses, which included: 1. Severe Mental Retardation, 2. Autism, and 3. Impulse Control disorder NOS. Review of the Description of Approaches and Strategies dated April 18, 2002, revealed the client had unacceptable behaviors that included hitting others and biting others. The client also required direct supervision. On August 7, 2002 at 1:30 p.m. the interdisciplinary notes documented, "Staff reported that ...[Client A] had marks on his back lower back and at the L (left) shoulder area." The HSS (Health Services Specialist) at 2:05 p.m. documented, "...[Client A] was seen skin marks at back appear to match metal buckle." Interview with Staff 1 providing direct care for Client A on August 7, 2002, stated she dressed the client in the morning and did not observe any belt marks. The client was taken to day program without any unusual occurrences and returned at approximately 11:10 a.m. Client A returned for lunch and then was left in Staff 2’s care at approximately 11:30 a.m. An interview was conducted with Staff 2 on March 4, 2003 at 12:30 p.m. Staff 2 stated, he was caring for Client A at 11:30 a.m. in the group room along with other clients and during this time there were no altercations between clients that included the use of belts. Staff 2 further stated, Client A was in his direct care during this time. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000310 State of California - Health and Human Services Agency Department of Public Health S~E,CTION ~1424 NOTICE Page 3 of 4 CITATION NUI~IBER: SECTIONS VIOLATED 17-1235-0001747-S Date: 05/06t2003 Time: CLASS AND NATURE OF VIOLATIONS Interview with Staff 3 on January 22, 2003 stated, on August 7, 2002 (date of incident) at approximately 12:00 p.m. Staff 3 and Staff 4 relieved Staff 2 for lunch. Staff 3 also stated Client A did not appear agitated and the client was never left alone or out of sight. During this time there were no altercations observed between Client A or other clients in the group. Staff 3 also stated that Staff I took Client A at 12:30 p.m. to be changed and that was when the reddened area was discovered. She immediately reported this to the charge nurse. Copies of photographs taken by the facility policy obtained on August 12, 2002, revealed reddened areas appear to be belt marks. Review of the narrative investigative summary completed by the Special Investigator dated December 23, 2002 stated, "the doctor’s findings that the physical evidence on [Client A’s] back is consistent with a belt buckle." The investigative report continued to stated that eleven red welts on various parts of Client A’s back were noted. The facility report revealed that the facility was unaware as to how, when, or who caused the belt marks on Client A’s body. Therefore the facility failed to: 1. Ensure that Client A remained free of physical abuse despite the facility claim that the client was in the direct care and supervision of staff at all times, and 2. To treat Client A with dignity, respect and humane care. The failure of the facility to ensure Client A was free of NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000311 State of California - Health and Human Services Agency Department of Public Health SEOTIO~I ’i424 NOTICE Page 4 of 4 CITATION NUI~IBER: SECTIONS VIOLATED 17-1235-0001747-S Date: 05t0612003 Time: CLASS AND NATURE OF VIOLATIONS physical abuse caused the client to suffer from lack of dignity, respect, humane treatment, and unnecessary pain due to the multiple injuries caused by a whipping with a belt buckle of an unknown perpetrator. 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. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY" CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000312 State ?f California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE CITATION NUi~1BER: ’ Page 1 of 4 17-’1419-0001749-S Date: 06t12/2003 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) IncidenlfComplaint No,(s) ¯ 170018322, 170016762, 170016755 Department Of Developmental Services 3530 POMONA BLVD POMONA, CA 91766 170000772 Type of Ownership: State Agency LANTERMAN DEVELOPMENTAL CENTER DIP ICFDD 3530 Pomona Blvd Pomona, CA 91768 (909) 595-1221 intermediate Care FacilitytDevelopmentally Disabled Capacity: 716 170001773 CLASS AND NATURE OF VIOLATIONS CLASS .B PENALTY ASSESSMENT $800.00 trebled to $2,400.00 DEADLINE FOR COMPLIANCE 9/19/03 12:00 a.m. CITATION .- PATIENT RIGHTS 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as proVided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. During an investigation of a facility reported event that commenced on March 25, 2003, the facility was identified as having failed to ensure that each client has the right to be free from sexual abuse. Medical record review of Client A revealed a 59-year old female, who was admitted to the facility on March 20, 1959, with diagnoses that included: Name of Evaluator: Aurora Calaguas HFEN Without admitting guilt, 1 hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000313 State of California - Health and Human Services Agency Department of Public Health SECTION ’1424 NOTICE Page 2 of 4. CITATION NUI~BER: SECTIONS VIOLATED 17-1419-0001749-S Date; 06/12/2003 Time: CLASS AND NATURE OF VIOLATIONS 1. Profound Mental Retardation, 2. Atter~tion-deficit Hyperactivity Disorder, and 3. Epilepsy. Review of the Annual Psychological Evaluation dated January 14, 2003, revealed that the client’s mental age is 3 years and 6 months. Further review of the Psychological Evaluation showed that Client A’s Social - Sexual Issues indicated that the client is "affectionate to men and women." The client was described as "does not make any obvious gender discriminations and appears to have no interest in sexual relationships." Review of the Individual Program Plan narrative dated February 18, 2003, revealed that Client A’s open behavior problems included self-injurious behavior as manifested by hitting hands, face and knees against the wall or floor and hyperactivity as manifested by pacing, impulsive tapping of others with. her hands, scratching and rubbing her body. The Physician’s Progress notes dated March 23, 2003 at 1:45 p.m. revealed that a physical examination was performed related to the "alleged sexual assault." The physician documented that the "Total body check reveals no sign of injury or unusual sign" and assessment was "negative and WNL (within normal limits) physical." Review of the Interdisciplinary (ID) notes dated March 23, 2003 at 2:00 p.m. revealed an Assistant Coordinator of Nursing Services (ACNS) notes that indicated "Called in to see client due to alleged abuse." Interview with Staff 1 conducted on May 21, 2003 at 10:00 a.m. revealed that on March 23, 2003 at approximately 1:30 p.m., she went to the group room to take one of her clients to the bathroom. She saw Staff X in the group room with Client A and two other clients. Staff 1 observed Client A NOTE: tN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTE¥ CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000314 State, of.California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-141g-0001749-S Date: 06/12/2003 Time: CLASS AND NATURE OF VIOLATIONS lying in the sofa, and Staff X was standing by the sofa in a bending position with his hands inside the pants of Client A. Staff 1 further disclosed that she observed Staff X immediately pulled his hands from Client A’s pants. Staff I took Client A and two other clients out of the group room and immediately reported what she had witnessed to the Acting Shift Supervisor. During observation of Client A conducted on May 21, 2003 at 11:00 a.m., the client was ambulatory, and was asking the question "When is your birthday ?% Client A was easily distracted and continued to ask questions about "birthdays" repeatedly. Interview with the Residence Manager conducted on May 21, 2003 at 11:15 a.m. revealed that the client was unable to recall the incident that happened on March 23, 2003. They have not observed any unusual signs or changes with the client’s behavior after the incident. She added that Staff X was a contract janitor and had been working in their unit for about 2 years. Review of facility Administrative Directive (AD)-227 on Alleged Neglect or Abuse dated October 21, 2002, indicated that "Any neglect, abuse, or exploitation by person, whether staff, visitor, volunteer, family, or other clients, is prohibited." The AD defined Sexual Abuse as "Any unwanted or exploitive sexual contact, advance or assault." AD 227 documented that each. staff member shall be oriented to the provisions of this Directive at the initiation of employment or assignment to the facility. The AD further indicated that school district employees, county teaching staff, foster grandparents and senior companions, volunteers, contract janitors, student interns, and any NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000315 State of California- Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 4 CITATION NUI~I£ER: SECTIONS VIOLATED 17-1419-0001749-S Date: 06/12/2003 Time: CLASS AND NATURE OF VIOLATIONS other persons who work with or around clients shall be oriented to this policy and are expected to comply with its prohibitions and requirements. AD 227 further indicated that "All staff shall receive training annually on prevention of client abuse and reporting procedures." AD 227 did not address how the facility will ensure that on-going training sessions on client abuse prevention will be provided to other persons who work around the clients, which include contract janitors. During.interview with Staff 1 conducted on May 21,2003 at 10:00 a.m., she confirmed that on March 23, 2003 at approximately 1:30 p.m., she witnessed Staff X had his hands inside Client A’s pants. Interview with the Senior Special investigator conducted on May 21, 2003 at 1:30 p.m. revealed that on March 23, 2003, Staff X admitted that he touched Client A inappropriately in the "crotch area." Therefore Client A was touched sexually without her consent by a contract employee, and the client has been subjected to abuse. This failure resulted in the violation of Client A’s rights to be free from sexual abuse. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to .the client. NOTE; IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000316 State of C, alifomia - Heaffh and Human Services Agency Department of Public Health ,~EL3T]ON 1424 NOTICE Page 1 of 7 CITATION NU N[BER: 17-1235-0001750-S Date: 06/19/2003 Time: Type of Visit YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE IncidenttComplaint No.(s) ’ 170016756 FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76315(b) 76525(a)(7) 76525(a)(20) Department Of Developmental Services 3530 POMONA BLVD POMONA, CA 91766 170000772 Type of Ownership: Stale Agency LANTERMAN DEVELOPMENTAL CENTER DIP ICFDD 3530 Pomona Blvd Pomona, CA 91768 (909) 595-1221 Intermediate Care FacilitytDevelopmentally Disabl’ed Capacity: 716 170001773 PENALTY ASSESSMENT $25,000.00 CLASS AND NATURE OF VIOLATIONS DEADLINE FOR COMPLIANCE 7/2/03 12:00 a,m. CLASS AA CITATION -- PATIENT RIGHTS 76315.Developmental Program Services--Individual Program Plan. (b) The individual program plan shall be implemented as written. 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. (20) To be free from harrn, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. Name of Evaluator: Rosie Soliz Evaluator W;thout admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature " Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000317 State of ,California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page ). of 7 CITATION NUI~IBER: SECTIONS VIOLATED 17-1235-0001750-S Date: 06tl 9t2003 Time: CLASS AND NATURE OF VIOLATIONS On August 12, 2002, an unannounced visit to the facility was conducted and subsequent visits were made to investigate a facility reported event regarding the death of a client. The results of the investigation, showed that the facility failed to: I. Impfement facility policy by which client-to-client altercations and injuries of unknown origin are thoroughly investigated to ensure each client be free from physical abuse. 2. To ensure clients are free from harm, and 3. "1-o implement the individual program plan developed for clients, Client A, was a 31 year old male, who was admitted to the facility on February 28, 2002, with diagnoses, which included: 1. Severe Mental Retardation, and 2. Impulse Control Disorder Not Otherwise Specified. Review of the Individual Program Plan (IPP) Narrative dated March 19, 2002, revealed Client A had identified behaviors that included: "hits, bites, scratches, head butts others, spits on self and others, urinates inappropriately, engages in property destruction, slap and scratches self, attempts to leave supervision." The risks of the behaviors to himsel{ and others included the possibility of injuries such as, bruises, contusions, lacerations, and broken bones for his victims as well as himself when his victims retaliate. The Interdisciplinary Team (IDT) identified Client A was at risk for injuries from "retaliation of peers." Review of the Interdisciplinary notes revealed the following: NOTE: IN ACCORDANCE WITH CALII=ORNfA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000318 State of Qalifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 7 CITATION NUI~IBER: SECTIONS VIOLATED 17-1235-0001750-S Date; 06f19f2003 Time: CLASS AND NATURE OF VIOLATIONS 1. March 25, 2002 at 11:00, "Laceration left side of head .... Client [Client A] attempted to enter kitchen and (another) c[ient...pushed client [A] making him fall to the floor hitting his head..." The injury required 4 sutures. 2. March 29, 2002 at 6:30 p.m., "While redirecting resident [Client A] from peer, (peer) grabbed...[Client A] and bit him on top of his head. Area opened 112 inch..." The physician ordered Augmentin (antibiotic medication) to prevent infection. 3. April 1, 2002 at 6:45 a.m., "[Client A] attempted to bite (another peer). .. peer swung (and) hit elbow to ...[Client A’s] head a lump began to appear beneath right eye." 4. April 7, 2002 at 4:45 p.m., "When changing resident clothes...staff noticed 3 bruises on his [Client A’s] ieft breast 2 bruises to right breast." 5. April 7, 2002 at 10:15 p.m., "right leg abrasion buttock discoloration." In less than two weeks, Client A had received multiple injuries two of the injuries resulted in lacerations from client-to-client altercations and one injury required sutures. Review of the iDT narrative dated April 8, 2002, stated IDT met to review several recent injuries that Client A sustained, and resulted from assault by his peers. The team agreedthat a special team meeting will be held to discuss the appropriateness of Client A’s current placement. In less than 3 weeks after the IDT met, the interdisciplinary notes revealed that Client A continued to receive injuries as follows: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000319 State of .California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 4 of 7 CITATION NUMBER: SECTIONS VIOLATED 17-1235-0001750-S Date: 06/19/2003 Time: CLASS AND NATURE OF VIOlATiONS 6. May 2, 2002 at 7:00 a.m., "it was observed by staff when entering room...[Client A] had blood running down his face." The wound required 3 sutures. 7. May 11,2002, "While staff was redirecting [Client A] [another client] walked by, [Client A] bit him on stomach area." Documentation showed that the Interdisciplinary Team [1DT] met again on May 13, 2002, to discuss the appropriateness of Client A’s placement on the residence. The Individual Program Plan (IPP) Narrative documented, the Program Director advised the team that she feels that the residence is not appropriate for the client and is not meeting his need. The IPP further stated, that Client A will attempt to turn over the patio benches while his peers are sitting on them which upsets his peers and may invite retaliation (to get revenge). The team agreed the client Should be on a residence with less aggressive peers. Further review of the ID notes revealed more documented injuries to Client A. 8. May 20, 2002, "During dressing, bruises on R [right] and L [left] breast were observed by group leader with redness slight rash." 9. June 4, 2002 at 8:00 p.m., "When resident came to group area staff observed redness around right eye..." 10. June 15, 2002, 6:30 p,m., " Discoloration L (left) cheek size is larger than a dime smaller than a nickel, dark purplish." On JuNe 16, 2002, the bruise measured 4 c.m. X 2 11. June 30, 2002 at 7:30 a.m., "When dressing resident [Client A] ...staff noticed purple Lt (left) ear, purple NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000320 State of ,California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 5 of 7 CITATION NUI~BER: SECTIONS VIOLATED 17-1235-0001750-S Date: 06t19/2003 Time: CLASS AND NATURE OF VIOLATIONS groin area swollen both eyes, swollen lower lip and Lt (left) foot swollen..." 12. June 30, 2002 at 9:30 a.m., "multiple bruises noticed...on face abdomen, groin and lower extremities...both eyes dark bluish purple discoloration." Multiple bruises were noted on eyes, lips, ear and groin area. The IDT met again for the third time, on July 8, 2002, to discuss a recent incident on June. 30, 2002, where (Client A) was awakened by his morning Group Leader, and was found to have several bruises on his face and trunk. The 1DT again, recommended that Client A be transferred to another program, stated a referral request is being processed. This was 2 months after the first recommendation. During an interview with the Program Director on April 15, 2003 at 2:30 p.m., a transfer referral form dated July 16, 2002was produced, two months after the IDT’s original recommendation. The following documentation in the tD notes showed that Client A continued to receive injuries. 13. On July 16, 2002 at 8:00 p,m., "...observed discoloration and swollen on Lt (left) hand 3rd and 4th fingers and Rt (right) hand 3rd finger swollen..." The X-ray showed fractures of the left 3rd and 4th fingers and right 3rd finger. 14. July 31, 2002, at 1:35 p.m., "While attempting to offer (Client A) physical prompts to get off of floor...(another client) became agitated and struck (Client A) on the right side of face...causing bleeding in the mouth followed by swelling of the right cheek." On May 13, 2002, when the IDT first recommended for Client A NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000321 State of California - Health and Human Services Agency Departmenl of Public Health Si2OTION 1424 NOTICE Page 6 of 7 CITATION NUMBER: SECTIONS VIOLATED 17-1235-0001750-S Date: 06/1912003 Time: CLASS AND NATURE OF VIOLATIONS to be transferred to a place where clients were less aggressive, to July (approximately 3 months), Client A remained on the same residence, and continued to sustain multiple injuries due to client-to-client altercations and injuries of unknown origin. These injuries included bruises to face and body, bites and fractured fingers. Review of the facility policy #124: Alleged Neglect or Abuse, dated June 27, 2000, stated, "client to ctient altercations is reported as an aggressive act to another client and particular attention shall be given to repeated unexplained injuries, unusual injuries, unobserved injuries, patterns of bruises, and anatomical distribution and extent of injuries." Interview with the Program Director on April 15, 2003 at 2:30 p.m., stated client-to-client altercations are not considered abuse and not all injuries of unknown origin are investigated. Review of the incident reports and investigations regarding Client A’s injuries, revealed no evidence of a completed thorough investigation of the injuries of unknown origin, despite Client A’s risk for retaliation from peers, and Client A sustaining repeated multiple injuries. On August 7, 2002 at 5:06 a.m. the ID notes documented, "During 3:45 a.m. checks, resident required shower and returned to bed. At 3:55 p.m. (another client) came out of bedroom agitated biting his hand. Staff redirected [peer] to bedroom and found (Client A) slumped over, pallor appeared pale and had shallow breathing...staff immediately called...code blue team..." Client did not respond and was 3ronounced dead at 5:06 a.m. An autopsy was conducted on August 21, 2002, and the report revealed multiple blunt force injuries on the anterior abdomen, chest, arms, forearms, right thigh, left inner NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000322 State of ,California - Health and Human Services Agency Departmenl of Public Health SEC’~ION "1424 NOTICE Page 7 of 7 CITATION NUMBER: SECTIONS VIOLATED 17-1235-0001750-S Date: 06119/2003 Time: CLASS AND NATURE OF VIOLATIONS ankle, chin, neck and frontal scalp. The immediate cause of death was determined to be caused by Hemoperitoneum (internal bleeding in the abdomen) due to blunt force trauma. It was determined to be homicide (a killing of one human being by another) caused by physical assault (a violent physical attack). The failure of the facility to protect Client A from the repeated client-to-client altercations, and thoroughly investigate injuries of unknown origin and the facility’s failure to implement the individual program plan to transfer Client A to a safer environment for his protection from retaliation, resulted into Client A receiving multiple injuries during his 6 months stay in his residence, and then finally died from internal bleeding caused by blunt force trauma by an unknown perpetrator. Therefore the facility failed to: 1. To implement their own facility policy and procedure to pay particular attention to thoroughly investigate repeated injuries of unknown origin and to ensure Client A be free from physical abuse from other clients. 2. To ensure CIient A remain free from harm, and 3. To implement the individual program p~an dated May 13, 2002, to transfer Client A to a safer environment to protect the client from retaliation from other clients, which resulted in Client A’s death. 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 the death of the patient. NOTE: IN ACCORDANCE WITH CAUFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000323 State of qalifornia - Health and Human Services Agency Department of Public Health ’S’£CTION 1424 NOTICE CITATION NUMBER: Page 1 of 3 17-1235-0001775-S Date: 07/3012003 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(7) I ncidenttComplaint No.(s) : 170016915 Department Of Developmental Services 3530 POMONA BLVD POMONA, CA 91766 170000772 Type of Ownership: State Agency LANTERMAN .DEVELOPMENTAL CENTER DIP ICFDD 3530 Pomona Bird Pomona, CA 91768 (909) 595-1221 Intermediate Care Faci]itytDevelopmentaIly Disabled 170001773 CLASS AND NATURE OF VIOLATIONS Capacity: 716 PENALTY ASSESSMENT $9,000,00 DEADLINE FOR COMPLIANCE 8It3/03 12:00 a.m. CLASS A CITATION .. PATIENT RIGHTS 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. On October 15, 2002, an unannounced visit to the facility was conducted to investigate a facility reported event. Subsequent visits were made to the facility to investigate the complaint further. During the investigation, it was determined that the facility failed to: 1. Ensure that each client admitted is afforded rights to be free from physical abuse. Review of the medical record for Client A revealed the Name of Evaluator: Rosie Soliz Evaluator Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature ¯ ~ritle : NOTE: tN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000324 State of C, alifornia - Health and Human Services Agency ~Si=CTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Hea~th Page 2 of 3 17-1235-0001775-S Date: 07/30t2003 Time: CLASS AND NATURE OF VIOLATIONS client had diagnoses, which include: 1. Profound Mental Retardation, and 2. Impulse Control Disorder Not Otherwise Specified. Review of the Individual Program Plan (IPP) dated June 12, 2002, documented, "...[Client A] is able to verbally communicate his needs and wants with simple 1-2 word phrases...He often screams to communicate or to get others attention." Client A was also identified as having selfinjurious and aggressive behaviors and used a wheelchair with a padded lap-tray for proper body alignment and transportation. Review of the Interdisciplinary Notes (IDN) dated October 6, 2002 at 1:00 p.m. stated, "While monitoring clients in dining room staff [2] approached this writer and told me that they had witnessed... [Client A] being punched in the back. of the head. They further reported that he was also punched on his back..." Interview with Staff 2 on May 20, 2003 at 10:50 a.m., it was stated, that on October 6, 2002, she was cleaning the hallway when she heard Client A crying and yelling and witnessed Staff 1 taking Client A down the hallway from the dining room, and Staff 1 was hitting Client A on the head and shoulders, with his closed hand approximately 4 to 5 times, and then with a towel 4 or 5 times to the upper back. Client A was observed crying and holding out his hands to protect himself. Review of the IDN’s dated October 6, 2002 at 3:15 p.m. documented, "Examined Client [A] and found ’Vee’ upside down formed red abraised area to mid-thoracic area, also had redness/discoloration to mid-chest area." The failure of the facility to protect Client A from NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000325 State of California - Health and Human Services Agency Department of Public Health ’Si=CTION "1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1235-0001775-S Date: 07/30/2003 Time: CLASS AND NATURE OF V~OLATIONS Staff 1 ’s physical abuse caused Client A to suffer unwarranted pain due to multiple blows to head, chest, and back which caused redness to the mid-thoracic area and chest. Therefore the facility failed to protect Client A from physical harm. The violations of the above regulations pres.ented either imminent danger that death or serious harm would result or a substantial probability, that death or serious physical harm could result. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000326 State of" .C.alifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 4 CITATION NUfllBER: 17-1235-0001779-S Date: 08/28/2003 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility 113: SECTIONS Incident/Complaint No.(s) ’ 170016925 Department Of Developmental Services 3530,POMONA BLVD 170000772 POMONA, CA 91766 Type of Ownership: State Agency LANTERMAN DEVELOPMENTAL CENTER DIP ]CFDD 3530 Pomona Blvd Pomona, CA 91768 (909) 595-1221 Intermediate Care FacilitytDevelopmentally Disabled 170001773 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $9,500.00 trebled to $28,500.00 VIOLATED 76661(d) 76525{a)(20) Capacity: 716 DEADLINE FOR COMPLIANCE 9/’15/03 12:00 a.m. CLASS A CITATION -- PATIENT CARE 76661. Water Supply and Plumbing. (d) Hot water temperature controls sha]I be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature not less than 40.5oC (I05oF) and not more than 48.8oC (120oF). 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld, except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. On October 16, 2002, an unannounced visit to the facility Name of Evaluator: Rosie Soliz Evaluator Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000327 State of, California - Heatth and Human Services Agency Department of Public Health SECTION’1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS VIOLATED t7-1235-0001779-S Date: 08t28t2003 Time: CLASS AND NATURE OF VIOLATIONS was conducted to investigate a faciiity reported event. After completion of the investigation, it was determined that the facility failed to maintain water temperature below 120 Fahrenheit and prevent each client from harm. Client A was a 64-year-old female with the diagnosis: 1. Profound Mental Retardation, 2. Blind, and 3. Deaf. Review of the Description of Approaches and Strategies dated October 19, 2000 stated the client requires staff to complete activities of daily living and will toilet with physical reminders. The client also communicates by using facial expressions and limited gestures and will pull staff to make her needs known. The facility reported incident report dated, September 30, 2002 at 5:30 a.m. stated, "While giving care and escorting client [Client A] to bathroom observed large blister on right upper thigh approximately 5 rf/2 inches long and 3 inches wide also observed broken skin on Right bicep area... The regulator (hot water heater) had malfunctioned after clients had taken evening showers (on September 29, 2002). [Client A] had a shower after regular shower [time] when staff noticed shower water was too hot." Client A was sent to the acute care hospital on October 8, 2002, for consultation and the physician’s documented diagnostic impression was, "multiple third degree burns" to the right arm, right thigh and also small blisters to both knees and the right breast area due to burns. The plan was surgical debridement (surgical excision of dead, devitalized,’ or contaminated tissue and removal of foreign matter from a wound), intravenous fluids, and intravenous NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000328 State oi: California - Health and Human Services Agency Department of Public Health SECTIQN’ 1424 NOTICE Page 3 of 4 CITATION NUI~BER: SECTIONS VIOLATED 17-1235-0001779-S Date: 08~’28/2003 Time: CLASS AND NATURE OF VIOLATIONS antibiotic coverage. Interview with the Plant Operation Staff 1 on October 16, 2002, stated that at 7:00 a.m. the next day, (September 30, 2002) she went to the unit and the steam valve (device preventing acceleration of water temperatures) was not working properly and it was immediately shut off and replaced. Interview with Administrative Staff 2 on July 22, 2003 at 12:00 p.m., stated it was the steam valve that failed and the thermostat also failed which cause the alarm to fail causing the shut off valve to fail (the valve that automatically shuts water off when it is to hot). The facility policy titled, "Engineering preventive maintenance," dated, November 11, 1.998, revealed all equipment rooms (including water heaters) were to be inspected weekly under normal circumstances. Review of the equipment room inspection documentation revealed the equipment had last been inspected on October 6, 2002 approximately 2 weeks prior to the incident. The Nursing Procedure Manual number 209 entitled, "Hot water temperature checks in resident accessible areas stated, to assure residents safety the hot water temperature in all resident accessible sinks, tubs, and showers was to be checked monthly by residence staff to prevent scalding or burns. The procedure was to check water temperature of all resident accessible sinks showers, and tubs by using a bath thermometer and record on form SR 2214, "Emergency items and temperature monitoring" the water temperature range was not to exceed 110 degrees F-112 degrees F. Review of the SR 2214 revealed the temperatures had not been monitored for at least 6 months prior to the incident. The failure of the facility to maintain the hot water NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000329 State of California - Health and Human Services Agency Department of Public Health SECTION’ 1424 NOTICE Page 4 of 4 CITATION NUMBER: SECT;ONS VIOLATED 17-1235-0001779-S Date: 08128t2003 Time; CLASS AND NATURE OF VIOLATIONS temperature below 120 resulted in Client A to endure third degree burns to the right leg and right arm which caused her unnecessary harm, pain, undue surgical procedures, intravenous therapy and permanent scaring. Therefore the facility .failed: 1. To maintain water temperature to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature not less than 40.5 (105 F and not more than 120 F), 2. Prevent Client A from receiving harm. 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. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000330 State tqf,California - Health and Human Services Agency Deparlment of Public Health SECTION 1424 NOTICE Page 1 of 3. CITATION NUMBER: 17-1220-0001781-S Dale; ,10/21/2003 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) IncidenttCompfaint No.(s) : 170020111 Department Of Developmental Services 3530 POMONA BLVD 170000772 POMONA, CA 91766 Type of Ownership: Slate Agency LANTERMAN DEVELOPMENTAL CENTER DIP ICFDD 3530 Pomona Bird Pomona, CA 91768 (909) 595-1221 Intermediate Care FacilitytDevelopmentally Disabled 170001773 CLASS AND NATURE OF VIOLATIONS Capacity: 716 PENALTY ASSESSMENT $1,000.00 trebled to $3,000.00 DEADLINE FOR COMPLIANCE 10130/03 12:00 a.m. CLASS B CITATION .- PATIENT RIGHTS 76525. Clients’ Rights, (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. On July 18, 2003, an unannounced visit was made to the facility to investigate a facility reported event. Subsequent visits were made to the facility on July 23, 2003, and August 1, 2003. The facility failed to ensure that each client was free from physical abuse. Client "A", a male, 26 years of age, was admitted to the Name of Evaluator: Naomi Russell HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature " :Fitle : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000331 State 0f.California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1220-0001781-S Date: I0/21/2003 Time: CLASS AND NATURE OF V]OLATIONS facility on June 28, 1990, with a diagnosis of Profound Mental Retardation. The client is non-verbal. He needs staff assistance to complete hygiene and grooming tasks. He has to be closely supervised when on residence and off the residence. Review of the facility’s incident report dated July 17, 2003 at 10:50 a.m., Staff 1 described the incident, "knocked on door and entered group area and observed staff member slug client in the stomach twice with closed fist and heard him say Don’t touch me again..." On July 23, 2003 at 11:00 a.m., an interview with Staff 2, who stated "1 Was doing a 1:1 (one to one) with [Client "A"] on July 17, 2003, this happened when I was at lunch. [Client !’A"] on July 17, 2003, this happened when I was at lunch. [Client "A"] if hit by someone would probably duck, he would not defend himself or yell-he is non-verbal. On August 1, 2003 at 1:30 P.M., an interview with Staff 1 was conducted. She stated, "1 knocked on the group room door before going into the room, 1 could not believe what i saw, he slugged him [Client A] twice in the stomach. " On review of the written declaration frdm Staff 1, dated August 1, 2003, it stated, "At 10:50 [a.m.] I was returning a [Client "B"] from active senior program. Attempted to find staff to let them know [Client "B"] was home. I told a staff member in one group room and he told me to tell the staff down the hall. So I went down the hall and knocked on the door and when i entered the room I observed a staff member slug a client [Client "A"] with his left hand in the stomach while his right hand holding on to the clients left arm. The client then doubled over and the staff told him to "Don’t touch me again." So I told him to be nice and he looked at me patted the client on the back and said "be nice." I let him know that [Client "B"] was in the group room. I walked back to the nurses station looked for NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS iS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000332 Sla!e, ~(.California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: 17-1220-000!781-S Date! 10/21!2003 Time: SECTIONS CLASS AND NATURE OF VIOLATIONS VIOLATED .................................................... another staff when I could not find one I left and advised senior program coordinator who then advised CPS (Central Program Services), PD (facility police department), the RM (residence manager) and the Rec./leisure sup. (Recreation/leisure Supervisor) Then I returned back to the unit and advised the RM (residence manager) of what I observed. The RM (residence manager) then removed the client from the group area so he could be seen by a physician and then dialed "888" (emergency code to facility police department) at 11:05." Client "A", who is nomverba], dependent to staff for supervision and assistance with his activities of daily living, was subjected to unnecessary physical abuse from Staff I. Therefore, the facility failed to ensure that Client "A" was free from physical abuse from Staff 1. The violation of the above regulation jointly, separately or in any combination had a direct or immediate relationship to the health, safety, and security of all patients of the facility. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000333 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 6 CITATION NUMBER: 17-1220-0001784-S Date: 03/04/2004 Time: Type of Visit ¯. YQU. ARE. H EREBY_F.OU.N D_IN._~ZIO LA.T_I.O.N_OE_AP_P_LI.CABLE.__ CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FED ERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facitity Type: Facility ID: SECTIONS VIOLATED 76521(b) 76525(a){20) IncidentZComplaint_No.(s)4_1_70020538 Depertmen[ Of Developmental Services 3530 POMONA BLVD 170000772 POMONA, CA 91766 Type of Ownership: State Agency LANTERMAN DEVELOPMENTAL CENTER D/P ICFDD 3530 Pomona Blvd Pomona, CA 91768 (909) 595-1221 Intermediate Care Facility/Developmentally Disabled Capacity: 716 170001773 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 trebled to $3,000.00 I DEADLINE FOR COMPLIANCE 3/11/04 12:00 a.m. CITATION *- PATIENT RIGHTS 76521. Policies and Procedures. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to clients or their agents, employees and the public, and shall be carried out as written. Policies and procedures shall be reviewed at least annually, and revised as needed. 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. On NovemBer 25, 2003, an unannounced visit was made to the Name of Evaluator: Naomi Russell HFEN Without admitting guilt, 1 hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT V~OLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000334 State of California - Health and Human Services Agency Depadment of Public Health SECTION 1424 NOTICE Page 2 of 6 CITATION NUI~BER: SECTIONS VIOLATED 17-1220-0001784-S Date; 03/04/2004 Time: CLASS AND NATURE OF VIOLATIONS facility to investigate a facility reported unusual occurrence. Subsequent unannounced visits were made to the facility on December 4, 2003, December 11, 2003, January 7, 2004 and January 20, 2004. The results showed that the facility failed: 1) to ensure that clients were free from harm, and 2) to follow their policies and procedures on client’s supervision. Client "A", 40 years of age, was admitted to the facility on April t6,1997, with diagnoses that included Mental Retardation Mild to Moderate range, secondary to Tuberous Sclerosis. The client requires "close supervision" due to limited safety awareness and lack of Impulse Control. A review of the [Client "A"] medical record on November 25, 2003 was done, and the following was noted: 1 .)Interdisciplinary notes dated November 16, 2003 at 1700 (5:00p.m.) stated "Laceration to(R)-[right] side of scrotum approx, [approximately] 1" x’l/2", discoloration to tip of penis, and 2" [inches] discoloration to (R) [right] upperinner thigh. While participating in active TX [treatment], on a nature walk, [Client A] stated he "needed to urinate," Staff asked if the client would be able to wait until the group reached the closest restroom at Rustic Camp. [Client" A"] refused to wait and pulled out his genitalia. Staff observed.a laceration to (R) [right] side of scrotum and discoloration to the tip of penis and inner (R) [right] thigh. Staff provided privacy while client urinated in a bush. Staff asked what happened. [Client" A"] pointed, at peers, the other clients that were on the nature walk, and stated, "These kids did it." Staff further asked "Did what? Who? [Client "A"] stated,"[Client "B"], (who was not on nature walk) kicked me." Staff ended activity and returned to unit (with the group of clients that had been on nature walk). [Client "A"] was accompar~ied to med [mediation] room and was seen by med. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT V{OLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000335 State ofCalifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 6 CITATION NUMBER: SECTIONS VIOLATED 17-1220-0001784-S Date: 03104/2004 Time: CLASS AND NATURE OF VIOLATIONS [mediation] person and charge nurse. Injured areas cleansed with soap and water. NCP [Nursing Care Plan] documented: (1) Monitor for sis [signs or symptoms] of infection. (2) Monitor for cto (complaint) of pain. (3) Keep areas clean and dry. Will be seen by ACNS (Central Nursing Services) and Res. [Residence] Physician. Will continue to monitor." 2.) Physicians’ Progress Notes dated November 16, 2003 at 1800 (6:00 pm,), ]nd.icated," Laceration of lateral aspect (R) [right] scrotum 2 cm. [centimeter] in length superficial,., testis are seen fine on examination, no bruises minimal bleeding, [5] Stitches under local anesthetic. Tolerated procedure well. Penis/RL [righfJleft] testis last ID [interdisciplinary notes] 1996," 3.) The Individual Program Plan under Approaches and Strategies stated: "Lacks safety awareness, will wander away from the group. [Client "A"] is unaware of danger to himself from the environment and/or aggressive peers. He requires close supervision." This report also states under Behavior Barriers: " Indecent exposure when angry, spitting, disrobing, cussing, aggressiontassault, property destruction, yellingtscreaming, making false accusations of others (i.e. blames peers who are not present), collecting trash (needs to be reminded to wash hands) and public urination." On November 25, 2003, a review of the medical record for Client "B" was done and it was noted that: The Individual Program Plan under Approaches and Strategies, stated: "Requires "direct supervision" on and off the residence. Behaviors: Hitting, biting, kicking, or striking others with objects. Steals from others and has a history of property destruction, such as breaking windows, or furniture, throwing objects, banging on the wall, ect" NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000336 State of California - Health and Human Services Agency Department of Public Health ~ECTION 1424 NOTICE Page 4 of 6 CITATION NUMBER: SECTIONS V-I QLA.T-F--D 17-1220-0001784-S Date: 03t04t2004 Time: CLASS AND NATURE OF VIOLATIONS On December 4, 2003, review of the facility Administrative Directive 226-"Client supervision and Personal Care" define close supervision as, "for individuals who may require medical and/or behavioral interventions, an assigned staff person provides supe[vision in close proximity (as defined in Webster’s Dictionary means: close; very near) and intervenes or provides assistance and/or guidance, as needed, while individuals engage in activities of daily living. It was further noted that," Direct supervision is defined as "for an individual who may require immediate medical and/or behavioral interventions this includes proactive measures to assure the protection of clients from themselves and others when they are agitated, an assigned staff person provides direct observation. The individual engages in activities of daily living and one staff person directly observes the ¯ individual while he or she is either: integrated within the general population.., during designated activities or for designated time periods throughout the day; or separate from the general population," On December 11, 2003 at 1:00 pm, an interview was held with the Acting Residence Manager. The staff stated, she did an interview with the staff on duty on the day of the incident .She further stated, "1 interviewed on 11-16-03 am [morning] Shift Lead, [Staff 12], who stated," No one told me of any incidents and I did not see any." I also spoke with, [Staff 1], who stated he had not been told any thing by other staff nor did he see any incidents. The next day I spoke to [Staff 2]. [Staff 2] was one of the day shift Group leaders of [Client ’A"] and [Client "B"]. She told me nothing happened". She further stated, [Staff 3], was the other am [morning] group leader of [Client "A"] and [Client "B"] she said that [Client "A"] was already dressed when she came on duty, all she did was help him change his shirt. [Staff 3] said she NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000337 State of California - Health and Human Services Agency Deparl~nent of Public Health ~ECTION 1424 NOTICE " Page 5 of 6 CITATION NUMBER: SECTIONS V-f.O LA-T-E D 17-1220-0001784-S Date: 03t04t2004 Time: CLASS AND NATURE OF VIOLATIONS did not remember a fight or kicking episode. " I then spoke to the med [medication] person [Staff 4] on November16, 2003, who stated no one reported any injuries or incidents and " [Client "A"] did. net cgmplain of pain". " Next I spoke with [Staff 5], and he said that there had been an incident at lunch with [Client "A"] were he pulled his pants down twice, he did not remember seeing any injury or bleeding on his underwear. The two food service workers [Staff 6 and 7] were in the dinning and they stated that they saw no injury". "1 then spoke with [Staff 8], he stated, he had them both in the living room after-lunch. They had no problems. 1 spoke with [Staff 9] who was also in the group after lunch. He stated, "There. were no problem." Interview with [Staff 10], ACNS [Central Nursing Services] on December 11,2003 at 2:00 pro, stated she had helped [Staff 11] with the sutures and was present when afternoon charge nurse asked [Client "A"] who did it to him. [Client "A"] stated, "["Client "B"] kicked me". The staff then said," When did [Client "B"] Kick you?" [Client "A"] stated, "This morning." [Client "A" ’s] medical record stated, "He [Client A] requires close supervision," and [Client "B" ’s] medical record, it stated, "Requires direct supervision on and off the residence, Interviews conducted with staff members, confirmed that none of the staff were aware how [Client ’A"] received his injuries while under close supervision. The staff failed to foftow the Administrative Directive on "Client Supervision" for both [Client "A"] and [Client "B"] and due to this, Client "A" sustained laceration to the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS 1S GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000338 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 6 of 6 CITATION NUMBER: SECTIONS VIOLATED 17-1220-0001784-S Date: O3/04/2004 Time: CLASS AND NATURE OF VIOLATIONS right side of scrotum approximately 1 inch by 1/2 inch that required 5 sutures, discoloration to tip of the penis, and 2-inch discoloration to the right upper-inner thigh due to [Client "B’s"] aggressive behavior. The facility staff assigned to care for Client A was unable to explain how the client sustained the above injuries, while under his care. Therefore, the facility failed: 1) to ensure that Client "A" was protected from sustaining bodily harm, which required medical care, five sutures and the po.tential for infection. 2) To follow the facilities directive to assist in protecting Client A. The above violation had direct or immediate relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT ¯ VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000339 State of California - Health and Human Services Agency Department of Public Health SE~TION 1424 NOTICE Page 1 of 4 CITATION NUMBER: 17-1220-0001785-S Date: 04t20t2004 Time: Type of Visit ¯ --YOU-fiRE-HERE BY-FOt3IqD-I KI-~7IUEAT IO-Iq qSF-A P-I~EIC-A B-LqE IncidenttComplaint No.(s) " 170020680 CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Department Of Developmental Services Licensee Name: Address: License Number: Facility Name: 170000772 Type of Ownership: State Agency 3530Pomona Blvd Pomona, CA 91768 (909) 595-122t Intermediate Care Facility/Developmentally Disabled 170001773 Facility Type: Facility ID: 76525(a)(20) 76315(b) POMONA, CA 91766 LANTERMAN DEVELOPMENTAL CENTER DIP ICFDD Address: Telephone: SECTIONS VIOLATED 3530 POMONA BLVD I CLASS AND NATURE OF VIOLATIONS CLASS A CITATION 11 Capacity: 716 PENALTY ASSESSMENT $10,000.00 DEADLINE FOR COMPLIANCE 4/25/04 12:00 a,m. PATIENT RIGHTS 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withhefd except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. 76315. Developmental Program Services--individual Program PLan, (b) The individual program plan shall be implemented as written. On February 19, 2004, an unannounced visit was made to the facility to investigate a facility reported event. Name of Evaluator: Naomi Russell HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluater Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000340 State of California - Health and Human Services Agency Department of Public Health SISCTION ’1424 NOTICE Page 2 of 4 CITATION NUIV]BER: 17-1220-0001785-S Date: 04t2012004 Time: CLASS AND NATURE OF VIOLATIONS Subsequent unannounced visits were made to the facility on February 26, 2004, February 27, 2004 and March 4, 2004. The results showed that the facility failed to ensure that Clients were free from harm, by ensuring that the staff follows the clients Individual Program Plan. Client "A" 49 years of age was admitted to the facility on March 4, 1964, with a diagnosis of Profound Mental Retardation. The client requires staffs assistance to complete all activities ot~ daily living. He is also incontinent, which requires wearing of adult diapers at all times. Interview with Staff 1, was conducted on March 3,2004, who stated, ’I went into [Client "A’s"] room and found him trapped in his chair. He had slid under his lap tray trying to get out and his seat belt was very tight around his neck. He was blue and could not breath. I called for help. [Staff 2] got the seat belt and lap tray. off. Then [Staff 2] tofd [Client !’A"] to breath and he was all right then." A Special Team meeting was held on February 9, 2004, which stated, "A special team convened today, February 9, 2004, to discuss a recent incident that occurred involving [Client "A"] on 2/6/04. DTAC (Day -[raining Activity Center) instructor brought [Client "A"] home early from his DTAC, stating that [Client ’A"] was attempting to get out of his wheelchair and left him with residence staff. [Client "A"] made his way to his bedroom and while there; he attempted to get out.of his wheelchair without assistance. [Client "A"] is to have direct supervision when ambulating due to his osteoporosis. Rather than waiting for staff to assist him, he [Client "A"] tried to slide down under his lap tray and in the process his chin got caught up in his lap belt. Staff member went to his room to check on him [Client "A"] and found him caught up on the seat belt and called for assistance. The [Staff 3] came and examined [Client "A"] and NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000341 State of California - Health and Human Services Agency Department of Public Health SEOTIOI~/1424 NOTICE Page 3 of 4 CITATION NUMBER: SECTIONS ---V-I.O. -b~-T- E- D 17-1220-0001785-S Date: 04t20/2004 Time: CLASS AND NATURE OF VIOLATIONS noted bruising on the right side of his neck and right shoulder. During the examination, [Client "A"] was breathing without difficulty, he was able to walk, and had full range of motion using his arms. As a precautionary measure, [Staff 3] ordered x-rays to check his trachea and cervical spine. X-ray revealed a~ fracture of the C-2 area and a fracture of his left clavicle." On February 17, 2004, a review was done of [Client "A’s"] medical record. The following was noted: The IPP (individual Program Plan) dated March 25, 2003, stated: [Client "A"] uses a wheelchair for mobility due to his being prone to spontaneous fractures. He has no fracture since October 2000. [Client "A"] is capable of ambulating with staff assistance and is provided with opportunities daily with direct supervision from staff holding his hand. Heis not safety aware in his home or off his residence’". [Client "A"] is non-verbal and has not developed the ability to express himself using speech or signs. Client ’A" is not conserved and is unable to provide informed consent, His mother and brothers advocate for him. No consents were found within his medical record for his lap tray or his seat belt. Review of "Description of Approaches and Strategies" dated March 25, 2003, which stated: "General supervision in his wheelchair except close (supervision) when propelling from area to another." Interview with [Staff 3] on February 25, 2004, confirmed that the family had never been asked to sign consents for his lap tray or his seat belt nor had restraints been sent to Human Rights Committee for review prior to use. [Client "A"] who is non-verbal, has a diagnoses of Osteoporosis and needs close supervision when propelling his W’C (wheel chair) from one area to another, was not supervised by staff, and therefore sustained fracture of the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000342 State of California - Health and Human Services Agency Department of Public Health SECTION ’I424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS V-IO.LA.T_E D 17-1220-0001785-S Date: 04f20/2004 Time: CLASS AND NATURE OF VIOLATIONS C2 vertebrae and a fracture of his left clavicle and almost strangled with the restraint when tried to get out of his wheel chair without supervision. The client was subjected to unnecessary pain and suffering due to the staffs failure to failure follow the IPP. Therefore, the facility failed to ensure that Client "A" was protected from sustaining bodily harm that required medical care. The above violations jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would result on a substantial probability that death or serious harm would result. NOTE: 1N ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000343 State of California - Health and Human Services Agency Department of Public Health "SECTION 1424 NOTICE CITATION NUi~IBER: Page 1 of 4. 17-1354-0001849-S Date: 08t20/2004 Time: Type of Visit : --Y-O-U-A RE-N E-R BB-Y-F-Q ~--N D-I.N-Vl (~.-[~-T-I.O N-O.F-A.FF~L-I C-A-B L-E CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS ¯ Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(7) 76525(a)(14) I n elsie n f2C-em pla in.t-N e~(s-) :~1-700£060-1 Department Of Developmental Services 3530 POMONA BLVD 170000772 POMONA, CA 91766 Type of Ownership: State Agency LANTERMAN DEVELOPMENTAL CENTER D/P ICFDD 3530 Pomona Blvd Pomona, CA 91768 (909) 595-1221 Intermediate Care FacilitytDevelopmentally Disabled 170001773 CLASS AND NATURE OF VIOLATIONS Capacity: 716 PENALTY ASSESSMENT $1,000.00 trebled to $3,000.00 DEADLINE FOR COMPLIANCE 9/1/04 I2:00 a.m. CLASS B CITATION .. PATIENT RIGHTS 76525. Clients’ Rights. 76525(a)(20) (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld excel:it as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. (14) To dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs. (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. An unannounced investigation visit to the facility was conducted on January 8, 2004, to initiate a reported event received on January 2, 2004. The results of the Name of Evaluator: Lea Ann Reseigne Evaluator Without admitting guilt, I hereby acknowledge receipt of lhis SECTION "1424 NOTICE Signature : Name : Evalualor Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS 18 GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000344 State of California - Health and Human Services Agency Department of Public Health SECTION ’1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS V_]_QLA_’EE D 17-1354-0001849-S Date: 08120i2004 Time: CLASS AND NATURE OF VIOLATIONS investigation demonstrated that the facility failed to ensure: 1. Clients the right to be free from mental and physical abuse and free from restraint. 2. Clients remain free from harm, including unnecessary physical restraint and abuse, and 3. Clients the right to dignity, respect, and humane care. Client A is a 41-year-old mate admitted with diagnoses, that include Moderate Mental Retardation, Impulse Control Disorder, and Anxiety Disorder. On March 16, 2004 at 11:00 a.m., a review ofthe Individual Program Plan for Client A, dated October 7, 2003, indicated that Client A has open behavioral training plans for Harm to Self, Harm to Others, and Socially Undesirable Behavior. The behavior plans did not include the use of any type of physical restraints. The Individual Program Plan stated, "His behaviors tend to increase significantly when he is upset/frustrated and when he is under stressful situations." The Approaches and Strategies section indicated Client A is not able to verbalize or provide any appropriate response to indicate his understanding of his personal rights. On August 4, 2004 at 3:00 p.m., an interview with Staff I was conducted. Staff 1 stated he was uncertain of the date but that sometime during the month of November 2003, he had walked into group room 4 to give medication to Client A. Once in the group room Staff 1 noticed one client [Client A] standing in the center of the room and one staff [Staff 2] sitting in the room. Staff 1 asked Client A to come and get his meals, when the client moved he noticed Client A’s hands were tied behind his back with a soft tie restraint. Staff 1 reported he then asked Staff 2 to untie Client A. Staff 1 stated Staff 2 then untied Client A, and Client A approached NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS tS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000345 State of California - Health anti Human Services Agency Depadment of Public Health SECTION ’1424 NOTICE Page 3 of 4 CITATION NUI~IBER: SECTIONS VIQLATED 17-1354-0001849-S Date: 0812012004 Time: CLASS AND NATURE OF VIOLATIONS Staff t to take his medications. Staff 1 stated Client A was quiet and he did not notice any markings on Client A’s hands or wrists. Staff I continued and stated that on another evening following the previous incident (he could not recall the date) he had opened the door to group room 4 and observed Client A lying prone on the floor of the room with his hands tied behind his back using a soft tie. Staff 2 was in the room sitting in a chair that was positioned over Client A (who was on the floor). Staff I stated he again asked Staff 2 to release Client A. Then Staff 2 moved his chair from over the top of Client A and did release the soft tie restraint from Client A’s wrists. Staff 1 proceeded to give medications to Client A and left the room. Staff 1 could not recall the emotional status of Client A at the time of the observation. Staff 1 reported no other clients or staff members were in the room at the time of the observation. Staff 1 further stated he did not report either incident to anyone until December 30, 2003. On May 17, 2004, at 11:00 a.m., a review of the facility’s "Investigation Report" dated March 15, 2004, revealed an interview conducted with Staff 2 on February 5, 2004. The report indicated that Staff 2 admitted to tying Client A’s hands behind his back on one occasion, but denied sitting in a chair set over the top of Client A. Client A was subjected to unnecessary physical restraint and emotional anguish when Staff 2 tied his hands behind his back causing the client physical discomfort and denying the client’s right to freedom of movement, dignity, respect, humane care, and leaving the client vulnerable to further abuse from staff and peers. Therefore, the facility failed to ensure Client A was free from harm including unnecessary physical restraint, mental and physical abuse, and the facility failed to ensure that NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000346 Stale of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS V-ID-LA-T-ED 17-1354-0001849-S Date: 08/20t2004 Time: CLASS AND NATURE OF VIOLATIONS Client A was treated with dignity, respect, and humane care. The above violations caused or occurred under circumstances iikely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Client A and has a direct and immediate relationship to Client A’s health and safety. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND.SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000347 S.tate of California - Health and Human Services Agency Departmenl. of Public Health SECTION 1424 NOTICE Page 1 of 4 CITATION NUMBER: 17-1706-0001858-S Date: 12t07t2004 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) 76315(b) Incidenb’Complaint No.(s) : CA00029179 Department Of Developmental Services 3530 POMONA BLVD 170000772 POMONA, CA 91766 Type of Ownership: Stal,e Agency LANTERMAN DEVELOPMENTAL CENTER D/P ICFDD 3530 Pomona Bird Pomona, CA 91768 i909) 595-1221 Intermediate Care FacilitylDevelopmentally Disabled 170001773 CLASS AND NATURE OF VIOLATIONS CLASS B Capacity: 716 PENALTY ASSESSMENT $1,000.00 trebled to $3,000.00 DEADLINE FOR COMPLIANCE 12/21/04 12:00 a.m. CITATION --PATIENT RIGHTS 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. 76315. Developmental Pregram Services--Individual Program Plan, (b) The individual program plan shall be implemented as written. An unannounced visit was made to the facifity on August 51 2004, to investigate an unusual occurrence received on JL~ly 30, 20O4. Name of Evaluator: LYNN JANOSCO HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000348 S,tate of California ~ Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 4 CITATION NUI~IBER: SECTIONS VIOLATED 17-1706-0001858~S Date: 12/07/2004 Time: CLASS AND NATURE OF VIOLATIONS The results of this investigation revealed that the facility failed to: 1. Implement Client B’s Individual Program Plan (IPP) dated September 17, 2003 when they failed to provide "Direct Supervision" and escort Client B to a quiet place, away from peers, when agitated, and 2. Prevent harm when the staff failed to prevent Client B from biting Client A on two separateoccasions. Client A was a 40 year old, admitted to the facility with diagnoses that included Profound Mental Retardation. The Individual Program Plan dated March 19, 2004 described Client A as, "Non-verbal"... and "Does not verbally indicate the intensity or severity of her pain..." Client B was a 47 year old, admitted to the facility with diagnoses that included Profound Mental Retardation and behaviors that include biting self and biting others. Review of Client B’s Approaches and Strategies dated June 21, 2004, identified behaviors that include biting others, agitated/tantrums, throwing self to floor, screams and cries. It further stated Client B "Requires direct supervision when she is agitated due to her self injurious behavior...and aggression towards others, (Biting others)," Review of the Individual Program plan dated September 17, 2003, included Training Plan B-5-1 to reduce episodes of behaviors described as "Agitation/Tantrums (related to Impulse Control Disorder, Anxiety Disorder and Autism)...(Throws self to floor, screams whines, cries, paces, jumps fingers to nose...)" It indicated: When target behavior occurs intervene to prevent injury. Escort the client to a quiet area away from peers. Give verbal and physical prompts to calm her. She may respond to NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000349 State of California - Health and Human Services Agency Depadment of Public Healt.h SECTION 1424 NOTICE Page 3 of 4 CITATION NUIVIBER: SECTIONS VIOLATED 17-1706-0001858-S Date: 12/07t2004 Time: CLA,~S AND NATURE OF VIOLATIONS quiet time and staff should observe until calm. Reintroduce activities as tolerated and reinforce. Review of an incident report dated March 5, 2004 revealed Client B bit Client A and caused bleeding to Client A’s shoulder requiring a Physicians order to treat the wound by cleansing it with saline solution and applying Triple Antibiotic Ointment two times a day for seven days. Review of the incident report dated July 29, 2004, revealed Client A was participating in a small group activity on a visitingresidence, when without warning; Client B bit Client A on the back area. Prior to the incident, Client B was noted to be combative-engaging in self-injurious behavior: yelling, swinging at others and throwing herself to the floor. On September 2!, 2004 interview with Staff 1 was conducted. Staff I stated she and Staff 2 were assigned to "Life Skills" group. The entire group consisted of five clients, including Client A. Staff 3 entered into the group area with Client B, who was highly agitated, and "Dropped her off." Client B immediately bit Client A. Staff I described Client B’s behavior upon entering the Life Skills group room, as combative-hitting self, yelling, swinging at others and throwing herself to the floor. Staff 1 concluded the interview stating that she did not know Client B or her behavioral plan, Interview with Staff 2 on September 2I, 2004 at 10:35 a.m., stated When Staff 3 brought Client B into the "Life Skills" group, Client B was exhibiting self abusive behaviors such as biting herself and pulling on her own hair. Staff 3, without saying anything, left the group room, leaving Client B behind. Staff 2 further stated that she did not know Client B or her behavior plan. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000350 S!at,a of California - Health and Humar~ Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1706-0001858-S Date: 1210712004 Time: CLASS AND NATURE OF VIOLATIONS Interview with Staff 3 on November 2, 2004, indicated that Client B was in the "Rose" group, agitated. At that time, Staff 3 decided to remove Client B from the Rose group and place her in the "Life Skills" group room, next to Client A, near Staff 2 and then left the room. Staff 3 stated that she did not inform Staff 2 that Client B was on "Direct Supervision." She further stated, "1 assumed [Staff 2] was familiar with Client B’s behaviors." Review of the Physician’s Progress Notes dated July 29, 2004 at 3:15 p.m., stated," There is a bite mark on the posterior aspect of left back close to the left shoulder...there is a skin abrasion..." Therefore, the facility failed to: 1. Implement Client B’s individual program plan as written and provide direct supervision to prevent biting others. 2. Protect Client A from repeated physical abuse from Client B. The failure of the facility to implement the Client B’s program plan to provide direct supervision to prevent biting caused Client A unnecessary pain and treatment. The violation of the above regulation, either jointly, separately, or in any combination had a direct or immediate relationship to client health, safety or security. NOTE: IN ACCO)RDANCE WITH CALIFORNIA HEALTH AND 8AFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000351 State q.f California - Heatth and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 4 CITATION NUMBER: I7-1706-0001862-S Date: 04/20/2005 Time: Type of Visit ’Y-OLI-AR E- HIE R EBY-FOUIRD-III,q-V IOIzA-F I-O N -O F-A:p F~EI-C-A B- El.- Ih~Td~ldi~f- F~,~O00~507 CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: FaciIity Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) 76315(b) Department Of .Developmental Services 3530 POMONA BLVD 170000772 POMONA, CA 91766 Type of Ownership: State Agency LANTERMAN DEVELOPMENTAL CENTER DIP ICFDD 3530 Pomona Blvd Pomona. CA 91768 (909} 595-1221 Intermediate Care Facility/Developmentally Disabled 170001773 CLASS AND NATURE OF VIOLATIONS Capacity: 716 PENALTY ASSESSMENT $1,000.00 trebled to $3,000,00 DEADLINE FOR COMPLIANCE 5/4/05 12:00 a.m. CLASS B CITATION -- PATIENT RIGHTS 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement v~ritten policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. 76315. Developmental Program Services--Individual Program Plan. (b) The individual program plan shalt be implemented as written. During an investigation of a facility reported event it was determined that the facility failed to: Name of Evaluator: LYNN JANOSCO HFEN Without admitting guitt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signalure : Title : NO’lrE: tN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000352 Slate c~l California - Health and Human Services Agency Department of Public Health SECTION 1422~ NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS ’~tO -I=A-T-E- D 17-1706-0001862-S Date: 04/20f2005 Time: CLASS AND NATURE OF VIOLAT}ONS 1. Implement Client A’s program plan as written, 2. To ensure Client A remained free from harm including abuse and neglect. Client A, 29 years of age, admitted to the facility with diagnoses that included Profound Mental Retardation, Cardiomegaly, Retinal Detachment (both eyes) and Impulse Control Disorder secondary to Autism. The individual Program Plan (IPP), dated June 22, 2004, stated, the client could make his needs known by using gestures, body language, sign language, and leading the staff to a desired item. Review of Client A’s the medical record revealed a special team dated August 3, 2004 and identified maladaptive, "Aggressive" behaviors that include; hitting his head with his hands, hitting, kicking, biting, pinching, and pushing others. Risks include self injurious behavior, and destroying property. Further review of the medical record revealed a special team on October 28, 2004, held by the Behavior Review Group. The discussion included the client’s history of surgical repair to both eyes for retinal detachment requiring 1:1 direct supervision to prevent rubbing or causing further injury. It further stated, "Staff should remain within arms reach" of the client in all environments and that the clientis "At grave risk of becoming totally blind." Adaptive equipment required included a protective helmet with faceguard and Plexiglas cover, worn during walking hours and full-length arm splints as a protective device that will disable his attempts to beat on his head and face area. Review of the incident report dated November 21,2004, revealed on November 20, 2004, the night shift Staff I, NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000353 State %f California - Health and Human Services Agency Department of Public Health SEC~I’ION 1424 NOTICE Page 3 of 4 CITATION NUMBER: SECTIONS \LID_LA_T_ED 17-1706-0001862-S Date: 04/20/2005 Time: CLASS AND NATURE OF VIOLATIONS assigned as the 1:1 arrived at 11:00 p.m. and entered Client A’s bedroom. The client was found in bed, unsupervised, without any protective equipment in place. On January 19, 2005, at 6:20 a.m. interview with the assigned 1:1, night shift member, Staff 1 revealed that he found the client, laying on top of his bed, when he entered into Client A’s bedroom, on November 20, 2004 at 11:00 p.m. Staff I further stated that "[The client] was awake when I walked in his room and there was no staff around." Review of the incident report dated November 21,2004, revealed that Staff 1 did not report to the night shift charge person that the client was found unsupervised. It further stated in the morning, Staff 2,. the assigned 1:1, received the client and at 8:00 a.m., undressed the client. After the client’s shirt was removed, numerous bruises and . red marks were found. The marks were numbered, totaling 14. An assessment was made by the Senior Psychiatric Technician and indicated, 7 of the 14 marks "Have same similar shape, resembling same type of discolorations; Injuries are serious in nature, and are of unknown origin." Review of the photographs, taken by the Office of Protective Services on November 21,2004, noted marks to the client’s front and back torso. Review of a physician’s note dated November 21,2004 at 9:45 a.m.,following an assessment, revealed multiple skin lesions/bruises on chest/abdomen and back and the cause was "Unknown," Review of the physician’s order dated November 21, 2004, revealed an order for Tylenot 650 milligrams every four hours as necessary, for pain and discomfort for three days. Therefore, the facility failed to ensure the client remained free from harm, abuse and neglect when they failed to NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000354 State of California ~ Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 4 CITATION NUIVIBER: SECTIONS V-IO.-[=A-T-~D. 17-1706-0001862~S Date: 04/20/2005 Time: CLASS AND NATURE OF VIOLATIONS implement the Individual Program Plan as written when they failed to provide 1:1 direct supervision and protect the client from injuries of unknown origin which resulted in unnecessary emotional pain, physical pain and suffering. The above violations, either jointly, separately, or in any combination, had a direct or immediate relation to patient health, safety, or security. NOTE: IN ACCORDANCE WITH CAL I=ORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOOATION OF YOUR LICENSE DPH POD 000355 State.of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE ¯ Page 1 of 3 CITATION NUMBER: 17-1706-0001866-S Date: 05/2412005 Time: Type of Visit ¯ --¥OLI-ARE-H EREB¥-FOLI N D-IN-~71OL3~TION-OF-APP LICABLE lh-~Fd6fit/oC~l~-i~t-N .---(-.~)-T. o C;~0-0035987 CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: Lice nse N um ber: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS V~OLATED 76525(a)(20) Department Of Developmental Services 3530 POMONA BLVD 170000772 POMONA, CA 91766 State Agency Type of Ownership: LANTERMAN DEVELOPMENTAL CENTER DIP ICFDD 3530.Pomona Bird Pomona, CA 91768 (909) 595-1221 Intermediate Care FacilitytDevelopmentally Disabled 170001773 CLASS AND NATURE OF VIOLATIONS Capacity: 716 PENALTY ASSESSMENT $6,000.00 trebled to $18,000.00 DEADLINE FOR COMPLIANCE 6116/05 12:00 a.m. CLASS A CITATION -- PATIENT RIGHTS 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. On December 21, 2004, an unannounced visit to the facility was conducted to investigate a facility reported event. During the investigation, it was determined that the facility failed to: 1. EnsureClient A remained free from harm including abuse and neglect. Client A was 42 years of age, admitted to the facility with Name of Evaluater: LYNN JANOSCO HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000356 State t~f California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIO bA-’PED 17-’1706-0001868-S Date: 05124t2005 Time: CLASS AND NATURE OF ViOLATiONS diagnoses that included Osteoporosis, Profound Mental Retardation, Epilepsy, Anxiety, and Unsteady Gait. An incident report dated Decembe; 15, 2004, stated that Staff I was assigned as a. 1:1, for Client A’s protection, due to a fracture to his right foot. It further stated Client A became upset, jumped from his wheelchair and fell on the floor. While on the floor Client A was struggling and purposefully scratched Staff 1 on the face. The incident resulted in discoloration.to Client A’s right eye. An addendum was attached to the incident report, the next day, on December 16,. 2004. It stated that the reported incident was witnessed by Staff 2. Staff 2 reported after Staff 1 was scratched by Client A, he grabbed Client A around the neck and struck Client A in the right eye which resulted in discoloration to the area. Review of the physician’s note dated December 16, 2004, revealed "Area under Rt (right) eye is swollen with purple and blue discoloration, has a red line (1/2") within discolored area." Review of the interdisciplinary notes dated December 15, 2004, at 1:00 p.m., revealed the client was placed on head injury precautions. A declaration regarding the December 15, 2004, incident from the witness (Staff 2), was written February 23, 2005, and stated that while the witness was in the group room, Staff 1 entered, pushing client A in a wheelchair. Client A became anxious and Staff I attempted to verbally redirect him, but was unsuccessful. CLient A began demanding "Green pants." At that time, Staff I got up and began strangling the client. Staff 2 reported, "1 told him to stop and tried to intervene when the client reached up and scratched Staff l’s face, knocking off his glasses" ... Staff 1 "Knocked over the client’s wheelchair and grabbed Client A’s helmet. He jerked it off and began striking the client with a closed fist." Staff 2 stated she picked the wheelchair up and put the client’s helmet back on when she noticed swelling below NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000357 State t~f California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VlO -£A-TBB 17-1706-0001866-S Date: 05t24/2005 Time: CLASS AND NATURE OF VIOLATIONS Client A’s eye. Lastly, Staff 2 reported, "1 was shocked, ter~’ified and completely afraid..." On February 23, 2005 at 5:40 p.m., an interview with Staff 2 revealed before the incident, she was good friends with Staff 1. However, she did not report the abuse at the time of the incident because she was "Scared and intimidated" by Staff 1. Staff 2 did however admit that this was the second time she witnessed abuse to a client by a staff member and did not report either incident, at the time that the incident occurred. Therefore, the facility failed to: 1. Ensure Client A remained free from harm, abuse, and neglect. This resulted in Client A sustaining an injury to his right eye which resulted in swelling with purple and blue discoloration and head injury precautions being ordered by the physician. The above incident happened under circumstances likely to cause Significant humiliation, indignity, anxiety, or other emotional trauma, and presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS tS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000358 State ef California - Health and Hum&n Services Agency Department of Public Health SECTION t424 NOTICE Page 1 of 4 CITATION NUMBER: I7-1706-0001865-S Date: 05/24/2005 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORN IA STATUTES AND REGULATIONS OR APPLICABLE IncidenttComplaint No.(s) ’ CA00028890 FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a){16) Department Of.Developmental Services 3530 POMONA BLVD 170000772 POMONA, CA 91766 State Agency Type of Ownership: LANTERMAN DEVELOPMENTAL CENTER D/P ICFDD 3530 Pomona Bird Pomona, CA 91768 (909) 595-1221 Intermediate Care Facility/Developmentally Disabled Capacity: 716 170001773 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $25,000.00 DEADLINE FOR COMPLIANCE 6/16/05 12:00 a.m. CLASS AA CITATION .- PATIENT CARE 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section, Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (16) To prompt medical care and treatment. On July 29, 2004° an unannounced visit to the facility was conducted to investigate a facility reported event. The results showed that the facitity failed to provide Client A with prompt medical care and treatment. Client A was a 35 year old male admitted to the facility with diagnoses that incfuded Severe Mental Retardation, Epilepsy Grand Mal, Constipation Unspecified, Gastritis, and Status Post Ileum Colectomy in 1999. Client A’s Individual Program Plan (IPP) dated July 6, 2004, Name of Evaluator: LYNN JANOSCO HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature ¯ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000359 State ~f’ California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS ~1© L-A-7~D 17-1706-0001865-S Date: .05124/2005 Time: CLASS AND NATURE OF VIOLATIONS described the client as ambulatory, establishes eye contact, speaks in clear 2 to 3 word sentences and listens when others speak. Client A required close supervision while on the residence and direct supervision during mealtime, "Due to a history of bowel obstructions." The individual program plan dated July 6, 2004, stated that Client A required hospitalization on January 5, 2004, following episodes of emesis (vomiting) with diagnoses of Small Bowel Obstruction and returned to the residence on January 13, 2004. On June 28, 2004, the client required acute care hospitalization for diagnoses of recurrent emesis and hypotension (low blood pressure), and received intravenous fluids with added Potassium to replace fluid loss, due to emesis. The client returned to the residence on June 29, 2004. Review of Client A°s approaches and strategies dated July 6, 2004, described the client as having significant risks and safety issues that included, "... Lack of appetite may indicate bowel problems..." Review of the medical record documented the following on July 22, 2004: a. The interdisciplinary notes (IDN’s) documented at 2:20 p.m,, "While at D-tac (Day Treatment Activity Center), the client had an episode of emesis, large in quantity." "Med (medication) nurse was notified." b. Health Services Specialist documented on 4:30 p.m., "Monitor/record emesis and bowel movements" ... call MOD (Medical Doctor on duty) for any problems." c. The IDN’s documented at 9:00 p.m., "Client refused his dinner." At 10:1,5 p.m. the IDN’s indicated that the client had emesis two times and at 10:20 p.m., the Assistance Coordinator of Nursing Services (ACNS) was notified. ACNS NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS 1S GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000360 State ~f California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 4 CITATION NUI~IBER: SECTIONS VIOL-A-FED 17-1706-0001865-S Date: 05/24/2005 Time: CLASS AND NATURE OF VIOLATIONS instructed the staff to take vital signs and monitor. d. The IDN’s documented at 10:30 p.m. (approximately 8 hours after the first emesis) the MOD was contacted. A new order was obtained to take vital signs every 4 hours for 24 hours, and placed the client on a clear liquid diet for 24 hours. On July 23, 2004, the next day at 3:50 a.m., the IDN’s indicated that the client "Appeared restless" before he "Suddenly slumped to the floor and began emesis." A second episode of emesis occurred. The unit staff notified the ACNS and then the MOD and informed the physician of the client’s history of "Bowel Obstruction." Tlie MOD instructed staff to "Clean him up and put him back to bed, keep an eye on him and put him up for Doctor’s attention in the a.m." Review of the physician’s progress notes dated July 23, 2004, at 5:00 a.m. (15 hours after the first episode of emesis) stated, "Looks dehydrated and indicated the blood pressure was few." The physician documented, "Vomiting, R/O (Rule out) obstruction," and. ordered the client be sent to a community hospital emergency room. On July 23, 2004, at 6:15 a.m., the medical record revealed "Grand MaP’ seizure activity ... blood pressure 90/68. The client was.described as "Very pale," and at 6:55 a.m., the 1DN’s stated Grand Mal seizure activity was observed for the second time ... and the documented blood pressure was 80/60 and the MOD was notified. On July 23, 2004 at 7:00 a.m., ACNS notified the MOD of a low blood pressure of "80t50." Interview with licensed staff confirmed the physician did not return to the residence after he was notified of seizure activity and a decline in blood pressure. The paramedics arrived and {ransported the client to the NOTE: IN ACCORDANCE WITH CALIFORNIA HEAL~’H AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000361 Sta.te~f California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS V-IO.LA_T-F_D 17-1706-0001865-S Date: 05/24f2005 Ti~ne: CLASS AND NATURE OF VIOLATIONS community hospital at 7:08 a.m. (2 hours after Client A was ordered to be transferred to the emergency room for treatment). Review of the Emergency Room Department Stat Admission Report dated July 23, 2004, timed 8:12 a.m., documented "There are no bowel sounds." "The abdomen is extremely hard, rigid and tender." ... The client is "Well known to have bowel obstructions in the past." Diagnoses included "Probable Small Bowel Obstruction with Perforation." At 1:57 p.m., the client expired in the emergency room, with diagnoses that included Septic Shock and Bowel Obstruction. The Autopsy Report dated July 29, 2004, stated, "Small Bowel Obstruction with Ischemia," (Lack of blood supply). Therefore, the facility failed to provide Client A with prompt medical care and treatment. The failure caused Cient A to go without needed medical treatment for several hours. Client A suffered unnecessary pain and discomfort; the client became hypotensive, began seizure activity, developed Sepsis, and died due to a bowel obstruction. The above violations 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 death. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT WOLA’flONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000362 State of California - Health and Human Services Agency Department of Public Health SECTION ’1~i24 NOTICE Page 1 of 4 CITATION NUMBER: 17-1220-0001868-S Date: 06/15/2005 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE Incident/Complaint No.(s) " CA00037293 CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Department Of Developmental Services Licensee Name; Address: 3530 POMONA BLVD 170000772 License Number: Address: Telephone: State. Agency 3530 Pomona Bird Pomona, CA 91768 (909) 595-1221 Intermediate Care FacilitytDevelopmentally Disabled Facility Type: Facility ID: 76345(a)(2) 76345(a)(1) Type of Ownership: LANq’ERMAN DEVELOPMENTAL CENTER DIP ICFDD Facility Name: SECTIONS VIOLATED POMONA, CA 91766 Capacity: 716 t70001773 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 I DEADLINE FOR COMPLIANCE 6/28/05 12:00 a.rn~ CITATION-- PATIENT CARE 76345. Health Support Services--Nursing Services. (a) Facilities shall provide nursing services in accordance with the needs of the clients for the purpose of: (1) Development and maintenance of an environment that will meet their total health needs. (2) Assistance in achieving and maintaining optimal health. On January 19, 2005, an unannounced visit was made to the facility to investigate a facility reported event, Subsequent visits were made to the facility on January 26, 2005 a~d January 27, 2005. The 1) 2) 3) Name of Evaluator: Naomi Russell HFEN facility failed: To assure that each client was free from harm. Have an environment that meets the clients’ health needs. Achieve and maintain optimal health for the clients. Without admitting guilt, 1 hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature ’ Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000363 State of Ca~ifo[nia - Health and Human Services Agency Department of Public Hea;th SE(~T[ON 1424 NOTICE Page 2 of 4 CITATION NUI~BER: SECTIONS 17-1220-0001868-S Date: 06t15f2005 Time: CLASS AND NATURE OF VIOLATIONS Client "A", a female 51 years of age, was admitted to the facility on January 3, 1955, with a diagnosis of Profound Mental Retardation. She is blind in her left eye and has a mature cataract in her right eye. She communicates by gestures and taking people by the hand to make her needs and wants known. She also requires staff assistance to complete all activities of daily living and wears an adult brief at all times. Review of the Interdisciplinary Notes (IDN) dated January 7, 2005 at 10:07 p.m., it was documented, "Buttock area first layer of skin (epidermis) peeling off on some areas about 2 cm in diameter times two, also lower back area some blisters noted, no drainage, no areas open, area kept clean and dry, A&D ointment treatment applied and tolerated well." Review of the RN/HSS (Registered Nurse/Health Support Services) notes dated January 8, 2005 at 1:05 a.m. stated, "It was called to my attention at about 0110 hours (1:10 a.m.). This Client’s buttocks: Client standing up holding onto rail, supported by staff, buttocks reddened, blisters noted, about to burst. Reddened area on buttocks is shaped like a v. Buttockslperennial areas cleansed carefully by staff, measurements as followed; Reddened buttocks-20 cm x 26 cm, blisters that burst measures 3 cm, 4 cm and 7 cm, skin peeled off, redden. Skin reddened on right side of buttocks measures 7.5 cm times 6 cm and left side measures 2.5 cm." Review of the physician’s progress notes dated January 5, 2005 at 1:30 a.m., documented, ’1 was asked to see resident because of a big area of skin redness on buttocks. There is erythematic area on both buttocks measuring about 20 cm by 26 cm. There are several small areas of blister or peeling off of superficial skin layer - on red area. Plan: local RX (treatment), analgesic." A review of Approaches and Strategies dated July 28, 2004, NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000364 State of California - Health and H~Jrnan Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 4 CITATION NUMBER: SECTIONS --VlOEA--FED 17-1220-0001868-S Date: 06/15t2005 Time: CLASS AND NATURE OF VIOLATIONS which stated under Activities of Daily Living: "Toileting: Assist to use the bathroom at least every two hours." On January 27, 2005, at 1:30 p.m., an interview was held with Staff 1, who stated that she has had Client "A;’. on morning shift. Staff 1 further stated she had not seen any irritation to Client "A’s" adult brief area during her shift. Staff 1 stated she got the client up at around t2:30 p.m., and took her to the bathroom, which the client used. Client ’W’ was wearing new adult briefs and was placed back in her recliner. Staff 1 checked her between 2:00 p.m. and 2:30 p.m., and staff stated Client "A" was sleeping at that time and she was dry. On January 27, 2005, at 3:15 .p.m., an interview was held with Staff 2, who stated: "1 was floated to Residence 1 after the huddle, and then the unit decided that they didn’t need me so i came back to my residence around 4:15 p.m. Then, I was assigned Client "A" and helping the other group leaders with their clients on anything they need. At 1715 (5:15 P.m.) I helped everybody and assisted them with feeding too; clients usually finish eating a~-ound 1830 (6:30 p.m.). Then, I used the shower of the group leader who went to lunch, then 1 found Client "A" in really bad shape, ] called my supervisor and he looked at it, and told me to keep her clean and that she had an open problem for that, and apply A&D ointment, and write a good IDN. About 2130 (9:30 p.m.), I changed her again and wrote my IDN at the end of my shift," Review of the facility’s incident report level one dated January 8, 20905, stated: "...Client "A" was not changed from 1215 p.m. (12:15 p.m.) to 1830 (6:30 p.m.) a period of 6 hours and 15 minutes..." Client "A", is non-verbal and depended on staff’s assistance with her activities of daily living, including toileting (changing her adult brief). Client A sustained erythematous NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000365 State of California - Health and Human Services Agency SEC,TION’ 1424 NOTICE CITATION NUMBER: SECTIONS V-I O IA-T- E-D Department of Public Health ¯ Page 4 of 4 17-1220-0001868-S Date: O611512005 Time: CLASS AND NATURE OF VIOLATIONS area on both buttocks measuring about 20 cm by 25 cm and several smalJ areas of blister or peeling off of superficial skin layer area. Therefore, the facility failed to provide nursing services in accordance with the client’s needs for the purpose of assistance in achieving and maintaining optimum health. The violations of the regulations jointly, separately or in any combination had a direct or immediate relationship to the health, safety, and security of all patients of the facility. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAI=TEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000366 State’0f California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 174104"1-0001797-S Date: 11/04t2002 Time: Type of Visit: YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLfCABLE Incident/Complaint No.(s) " 170021024 FEDERAL STATUTES AND REGULATIONS State Of Calif, Dept. Of Developmental Services Licensee Name: Address: P. Q, BOX 2000 170000837 License Number: Facility Name: Type of Ownership: State Agency PoR:rERVILLE DEVELOPMENTAL CENTER D/P ICFDD (STP) Address: Telephone: 26501 Avenue 140 Poiterville, CA 93257 (559) 782-2876 Intermediate Care FacilitytDevelopmentally Disabled 170001877 Facility Type: Facility ID: SECTIONS VIOLATED 76315(b) 76525(a)(20) PORTERVlLLE, CA 93258-2000 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $900.00 Capacity: 469 DEADLINE FOR COMPLIANCE 1t~11/02 12:00 a.m. CLASS B CITATION -- PATIENT CARE The facility failed to ensure that: a) Client L’s individual program plan was implemented as written; b) Client L was free from harm.. Client L was an 18-year-old male admitted to the facility on June 9, 1997, with diagnoses that included moderate mental retardation, unspecified disturbance of conduct and unspecified aggression. On July 29, 2001, at 1435 hours, while being escorted, from the nurses’ station to group therapy, by Staff F and R, Client L became aggressive and assaultive. According to the facility’s Incident Report, two staff members, Staff R and Staff F, implemented a ’prone containment,’ restraining Client L on the floor with their bodies. Five minutes into the containment, Client L continued with combative behavior and a ’pop’ of the right arm was heard and the client complained of pain. The prone containment was halted. An Name of Evaluator: Deborah Van Arsdel HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000367 State ~)t~ California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 17-~104"1-0001797-S Date: 11/04/2002 Time: CLASS AND NATURE OF VIOLATIONS x-ray confirmed a fracture of the client’s upper right arm. According to Staff F’s statement to the police and written declaration, on July 29, 2001, at the time they placed the client in ’floor containment,’ Client L ’kept twisting his arms ahd struggling,’ and then the ’arm broke.’ According to Staff R’s written statement, ’while in containment Client L continued with aggression, tugging and yelling. Five minutes into the containment, staff heard a pop.’ Facility administrative staff determined that the fracture resulted from ’increased pressure’ applied to the arm by staff during the prone containment. The IPP (individual Program Plan) in the client’s clinical record specified that when the client demonstrated antecedents to assault, as he did become upset, yelling and ran down the hall, staff were to immediately utilize prone containment with up to four staff members. If the prone containment was ineffective, then five point restraints were to be utilized. The IPP Desired Outcome and Milestones further directed that if the client ’becomes aggressive to staff or peers, get extra staff immediately.’ This process had been successfully followed without injury five days earlier on 7/24/01. Per a Restrictive Behavior Intervention Technique (RBIT) note, during the 7/24f01 prone containment, four staff members were utilized ’for protection of self and others.’ When he continued to attempt to pull out of the containment, he was put into five-point restraints. As documented on 7t29t01, only Staff R and F were physically involved in containing Client L on the floor and no other staff assisted with the containment as outlined in the IPP. There was a lack of evidence that an adequate number of staff participated in the prone containment or that five point restraints were utilized when the prone containment NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUND8 FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000368 Sta, te;of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUNIBER: SECTIONS VIOLATED 17-1041-0001797-S Date: 11/04/2002 Time: ’CLASS AND NATURE OF VIOLATIONS proved ineffective as indicated in the IPP. The facility’s failure to ensure the implementation of Client L’s individual program plan, as it related to containment, had a direct or immediate relationship to the health, safety, or security of Client L and constitutes a ’B’ citation. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000369 State,of California - Health and Human Services Agency Depadment of Public Health SECTION 1424 NOTICE Page 1 of 5 CITATION NUMBER: 17-1464-000t798-S Date: 11/07f2003 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number; Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED IncidentlComplaint No.(s) ¯ 170021862 State Of Calif. Dept. Of Developmental Services P. O. BOX 2000 170000837 PORTERVILLE, CA 93258-2000 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD (STP) 26501 Avenue 140 Porterville, CA 93257 (559) 782-2876 Intermediate Care Facility/Developmentally Disabled Capacity: 469 170001877 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $25,000.00 5o5~0(a)(8) CLASS AA CITATION -- PATIENT RIGHTS 76525(a)(20) The facility failed to ensure a client’s right to be free from harm, including unnecessary physical restraint and abuse or neglect and failed to follow the facility’s policies and procedures, when Client A died during a containment procedure. I DEADLINE FOR COMPLIANCE 11t7/03 12:00 a,rn. On April 14, 2003 at 3:57 p.m., via telephone; the Department received a special incident report from Porterville Developmental Center. The incident involved the death of faci]ity Client A during a prone containment procedure. The investigation into the incident was initiated on June 9, 2003. Review of client records on June 9, 2003 for Client A revealed that he was a 37 year-old male of large stature, (approximately 300 pounds and six feet tall), admitted to the facility on June 2, 1997. His admission diagnoses included mild mental retardation, pedophilia0 paranoid schizophrenia, and deafness. He used American Sign Language (ASL) to communicate. He had an open behavior plan for Harm to Others and a long history of arrests on charges that Name of Evaluator: Without admitting guilt, I hereby acknow]edge receipt of this SECTION 1424 NOTICE Linda Wilkinson HFEN Signature : Name : Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA.HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000370 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 5 CITATION NUMBER: SECTIONS VIOLATED 17~1464-0001798-S Date: 11/07f2003 Time: CLASS AND NATURE OF VIOLATIONS included molestation, kidnapping, and battery. Interdisciplinary Notes (lDN)’s revealed that he has a history of physical altercations with peers, multiple episodes of non-compliance with staff direction, refusal of meals and medications, refusing to attend his work site and a history of attempts to escape from his unit. On July 7, 2003 at 11:15 a.m and July 23, at 8:50 a.m., during interviews with Staff 2, he stated that on April 13, 2003 at 1:00 p.m. while working on Unit 17, he heard Staff 1 yell, ’he’s got my keys’, indicating Client A. Staff 2 stated Client A was deaf so he motioned with his hand for Client A to ’give up the keys’. Staff 2 stated that by the time he got to Staff 1, Client A had stabbed Staff 1 and ran down the hall where he (Client A) stabbed Client B. Staff 2 stated that he attempted to restrain Client A using a oneperson containment. He used his right arm around Client A’s shoulders, grasping Client A’s left shoulder with his right hand in an effort to restrain Client A. Staff 2 and Client A went to the .ground and Staff 2 was lying on Client A’s back. Client A attempted to bite Staff 2’s arm, so Staff 2 brought his arm closer to his body to prevent the client from biting him. Staff 2 stated he knew Active Treatment Crisis Management (ATCM) did not instruct the staff to lay on top of, a client or to initiate a one-person containment, but he had ’to do something’ to stop Client A from stabbing people. Staff 2 stated he wasn’t sure how long Client A struggled, but when Client A became limp, he was rolled onto his back and was not breathing. The facility emergency plan was activated, CPR was initiated, an ambulance was called and Client A was transferred to the GACH. On July 7, 2003 at 12:00 p.m., during an interview with Staff 3, he stated that he responded to an alarm on April 13, 2003 at 1:00 p.m., from Unit 17 to assist another staff person. When he arrived, he stated no other staff were assisting Staff 2 and that Client A and Staff 2 were on the ground. Staff 3 went to Client A’s right side and removed NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS tS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000371 Sta~e of California - Heal[h and Human Services Agency Page 3 of 5 ’SECTION 1424 NOTICE CITATION NUI~IBER: SECTIONS VIOLATED Department of Public Health 17-1464-0001798-8 Date: 11/07/2003 Time: CLASS AND NATURE OF VIOLATIONS the keys from Client A’s right hand. Staff 3 stated Client A was on his right side and Staff 2 was on his knees bent over Client A’s head with his arm around Client A’s head. On Jufy 7, 2003 at 1:00 p.m., during an interview with Staff 4, he stated that on April 13, 2003, a male staff member summoned him from Unit 17, waving his hands to indicate he needed help. When he arrived on unit 17, he saw Staff 2 lying on top of Client A using his weight to hold Client A down. Staff 4 stated that Client A ’struggled for about 15 to 20 minutes.’ Review of the facility crime report on August 7, 2003 that was completed by the Senior Special Investigator revealed Facility Peace Officer (FPO) 1 stated he observed Staff 2’s arm around Client A’s throat. The Special Investigations Crime Incident Report signed by the Senior Special Investigator on July 3, 2003, states that FPO 1 ’...reported that he saw (Staff 2’s) right arm around (Client A’s) throat and that (Staff 2) pulled up on (Client A’s) th[:oat to allow passage of a wrist restraint belt, The same document stated that Staff 7 ’...reported that he saw (Staff 2) pulling the upper part of the client’s body off the floor to allow passage of the wrist restraint under the client’s body.’ On July 7, 2003 at 11:15 a.m. and July 23, at 8:50 a.m., during interviews with Staff 2, he stated that he had been employed at the facility for three and one half years. He indicated he had received ATCM training during his new hire orientation and had received annual in-service training in ATCM. When Staff 2 was asked what the facility Policy and Procedure (P&P) was for Managing Maladaptive Behaviors, he said he was unsure of what the P&P required. On July 7, 2003 at 12:00 p.m., during an interview with Staff 3, he stated he had been employed at the facility for NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000372 St,ate ef California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 5 CITATION NUI~1BER: SECTIONS VIOLATED 17-1464-0001798-S Date: 11/07/2003 Time: CLASS AND NATURE OF VIOLATIONS 15 years. He had received ATCM training in his new hire orientation and had received annual in-services in ATCM. stated that he learned in the training that staff are to use the least restrictive method for a client containment. He Review of the Special Investigations Crime Incident Report on August 7, 2003 signed by the Senior Special Investigator on July 3, 2003, states that ’(Staff 2) admitted that he jumped on (Client A’s) back with his arms around (Client A’s) shoulders, (Client A) bent over at the waist, then went to the floor in a face-down position with (Staff 2) lying across (Client A’s) back.’ The report stated that FPO 1 ’...reported that he saw (Staff 2’s) right arm around (Client A’s) throat and that (Staff 2) pulled up on (Client A’s) throat to allow passage of a wrist restraint belt.’ The same document stated that Staff 7 ’reported that he saw (Staff 2) pulling the upper part of the client’s body off the floor to allow passage of the wrist restraint under the client’s body.’ Review of the Facility Bulletin #104-Behavior Management, ~11. CRISIS SITUATION, B. Requirements, #2. Active Treatment Crisis Management on August 7, 2003 revealed that the use of only enough force to control the situation must be used during the application of ATCM techniques. All physical interventions that require containment minimally utilize two-person containment proced ures. The final autopsy report dated April 15, 2003 states the cause of death for Client A was ’cardiac dysrhythmia due to prolonged left carotid artery compression.’ Under comments on the final autopsy report, it states, ’The cause of death appears to include an element of asphyxia with vagal inhibition.’ The Certificate of Death for Client A, dated April 29, 2003, states under cause of death, ’Cardiac dysrhythmia’ and ’Prolonged ]eft carotid artery compression.’ NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000373 Slate, ef California - Health and Human Services Agency Page 5 of 5 ’SECTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health 17-1464-0001798-S Date: 11f07t2003 Time: CLASS AND NATURE OF VIOLATIONS The facility failed to ensure Client A’s rights to be free from harm, including unnecessary physical restraint and abuse or neglect and failure to follow the facility’s 3olicies and procedures when Staff 2 initiated a one-person physical containment on Client A, falling to the floor in a tengthy struggle resulting in cardiac dysrhythmia due to 3rolonged left carotid artery compression and was the direct 3roximate cause of death of Client A. The above 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 and was a direct proximate cause of the death of the patient and constitutes a Class ’AA’ Citation. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDSFOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000374 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3. CITATION NUMBER: 17-1041-0001861 -S Date: 02f0112005 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS State Of Calif. Dept. Of Developmental Services Licensee Name: Address: P. O. BOX 2000 Facility Name: Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER DIP ICFDD (STP) Address: Telephone: 26501 Avenue 140 Porterville, CA 93257 . (559) 782-2876 Intermediate Care FacilitytDevelopmentally Disabfed Facility Type: Facility ID: Capacity: 469 170001877 SECTIONS VIOLATED 76525(a)(20) PORTERVILLE, CA 93258-2000 170000837 License Number: 76337(a) 76521 (b) Incident/Complaint No.(s) ’ No complaints found CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $800,00 DEADLINE FOR COMPLIANCE 2122105 12:00 a,m, CITATION- PATIENT CARE 76337. Developmental Program Services--Staffing. (a) Qualified personnel and necessary supporting staff to carry out the programs .shall be available. 76521. Policies and Procedures. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to clients or their agents, employees and the public, and shafl be carried out as written. Policies and procedures shall be reviewed at least annually, and revised as needed. 76525. Clients’ Rights. (a) Each client has the rights tisted in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: Name of Evaluator: Deborah Van Arsdel HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTIEY CODE, FAILURE TO CORRECT " VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000375 Stare’of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 17-1041-0001861-S Date: 02/01t2005 Time: CLASS AND NATURE OF VIOLATIONS (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. On October 12, 2004, an unannounced visit was made to the facility to investigate a facility reported event. The facility failed to: 1~ Provide qualified personnel and necessary supporting staff to carry out the programs. 2. Follow facility policy and procedures for prone containment. 3. Protect Client J from harm. Client J was a 29-year-old male admitted to the facility with diagnoses that included mild mental retardation, impulse control disorder, psychotic disorder, aggression, and epilepsy. Client J’s individual program plan dated June 9, 2004, identified interruption. "while using his radio" as an antecedent to physical assault. The facility’s Incident Report had the following description of the incident that occurred on October 3, 2004, at 5:00 p.m. Client J refused staff’s request to come inside the unit for dinner. Staff K approached Client J and removed the headphones for the client’s Walkman radio. The client became "violent" and "went" for staff, Staff placed the client in a "prone" containment (to physically restrain the client prone on the floor). While the staff had Client J in the prone position, Client A grabbed Client J’s Walkman and threw it over the fence. Client A then punched Client J in the face and Client T kicked Client J in the head. Client J sustained a 6.5 x 4 cm bump to the right side of his head, a 1 cm abrasidn to his right eyebrow and several superficial abrasions to the right eyebrow and several NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000376 State Of California - Health and Human Services Agency Department of Public Health SECTION t424 NOTICE Page 3 of 3 CITATION NUMBER" SECTIONS VIOLATED 17-1041-0001861-S. Date: 02/01/2005 Time: CLASS AND NATURE OF VIOLATIONS superficial abrasions to the right side of his face. The Senior Psychiatric Technician (SPT) on duty at the time of the incident was interviewed on October 17, 2004, at 3:30 p.m. The SPT stated the only two staff members in the immediate area performed the prone containment. She was doing a one-on-one supervision with another client when the incident occurred. She was not made aware of the situation by staff, b#t rather by other clients. Facility policy and procedures on behavior management, Facility Bulletin No. 104, was reviewed on November 16, 2004. The policy and procedure dated February 2004 stated physical floor containments could only be performed with minimum of at least three staff members. An additional "observer" iS required to watch for any signs of physical duress throughout the restraining episode. Therefore, the facility failed: 1. To protect Client J from harm inflicted by Clients A and T while staff held Client J down on the floor, 2. Failed to provide necessary supporting staff to carry out a safe physical prone containment on the floor, and by performing a prone containment with only two staff members, and 3. Failed to ensure staff followed the facility’s policy and procedure for a safe and proper prone containment. The above violations either jointly, separately, or in any combination had a direct or immediate relationship to the health, safety, or security of Client J and all clients in ~he facility. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000377 State of California - Health and Human Services Agency Department of Public Health SECTION ’1424 NOTICE Page 1 of 4 CITATION NUIt,/1BER: ‘17-1041-0001860-S Date: 02101t2005 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS State Of Calif. Dept. Of Developmental Services Licensee Name: Address: P. O. BOX 2000 PORTERVILLE, CA 93258-2000 170000837 License Number: Facility Name: Type of Ownership: State Agency POR:]-ERVILLE DEVELOPMENTAL CENTER DIP ICFDD (STP) Address: Telephone: 26501 Avenue 140 Porterville, CA 93257 (559) 782-2876 Intermediate Care FacilitytDevelopmentally Disabled Facility Type: Facility ID: Capacity: 469 170001877 SECTIONS VIOLATED 76337(a) 76525(a)(20) Incident/Complaint No.(s) " No complaints found CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $800.00 DEADLINE FOR COMPLIANCE 2/22t05 12;00 a.m. CITATION--PATIENT CARE 76337. Developmental Program Services--Staffing. (a) Qualified personnel and necessary supporting staff to carry out the programs shall be available. 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shalt not be denied or withheld except as provided in (c) of this section. Each facilityshall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect, On October 12, 2004, an unannounced visit to the facility was conducted to investigate a facility reported event. It was determined the facility failed to: Name of Evaluator: Deborah Van Arsdel HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evalualor Signature ’ Title : NOTE: iN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000378 State of California - Health and Human Services Agency Departmenl of Public Health SECTION 1424 NOTICE Page 2 of 4 CITATION NUI~IBER: SECTIONS VIOLATED 17-1041-0001860-S Date: 0210112005 Time: CLASS AND NATURE OF VIOLATIONS 1. Provide qualified personnel and necessary supporting staff to carry out the programs, and 2. Protect Clients A and S from harm. Client M~s individual program plan (IPP) dated August 25, 2004, documented a history of physical aggression and harm to others. It was documented that the clien’~ had required physical restraints on "many occasions" in the past year due to his tendency to overreact with anger and quickly escalate to physical aggression. There was an open behavior plan, B 2.1, for "Harm to Others." He had 32 incidents of harm to others in the past year. Conflict with peers was listed as an antecedent behavior. Client A was a 49-year-old male admitted with diagnoses that included moderate mental retardation, pervasive developmental disorder, impulse control disorder, and early childhood psychosis. Client S was a 42-year-old male admitted with diagnoses that included mild mental retardation, aggression, impulse control disorder and personality disorder. The facility’s Incident Report and the following description of the incident that occurred on October 1, 2004: At 9:00 p.m., Client M and Client A became involved in a verbal altercation that escalated into a physical exchange. Client A received multiple scratches to his face. Client M was not injured: The clients were separated and counseled. However, fifteen minutes later, at 9:15 p.m., Client M began yelling at Client S and then he struck him. A physical altercation ensued. Client S received multiple facial scratches and a bite to his right index finger. An interview on October 13, 2004 at 2:27 p.m., with Staff R, present at the time of both incidents, disclosed that the incident occurred at the end of a client meeting when a verbal confrontation began between Clients M and A. Staff R NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OI= YOUR LICENSE DPH POD 000379 State ef California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 3 of 4 CITATION NUI~IBER: SECTIONS VIOLATED 17~1041-0001860-S Date: 02/01/2005 Time: CLASS AND NATURE OF VIOLATIONS was the only staff member present and he successfully "redirected" the two clients. However, after the meeting was adjourned and the clients were exiting the room, client M physically attacked Client A. Staff R described Client A as "fragile" and not able to protect himself. Staff R stated he was not able to intervene because there wasn’t "enough support" present. Four or five staff members are required to intervene in a client-to-client physical altercation. Staff R did sound his alarm and other staff responded "in a minute or less." However, enough time had passed to enable Client M to inflict wounds. After the clients were separated, Client M was "redirected to his room or the short hall" where Staff P spoke to the client. According to Staff R, the second incident occurred when Client S approached Staff R "in the group area which is down the hallway far from the short hall." As Client M was coming quickly down the hall towards the activity room, Staff Rtried to verbally redirect the client. He refused to be redirected and sat down with the group. He did not attempt to get help from other staff or sound his alarm when Client M would not be redirected. Client S stated he could not stay in the room with Client M and got up to leave. Client M attacked Client S inflicting the wounds. Staff R was the only staff member present and therefore could not immediately intervene. Observation of photographs taken of Clients A and S by facility police following the incident, revealed severe scratches covering the left side of Client A’s neck, jawline and ear. There was bruising and scratches to the clients lips, right chin and below the right eye. There were severe, wide gouges covering most of Client B’s face from the eyes down, including his lips, eyes and bridge of his nose. The facility failed: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000380 State ef California - Health and Human Services Agency Department of Public Health ,SECTION "I424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-104"1-0001860-S Date: 02t01/2005 Time: CLASS AND NATURE OF VIOLATIONS 1. To protect Client S from harm when staff did not ensure Client M was calm and ready to rejoin his peers after demonstrating antecedent behavior, conflict with a peer, Client A. 2. To have the necessary support staff to intervene quickly enough to prevent Client M from inflicting substantial harm to Client A and Client S. Client M inflicted multiple severe neck and facial scratches to Client A and fifteen minutes later, Client M physically assaulted Client S, inflicting multiple, sever facial scratches and a bite to his right index finger. The above violation either jointly, separately, or in any combination had a direct or immediate relationship patient health, safety or security, NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000381 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 17-1041-0001879-S Date: 09/26/2005 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE IncidenttComplaint No.(s) : No complaints found FEDERAL STATUTES AND REGULATIONS State Of Calif. Dept. Of Developmental Services Licensee Name: Address: P.O. BOX 2000 170000837 License Number: Facility Name: Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER DIP ICFDD (STP) Address: Telephone: 26501 Avenue 140 Porterville, CA 93257 (559) 782-2876 Intermediate Care FacilitylDevelopmentally Disabled Facility Type: Facility ID: Capacity: 469 170001877 SECTIONS VIOLATED 76525(a)(7) PORTERVILLE, CA 93258-2000 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 I L)EADLINE FOR COMPLIANCE 10/12/05 12:00 a.m. CITATION -- PATIENT RIGHTS 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. On May 2, 2005, an unannounced visit to the facility was conducted to investigate a facility reported event. It was determined the facility failed to ensure CIient B was free from abuse. Client B was a 20-year-old male admitted November 16, 2004 with diagnoses including Mild Mental Retardation, Psychosis, Impulse Control Disorder, Epilepsy, Aggression, Hemiplegia, Hemiparesis, and history of head injury in 2000. Name of Evaluator: Deborah Van Arsdel HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000382 ,State of 0alifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1041-0001879-S Date: 09/26/2005 Time: CLASS AND NATURE OF VIOLATIONS Client A was a 28-year-old male admitted June 1, 2004, with diagnoses including Moderate Mental Retardation, Kleptomania, Pedophilia, Impulse Control Disorder, and Attention Deficient Disorder, Client A’s maladaptive behavior was identified and Plan B2.1 dated September 23, 2004, was in place for "Harm to Others." Antecedents included "conflicts with peers." Behavior tracking records indicated nine incidents of such behavior for the month ending March 31, 2005. According t~ a facility Incident Report dated April 13, 2005, the Clients’ Rights advocate was on the unit following up on another client when Client B requested to speak with her. He stated he had been assaulted eight times by a peer, Client A. He stated he wanted Client A to be moved to the other side of the residence or another unit. When assessed by the unit nurse, purple bruising was noted to his upper lip,. ]eft .earlobe, left elbow, and right index finger. He complained of pain and was treated with medication. He alleged Client A had tackled him the previous night, and his ankle was twisted and bruised. He stated all of the other visible bruises were sustained a couple of days earlier when Client A assaulted him with a badminton racket. Per the Level I Review, the assault with the racket occurred on April 10, 2005. A Crime Report dated April 14, 2005, documented Client B’s allegation of assault by a peer, Client A. Upon interview, the client implicated staff eyewitnesses to the alleged assaults. He stated Staff P had witnessed the tackle. He stated he had been struck four times with the rackets and that Client A had assaulted him eight times. Staff J stated Clients A and B had "been having problems for about six months," When Client A was interviewed by the officer on April 13, 2(~05, he admitted to tackling Client B the previous night NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000383 State’ of’California - Health and Human Sen4ces Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-104t-0001879-S Date: 09t26/2005 Time: CLASS AND NATURE OF VIOLATIONS because Client B had said "fuck you nigger so t tackled him." Six staff members were also interviewed. It was confirmed four staff, Staff J, M, P, and T, had witnessed the racket assault. Staff M stated Client A hit Client B three or four times. The Crime Report concluded that Client A was guilty of "assault with a deadly weapon." Staff P was interviewed on May 4, 2005, at 9:25 a.m. He admitted witnessing attacks on Client B on two different occasions. According to Staff P, Client A attacked Client B with two rackets and "hurt Client B real bad." He hit him on the face, nose, head, and neck. He witnessed the second assault on April 12, 2004, when Cliei~t A tackled Client B and began "beating on him." He stated he had also been attacked by Client A in the tech station and was hit around the face. Photos taken by facility police were observed on May 4, 2005. A photo taken on April 13, 2005 showed extensive bruising to the back of Client B’s left ear. A photo taken on April 14, 2005, showed the two badminton rackets utilized by Client A in his attack on Client B. There was no documented evidence in either client’s clinical records or in the Incident Report Level I Review, that staff had: a) Intervened quickly enough to prevent Client A from delivering multiple blows and injury to Client B’s upper lip, left earlobe, left elbow, and right index finger with two badminton rackets. b) Adequately intervened to prevent a second attack when Client A tackled Client B. This failure had a direct or immediate relationship to the health, safety, or security of Client B and all clients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000384 State qf Oalifl?rnia - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page "1 of 3 CITATION NUlV]BER: 17-I041-0001878-S Date: 09126t2005 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Incident/Complaint No.(s) : No complaints found State Of Calif. Dept. Of Developmental Services Licensee Name: Address: P.O. BOX 2000 170000837 License Number: Facility Name: PORTERVILLE, CA 93258-2000 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER DIP ICFDD (STP) 26501 Avenue 140 Porterville, CA 93257 (559) 782-2876 Intermediate Care FacililytDevelopmentally Disabled 170001877 Address: Telephone: Facility Type: Facility tD: SECTIONS VIOLATED CLASS AND NATURE OF VIOLATIONS I I PENALTY ASSESSMENT $1,000.00 trebled to $3,000.00 I 76347(b) 76525(a)(20) CLASS B Capacity: 469 DEADLINE FOR COMPLIANCE 10t12/05 12:00 a.m. CITATION -- I~IEDIOATION 76347. Nursing Services--Administration of Medications and Treatments. (b) Medications and treatments shall be administered as prescribed and shall be recorded in client records as given~ Recording shall include the name and title of the person administering the medication or treatment and date, time and dosage of the medication administered. Initials may be used provided that the signature of the person administering medications or treatments is also recorded on the medication or treatment record. 76525. Clients’ Rights. (a) Each client has the dghts listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section, Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or Name of Evaluator: Deborah Van Arsdet HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name: Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000385 State of California - Health and Human Services Agency Department of Pubtic Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1041-0001878-S Date: 09/26/2005 Time: CLASS AND NATURE OF VIOLATIONS neglect. On July 26, 2005, an unannounced visit to the facility was conducted to investigate a facility reported event. It was determined the facility failed-to ensure: 1. Medication was administered to Client A as prescribed and recorded in the client’s record .as given. 2. Client A’s right to be free from harm when he suffered multiple seizures after not receiving his anti-convulsant medication. Client A was a 36 year-old male admitted April 20, 2005 with diagnoses including moderate mental retardation and seizure disorder. Client A’s Individual Program Plan (IPP) dated April 13, 2005, documented a health plan for seizure disorder and history of a procedure to implant a vagal nerve stimulator (VNS) in the left chest to control seizures in 2003. A "Medical Alert" documented Client A’s "Significant seizure condition" in the IPP Approaches and Strategies. A health care plan for his seizure disorder dated June 2, 2005, included plan step No. 2 to "Adhere to regular scheduling of daily activities including medication ..." A facility Incident Report dated May 31, 2005 documented that at approximately 12 noon, Client A’s morning medications were found in his tray by Staff C. These medications included anti-seizure drugs Felbamate, Aborigine, and Levetiracetam. The facility’s Level 1 Review documented an interview with Staff C on May 31, 2005 at 12:30 p.m. Staff C stated Client A had "an episode of . cluster seizures" on May 31, 2005 at 12:06 p.m., 12:15 p.m., and I:30 p.m. and had to be given 1 mg Ativan at 2:00 p.m. Staff S was also interviewed on May 31, 2005 at 3:15 p.m. She stated she had given report to Staff B and reminded her NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000386 State of California ~ Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1041-0001878-S Date: 09t2612005 Time: CLASS AND NATURE OF VIOLATIONS about Client A’s medications that needed to be given at 5:00 a.m. and 6:00 a.m. According to the report, an interview with Staff B on June 6, 2005 at 8:30 a.m. determined she had been assigned to the clinic on the night of the error and reminded of the medications that needed to be given to Client A, but simply "forgot." She stated it was very busy and there was a lot of information provided to her at the change of shift. Prior to this incident, seizure activity had been documented in the Interdisciplinary Notes the day before, May 30, 2005, at 9:53 p.m. and the previous day, May 29, 2005 at 5:00 p.m. The client’s medication administration record was reviewed on July 27, 2005. it was disclosed that in addition to the missed 6:00 a.m. doses on May 31,2005, his 6:00 a.m. doses on May 30, 2005 had also not been documented as given. Physician medication orders dated May 18, 2005 included anticonvulsants Felbamate, 1000 mg at 6:00 a.m.; Lamatrogine, 500 mg at 6:00 a.m.; and Levetiracetam 1500 mg at 6:00 a.m. The facility’s failure to ensure administration of these medications on May 30th and 31st, 2005, resulted in multiple seizures suffered by Client A. These failures had a direct or immediate relationship to the health, safety, or security of Client A and all clients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000387 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUIVIBER: 17-1106-0001880-S Date: 10/04/2005 Time: Type of Visit - YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OFt APPLICABLE Incident/Complaint No,(s) ¯ No complaints found FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facitity Type: Facility ID: SECTIONS VIOLATED 76525(a)(7) Slate Of Calif. Dept. Of Developmental Services P. O. BOX 2000 PORTERVILLE, CA 1700b0837 93258-2000 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER DIP ICFDD (STP) 26501 Avenue 140 Porterville, CA 93257 (559) 782-2876 Intermediate Care FacililylDevelopmentally Disabled Capacity: 469 170001877 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 10/18/05 12:00 a.m. CITATION .. PATIENT RIGHTS 76525, Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. The facility failed to comply with the above regulation by failing to ensure Client R was free from physical abuse. Client J has a diagnosis that includes Moderate Mental Retardation and Impulse Control Disorder. Client R has a diagnoses that includes Mild Mental Retardation, Bipolar Disorder, and Parkinson’s Disease. The facility incident report notes that on February 28, 2005 Name of Evaluator: Christine Young Health Fac. Evaluator Nurse Without admitting guilt, 1 hereby acknowledge receipt of this SECTION 1424 NOTICE Signature " Name " Evaluator Signature " Title ¯ NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000388 State Of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1106-0001880-S Date: 10/04/2005 Time: CLASS AND NATURE OF VIOLATIONS at 5:15 a.m. Client J was awake. He was redirected back to his room and counseled on unit rules to remain in his bedroom duringthe night shift. Clier~t J then left his room and went into Client R’s room, which was next door, and struck Client R in the face. Client.J told staff he hit Client R in the face because he was mad that he woke up early. Client R’s nose was reddened and had slight swelling. He had two small abrasions to the tip of his nose. Minor head injury protocol was instituted. Client J has open problems for harm to others: assault, harm to self,, property destruction, inappropriate sexual behavior, and false allegations. Client J’s behavior plan has antecedents that include staff demands, peer teasing, and frustration. Client J’s IDN’s (interdisciplinary notes) state he was on line of sight supervision at the time of the incident. The IDN for February 28, 2005 at 5:15 a.m. state Client J got up from bed and went to the group area. Staff redirected Client J to go back to bed. Client J stated he wanted a shower. He was told he would have to wait until 7:00 a.m. Client J then went to his room. While staff was walking back to the foyer, Client J was seen coming out of Client R’s room. Client R’s tDN’s show he was in line of sight supervision at the time of the incident. The Client’s IPC (individual program coordinator) stated in an interview on March 24, 2005, that Client J was in line of sight while awake as he acts out sexually and is opportunistic. Client R was on line of sight as he had so many injuries of unknown origin in the past they wanted to keep an eye on him to see why he was getting these injuries.. When asked where these plans were, the IPC stated they were on the behavior plan. There was no intervention for line of sight supervision on Client J or Client R’s behavior plan. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000389 State of California - Health and Human Services Agency Department of Public lqeaith SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1106-0001880-S Date: 10/O4/2005 Time: CLASS AND NATURE OF VIOLATIONS The written procedure for line of sight supervision states it will be used for clients with a physical condition and/or periods in which clients may cause injury to themselves, peers, or staff. The supervisor will use regular staffing minimums. Staff will maintain Client 6 to 20 feet at all times. Staff will document observation minimally every two hours or as specified by IDT. Client J was in line of sight observation during waking hours. He got up at 5:15 a.m, spoke to staff who counseled him to go back to bed. While staff was walking back to the foyer, Client J entered Client R’s room, assaulted Client R, and was then observed walking back to his room. The violation was determined to cause or under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma, and had a direct or immediate relationship to the health, safety, or security, of long term health care facility patients or residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000390 State O’f California - Health and Human Services Agency Depa~ment of Public Health SEC’I"ION t424 NOTICE Page 1 of 5 CITATION NUNIBER: 17-1361-000t888-S - Date: 02f2t12006 Time: Type of Visit ¯ YOU ARE HEREBY FOUND iN VIOLATION OF APPLICABLE CALl FORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL ST,ATUTES AND REGULATIONS State Of Calif. Dept. Of Developmental Services Licensee Name: Address: P, O. BOX 2000 170000837 License Number: Facility Name: 76525(a)(20) Type of Ownership; State Agency 26501 AvenUe 140 Porterville, CA 93257 (559) 782-2876 Intermediate Care Facility/Developmentally Disabled Faci!ity Type: Facility ID: 76521 (c)(18) 76327(a) PORTERVlLLE, CA 93258-2000 PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD (STP) Address: Telephone: SECTIONS ’VIOLATED Incident/Complaint No.(s) : No complaints found Capacity: 469 170001877 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMEN-r $1,000.00 trebled 1o $3,000.00 DEADLINE FOR COMPLIANCE 3/8/06 12:00 a.m. CITATION-- PATIENT RIGHTS 7652I. Policies and Procedures. (c) Each facility shall establish the following policies and procedures: (18) Policies and procedures that define the conditions under which restraints are used, the application of restraints, staff members who shall authorize their use and the mechanism used for monitoring and controlling their use. 76327. Developmental Program Services--Restraints. (a) Restraints shall only be used as measures to protect the client from injury to self or others and only upon a physician’s o.r cl!nicalpsychologist’s written or telephone order. Telephone orders shall be received only by authorized licensed personnel, shall be recorded immediately in the client’s record and shall be signed by the prescriber within 48 hours. Restraint shall not be used as punishment, as a substitute for more effective programming or for the convenience of the staff. Name of Evaluator: Resurrecio Det Castillo HFE-N Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000391 State o7 California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 2 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1361-0001888-S Date: 02/21/2006 Time: CLASS AND NATURE OF VIOLATIONS 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including Unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to: 1. Implement its policy on patient’s rights to ensure Client A’s right to be free from abuse when Staff B, C, and D physically and verbally abused her as she !.ay on the ground in prone containment. 2. Ensure that restraints were not used on Client A as punishment, a substitute for more effective programming or the convenience of staff. 3. Implement its policy on manual containment in prone position (restraint) for Client A, who was identified by the facility as a high risk for prone containment due to her obesity and history of asthma. Client A is a 16 year old admitted with diagnosis that included mild mental retardation, conduct disorder and attention deficit hyperactivity disorder. Client A has been engaging in extreme maladaptive behaviors which have prompted the interdisciplinary team (IDT) to open behavioral plans for harm to others, harm to environment and harm to self and socially undesirable behaviors. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000392 State of California - Health and Human Services Agency Deparlment of Public Health SECTION "~424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-136"~-000"i888-S Date: 02/21t2006 Time: CLASS AND NATURE OF VIOLATIONS Client A weighs more than 268 pounds with a Body Mass Index (BMI) of 42.6 indicating Class 11 obesity. Client A is included in the prone risk list due to obesity and history of asthma. She is included in the unit’s "No Prone List." On February 25, 2005 at 6:00 p.m., Client A was observed to be agitated and disruptive. She was running around with a belt around her neck. When staff redirected her, she started to kick and hit staff. During an interview with StaffA on July 7, 2005, she revealed that she was in the unit on February 25, 2005 at 6:00 p.m. She confirmed that Client A was very agitated and disruptive. She observed Staff B, C, and D capture and contain Client A in a prone position on the floor. While Client A was prone contained on the floor, Staff B, C, and D applied pressure on her back and on each leg trying to restrain her. Staff B, C, and D struck Client A in the waist area approximately three times. Staffs B, C, and D were also observed to pinch Client A repeatedly. They also kneeled (using the knee to apply a person’s body weight) onto the back of Client A’s legs and twisted her arm behind her back while she lay on the ground. Staff B also told Client A, "Shut up, bitch." As a result of staff actions, Client A’s health, safety, and security was placed at high risk. Client A sustained multiple bruises measuring from 2 centimeters by 2 centimeters to 3 centimeters by 6 centimeters on her legs and back as a result of staff striking, pinching and kneeling repeatedly upon several parts of her body. Review of facility Bulletin #79, Clients’ Rights revealed that persons residing in the facility have the same rights to opportunities for growth and de~ielopment as other individuals. Each client has the same right to be free from NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000393 State df Cafifornia - Health and Human Services Agency Depar~rnenl of Public Heatth SECTION "1424 NOTICE Page 4 of 5 CITATION NUIV[BER: SECTIONS VIOLATED 17-1361-0001888~S Date: 02/21/2006 Time: CLASS AND NATURE OF VIOLATIONS harm, such as unnecessary physical restraint or isolation, excessive medication, abuse, or neglect. Client A was physically and verbally abused by staff while she was contained in a prone position on the floor. Review of Facility Bulletin #104, Behavior Management, revealed that manual containment in the prone position should only be used when an individual is violent and great bodily harm is imminent, only for a period not to exceed five minutes and only if other techniques are ineffective or otherwise contraindicated. Specific risk factors, that should warrant extreme caution with the use of prone containment, are obesity (BMI greater than 30), asthma, alcohol intoxication and pre-existing heart condition. The IDT will address the presence of risk factors and conduct a risk versus risk assessment prior to the use of prone containments. The attending physician will identify and communicate risk factors to the interdisciplinary team members and medically clear clients who may have prone containment used as an emergency situation. Contrary to the facility’s policy on Client’s Rights and the physician’s determination that the client should not be placed in restraints, restraint by physical containment was used on Client A. The facility failed to implement its policy to ensure Client A’s right to be free from physical and verbal abuse and unnecessary physical restraints. Client A was called names, repeatedly struck, pinched and kneeled upon in several par~s of her body that resulted in bodily injury, while she was prone contained on the floor. The facility failed to ensure that restraints were not used as punishment, a substitute for more effective programming or the convenience of staff for a client identified as a high risk for prone containment and included on the unit’s, "No Prone List." NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000394 State Of California - Health and Human Services Agency Department of Public Health SECTION t424 NOTICE Page 5 of 5 CITATION NUI~BER: SECTIONS VIOLATED 17-1361-0001888-S Date: 02t21/2006 Time: CLASS AND NATURE OF VIOLATIONS The facility failed to implement it’s policy on manual containment in prone position (restraint) for a client who was identified by.the facility as a risk for prone containment and included on the unit’s, "No Prone List", due to her obesity and history of asthma. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. NOTE: tN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000395 State 6f California - Health and Human Services Agency Department of Public Health SECTIQN 1424 NOTICE Page "i of 4 CITATION NUMBER: 17-1361-0004960-S Date: 04/29/2008 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Incident/Complaint No,(s) ¯ CA00073868 FEDERAL STATUTES AND REGULATIONS Slatd Of Calif. Dept. Of Developmental Services Licensee Name: Address: P. O. BOX 2000 170000837 License Number: Facility Name: Type of Ownership: State Agency PORTERViLLE DEVELOPMENTAL CENTER DIP tCFDD (STP) Address: Telephone: 26501 Avenue 140 Porterville, CA 93257 (559) 782-2876 Inlermediate Care FacilitylDevelopmentally Disabled 170001877 Facility Type: Facility ID: SECTIONS PORTERVlLLE, CA 93258-2000 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $1,000.00 VIOLATED 76333 CLASS B 76525(a)(23) 76527(c) 76333 Developmental Program Services - Client Abuse Capacity: 469 DEADLINE FOR COMPLIANCE 5/5/08 12:00 a.m. CITATION -- ABUSEIFACILITY NOT SELF REPORTED Clients shall not be subjected to corporal or unusual punishment, humiliation, or verbal or mental abuse. A behavior modification program carried out in compliance with section 76331 is not considered client abuse. 76525(a)(23) Clients’ Rights (a) Each client has the rights listed in (a) of this section, which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (23)To have access to individual storage for private use. 76527(c ) Denial of Rights (c) A right shall not be withheld or denied as a punitive measure, nor be considered a privilege to be earned nor as a part of a client’s individual program. The facility failed to: Name of Evaluator: Resurrecio Del Castillo HFE-N Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name: Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000396 State 6f California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1361-0004960-S Date: 04t29f2008 Time: CLASS AND NATURE OF VIOLATIONS 1. Protect its clients from verbal and emotional abuse. Unit staff did not attempt to stop or notify management as Staff B called clients derogatory names during a "group meeting." 2. Ensure that clients’ rights to have access their individual storage areas are not denied without proper authorization and notification. A search of clients’ lockers was conducted by unit staff despite not being given authorization to do so by management. 3. Ensure that clients’ right to social interaction and participation in community activities is not withheld or denied as a punitive measure. A planned super bowl party that clients were looking forward to was cancelled as a search of clients’ lockers was conducted instead. On February 4, 2006, Client 1 was found with a contraband item. Management denied Staff A’s, request to conduct a search of clients’ lockers. Staff A was informed that a search would not be approved solely based on one incident with one person. Management advised StaffA to give the clients the opportunity to turn in any contraband items, tt was done with clients.turning in more contraband items. However, on February 5, 2006, Staff A, who was in charge of the unit, informed unit staff that a search of clients’ lockers will be conducted. StaffA and B, especially Staff B were not satisfied with the management’s decision denying their request to search the clients’ lockers the day before. Staff Bconducted a group meeting with the clients in another side of the unit while other staff conducted the search. Staff B was observed to be very inappropriate with the clients during the meeting. Staff B repeatedly swore at the clients and called them derogatory names, such as "mother fuckers," "fucking retards," and "stupid." In addition, Staff B made rude comments against management and unit staff. Staff C, who was present during the incident, indicated that all staff present during the incident admitted to being concerned and disturbed with Staff B keeping the clients on one side of the unit and calling the clients derogatory names. However, not one of the staff in the unit who witnessed Staff B "lecture" and called the clients names tried to intervene and stop him or even called the management to report the ongoing abuse. This was contrary to the facility’s policy and procedure to protect clients from any kind of NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000397 State Of ~alifornia - Hea{lh and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 4. CITATION NUMBER: SECTIONS VIOLATED 17-1361-0004960-S Date: 04129t2008 Time: CLASS AND NATURE OF VIOLATIONS abuse and to report it immediately. Review of the staffing schedule for February 5, 2006 revealed that besides Staff A and B, there were six other staff (five licensed and one recreational therapist) on the unit the day the alleged verbal and emotional abuse occurred. The clients were kept in the meeting for several hours missing a planned Super Bowl party, which clients were eagerly looking forward to. Staff B told the recreational therapist that they had to cancel the Super Bowl party in order to conduct a proper search. Instead of watching the Super Bowl, clients were huddled on one area listening to Staff B lecturing on why the search was conducted and calling them derogatory names, Review Of FacilitY Bulletin 103. Alleged client abuse, mistreatment or neglect stipulates that the facility prohibits client abuse, mistreatment and neglect whether perpetrated by staff, volunteers, friends and families. Every staff member is responsible for the safety and well being of clients. Staff shall be constantly alert to ensure that the physical and emotional well being of clients is not endangered in any way. Any person having the information, .by direct o.bservation or through, report, of any behavior toward a client, which may be considered abuse, shall intervene as needed to protect the individual and report such information. Any person who reasonably should know that abuse or neglect exists and fails to report such abuse may be guilty of misdemeanor. Knowingly .allowing someone to abuse a client may itself be considered an act of abuse. Review of Facility Bulletin 79. Client rights, stipulates that persons residing in the facility shall have the same rights to opportunities for growth and development as other individuals. The facility is committed to protecting each clients’ property by providing each with a safe, private storage spacey training clients in the concept of personal ownership and "respect fro possessions. Each client has the right to social interaction and participation in community activities, right to be free from harm, such as abuse or neglect. Each client has also the right to have direct access to lockable cabinet or "wardrobe without the need to receive permission from an intermediary. The facility bulletin further stipulates that constitutional rights shall not be denied for any reason. Good cause for denying a client the exercise of a right exists when the exercise of the right would be injurious n to the patient, that there is evidence that the specific right, if exercised, would seriously infringe on the rights of others, the facility would suffer serious environmental or building damage if the specific right is not denied and there is NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000398 State ~f California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1361-0004960-S Date: 04/29/2008 Time: CLASS AND NATURE OF VIOLATIONS no less restrictive way of protecting the interests specified, These facility failures had a direct or immediate relationship to the health, safety or security of long-term health care facility patients or residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAF]’EY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000399 State ~f Calit’or:nia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUhlBER: 17-1361-0004958-S Date: 04/29t2008 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Incident/Complaint No.(s) " CA00073868 FEDERAL STATUTES AND REGULATIONS State Of Calif. Dept. Of Developmental Services Licensee Name: Address: P. O. BOX 2000 170000837 License Number: Facility Name: Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD (STP) Address: Telephone: 26501 Avenue 140 Porterville, CA 93257 (559) 782-2876 Intermediate Care Faci]itylDevelopmental~y Disabled 170001877 Facility Type: Facility ID: SECTIONS PORTERVlLLE, CA 93258-2000 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $1,000.00 VIOLATED 1418.91(a) CLASS B 1418.91 (b) 1418,91 (c) 1418.91 (a)-(d) Health and Safety Code 1418.91 (d) Capacity: 469 DEADLINE FOR COMPLIANCE 5/5/08 12:00 a.m. " CITATION -- ABUSEIFAClLITY NOT SELF REPORTED (a) A 10ng 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. (c) For purposes of this section, "abuse" shall mean any of the conduct described in subdivision (a) and (b) of Section i5610.07 of the Welfare and Institutions Code. (d) This section shall not change any reporting requirements under Section 15630 of the Welfare and Institutions Code, or as otherwise specified in the Elder Abuse and Dependent Adult Civil Protection Act, Chapter 11 (commending with 15600), of Part 3 of Division 9 of the Welfare and Institutions code. The facility failed to: 1. Report an incident of alleged or suspected verbal and emotional abuse of clients to the Department immediately or within 24 hours. On February 4, 2006, Client 1 was found with a contraband item. Management denied a request made by Staff A to conduct a search of all clients’ lockers: However, despite being denied to search the clients’ lockers, Staff A and B proceeded to conduct a Name of Evaluator: Resurrecio De} Castil]o HFE-N Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evalualor Signature " Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000400 State ’of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUI~BER: SECTIONS VIOLATED 17-1361-0004958-S Date: 04t29/2008 ’Time: CLASS AND NATURE OF VIOLATIONS search of the clients’ lockers the next day, February 5, 2006. During an Interview with Staff C on May 26, 2006, he stated that he received several reports on February 6, 2007 from staff and clients that Staff A and B, particularly Staff B, were verbally and abusive to clients on February 5, 2006. Staff D revealed on May 26, 2006, that she was instructed to initiate a management inquiry on February 6, 2006, regarding the conduct of Staff A and Staff B on February 5, 2006. She indicated she interviewed and took written statements from staff working in the unit the day the alleged abuse incident took place. Staff D indicated that she could not confirm the possibility of client abuse until she had verified unclear and vague statements from staff. On February 24, 2006, Staff D arrived at the conclusion that vex’hal and psychological abuse of clients had occurred after reviewing all the information from staff and clients. During an interview with Staff E on August 8, 2006, she stated that a search of clients’ lockers was conducted on February 5, 2007. While unit staff was conducting the search, Staff B conducted a group meeting with the clients on another side of the unit. Staff E indicated that Staff B was verbally, inappropriate and repeatedly swore at the clients, calling them derogatory names, such as "mother f ..... s ", "f ...... g retards" and "stupid". In addition, Staff B made rude comments against management and unit staff. Staff E relate4 that none of the staff who worked on February 5, 2006, reported the verbal aSuse to the Unit Supervisor or management while it was taking place. Review of Facility Bulletin # 64, Incident Reporting, stipulated that the facility has a system of reporting and documenting unusual occurrences and events that have or may have an adverse effect on the individual served, or on the. facility itself. All incidents are reported to management and documented according to Incident reporting guidelines. Significant incidents and emergency situations are reported to department headquarters and to other agencies as required by law and Department policy. Facility Bulletin # 64 further stipulated that Department of Health Services is notified written or verbal contact within 24 hours, or the following workday if incident occurs on a weekend or holiday. The criteria are listed in the Policy Memorandum (PM) 129. The written report must be completed following verbal notification. The incidents that are reportable within 24 hours include the following, but are not limited to: alleged /suspected abuse, results of abuse findings/neglect findings, dearth due to unnatural causes, serious injury, injuries of unknown origin, and others as determined by the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000401 st&re of, California - Health and Human Services Agency SECTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED " 17-1361-0004958-S Department of Public Health Page 3 of 3 Date: 0412912008 Time: CLASS AND NATURE OF VIOLATIONS Executive Directortdesignee, Verbal abuse is defined as any verbalization by staff (which is not considered a reasonable and prudent execution of one’s duties) or others that may be threatening, demeaning, and discriminatory, or using derogatory names. Psychological abuse is any act by staff (which is not considered reasonable and prudent execution of one’s duties) or others that causes or may cause emotional distress to a client. Examples include: use of demeaning language, use of intimidation by staff, family or visitors to achieve compliance, retaliation through the use of threats or fear, intentionally allowing a client to engage in a behavior that is demeaning without intervening, deliberate infliction of mental pain, anxiety, confusion or humiliation, harassment band coercion. The incident of alleged verbal and psychological abuse that occurred on February 5, 2006 was net reported by Staff D to the Department until February 24, 2006. (19 days after it allegedly occurred). These facility failures had a direct or immediate relationship to the health, safety or security of long-term health care facility patients or residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000402 State of, California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 2 CITATION NUMBER: 17-1473-0006056-S Date: 0410912009 Time: Type of Visit : Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 72565(a)(7) IncidenttComplaint No.(s) ¯ CA00144858 State Of Calif, Dept. Of Developmental Services P. O, BOX 2000 PORTERVILLE, CA 93258-2000 170000837 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD (STP) 26501 Avenue 140 ’ Poderville, CA 93257 (559) 782-2876 intermediate Care Facility/Developmentally Disabled 170001877 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 Capacity: 469 DEADLINE FOR COMPLIANCE 4/22/09 12:00 a.m. CITATION--PATIENT RIGHTS 76525. Client’s Rights (a) Each client has the rights listed in (a) section of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. The facility failed to protect the rights of Client A by failing to ensure that he was free from humiliation, verbal, and mental abuse by Staff Member 1. Review of the clinical records for Client A on March 25, 2008 at 2.30 p.m. indicated a 37-year-old male who was admitted to the facility on 10/29/99. Further review of the facility administrative records indicated that on March 21, 2008, Client A made a phone call to the office of the Clients Rights Advocate (CRA) and reported that a staff member (Staff Member 1) had called him "a mother fucking faggot" when he was at the Oasis Canteen. On July 1, 2008 during interview, Client A stated that he went to the Oasis snack bar with Name of Evaluator: Robert Ussher HFEN Wilhout admitting guilt, I hereby acknowledge receipt of this SECTION t424 NOTICE Signature : Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITFI CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000403 State of’California- Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 2 CITATION NUI~BER: SECTIONS VIOLATED 17-1473-0006056-S Date: 04/09/2009 Time: CLASS AND NATURE OF VIOLATIONS his friend (Clients B). Client A stated during the interview that he had his hands around the waist of Client B. According to Client A, when Staff Member 1 saw him with his hands around the waist of Client B, she shouted at the two of them saying "stop doing that faggot stuff here; you mother fucking faggots need to be shipped out of here." Client A further stated during interview, "I know I’m different; but because of what she said to me I don’t feel safe here anymore. I feel very upset about what she said." On July 3, 2008 at 10:52 a.m., Staff Member 1 stated during interview that she was at the Oasis snack bar on March 25, 2008. Staff Member 1 further stated that she was supervising eight clients at the Oasis snack bar including Clients Aand B. According to Staff Member 1, Client A was sitting on a bench with Client B. Staff Member 1 stated that she observed Client A putting his hands into the pants of Client B. Staff Member 1 stated that she tofd Client A to "stop all that faggot nonsense here." Staff Member 1 also stated that she realized what she said to the client was inappropriate and she was very sorry for that. The facility failed to protect the rights of Client A by failing to ensure that he was free from humiliation, verbal, and mental abuse by Staff Member 1. The statement made by Staff Member 1 to the clients had a direct relationship to the health and safety of the long term care clients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000404 State of California - Health and Human Services Agency Department of Public Health SECT~ION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 17-0929-0001798-S Date: 01114/2003 Time: Type of Visit ¯ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Incident/Complaint No.(s) ¯ 170020950 FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility SECTIONS VIOLATED 7231 t (a){2) 72523(a) State Of Calif. Dept. Of Developmental Services P. O. BOX 2000 PORTERVILLE, CA 93258-2000 170000837 Type of Ownership: State Agency PORTERVILLE :DEVELOPMENTAL CENTER D/P SNF 26501 Avenue 140 (559) 782-2222 Skilled Nursing Facility 170001876 Portewille, CA 93257 Capacity: 201 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $10,000.00 DEADLINE FOR COMPLIANCE 1/14/03 12:00 a.m, CLASS A CITATION -- PATIENT CARE During the investigation of a complaint initiated on March 8, 2002, it was determined that the facility failed to implement proper transfer techniques described in a patient care plan and failed to implement a policy and procedure to orient staff to the care r~eeds of a patient. These actions placed Resident A at risk for injury. According to the health care record, Resident A is a 44 year-old male who had diagnoses which include profound mental retardation, seizure disorder, hypothyroidism, asthma and osteoporosis. Resident A is non-verbal and nonambulatory. Resident A communicates minimally with some sounds and facial expressions which must be interpreted by staff who are famitiar with him and only rarely is he able to make eye contact. Resident A receives nourishment through a tube in his stomach and requires assistance with bathing, dressing and mobility. He has severe spastic quadriplegia with limited range of motion in all joints. On March 22, 2002 at approximately 8:00 p.m., Staff I and Staff 2 transferred Resident A from h.is wheelchair to his Name of Evaluator: ELIZABETH WALTMAN HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evalualor Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000405 Stale of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NU]VlBER: SECTIONS VIOLATED 17-0929~0001796-S Date: 01/14/2003 Time: ~LASS AND NATURE OF VIOLATIONS bed. Staff 2 lifted his lower body and legs while Staff t lifted his upper body. During the transfer, staff documented they heard a ’snap’ or a ’pop’ and that his [eft arm ’looked different.’ The physician was’ notified and orderect an X-ray of the left arm. The X-ray showed a spiral fracture of the left humerus (the bone in the left upper arm). Review of the health care record indicated that according to the Individual Program Plan (IPP) and a health care plan for osteoporosis, both dated May 31, 2001, Resident A was to be moved with extreme care and transferred using a mechanical lift only. This was confirmed in an interview with staff on March 12, 2002 at approximately 3:30 p.m. The lift intended for use with this resident consists of a soft cloth sling which is positioned by rolling the resident on his side, sliding the sling underneath and rolling the resident back onto the sling. The sling is then attached to a frame which mechanically lifts Resident A from the bed to the wheelchair to the bath. Staff 2 was from the registry and not a regular staff person. According to facility policy and procedure, staff who do not work regularly on a unit are required to be oriented to the unit and to any special needs of the ¯ residents in their care. A form titled ’Orientation Checklist’ is used to document this requirement and it is to be signed by the registry or float person as well as the regular staff responsible for the orientation. The facility was Unable to produce a signed copy of this checklist for the staff person involved in the improper lifting. When interviewed, Staff 2 indicated this was the third time she had worked this unit and that she had never been told to use a lift for Resident A. An interdisciplinary team of fifteen persons, including the physician, participated in developing the health care plan for Resident A. They determined that using a mechanical NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000406 State of California - Health and Human Services Agency Department of Public Health SE(~TION "1424 NOTICE Page 3 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 17-0929-0001796-S Date: 01/14/2003 Time: CLASS AND NATURE OF VIOLATIONS lift would provide the safest way to move Resident A and protect him from injury. Failure of the facility to implement the ptan and to follow facility policy and procedure placed Resident A at risk of physical injury related to his diagnosis of osteoporosis. 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 harm would result and therefore constitutes a CLass ’A’ Citation. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000407 State.of California - Health and Hu.man Service& Agency Department of Public Heaith SECTION ’[424 NOTICE Page 1 of 5 CITATION NUMBER: 17-1409-0001859-’S Date: 02/01/2005 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS State Of Calif. Dept. Of Developmental Services Licensee Name: Address: P. O. BOX 2000 Facility Name: Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER DIP SNF Address: Telephone: 26501 Avenue 140 (559) 782-2222 Skilled Nursing Facility 170001876 Facility Type: Facility ID: 72301 (f) 72517(a) (5) PORTERVlLLE, CA 93258-2000 170000837 License Number: SECTIONS VIOLATED Incident/Complaint No.(s) : No complaints found Porterville, CA 93257 Capacity: 201 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT DEADLINE FOR COMPLIANCE 2/22105 12:00 a,m. CITATION .. PATIENT CARE 72301 (f) Required Services. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. 72517 (a) (5) Staff Development (a) Each facility shall have an ongoing educational prograr:n planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to:, (5) Accident preventi6n and safety measures, During the investigation of a reported event the facility fail to: 1. Ensure that all orders, written by a person lawfully authorized to prescribe, were carried out for Client 1 relative to the need for a three-person manual lift and 2. Failed to ensure an educational program to provide the necessary skills and knowfedge for all facility personnel Name of Evaluator: Nancy Alvarez Evaluator Supervisor Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Sigr~ature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000408 State,of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1409-0001859-S Date: 02t01t2005 Time: CLASS AND NATURE OF VIOLATIONS for accident prevention and safety measures that resulted in a head injury to Client 1. Client 1 is a 55 year-old male who was admitted to the facility with diagnoses that included Profound Mental Retardation and Generalized Tonic/Ctonic Grand Mal Seizures. The client has a history of abnormal involuntary movements. Review of a an annual "Minimum Data Set "(MDS), dated May 25, 2004 revealed that Client 1 was totally dependent for transfers and required a two plus person physical assist for transfers. A physician’s order written November 23, 2004 noted that for transfers, Client 1 required an electric lift with a sling using two staff, or a three person manual lift. On December 4, 2004 at 3:45 p.m., Licensed staff documented in the. interdisciplinary notes that Staff A and Staff B, both Psychiatric Technician Assistants, were weighing Client 1, he became resistive towards staff and started squirming and fell off the weight scale and hit his head on the floor. Client 1 was initially alert and conscious, then lost consciousness for a few seconds. "181" emergency was called. Cardiopulmonary Resuscitation was not required. Oxygen was administered via facemask and the oxygen saturations were documented as between 90 and 93%. On December 4, 2004 at 4:05 p.m., the Health Service Specialist, (HSS) documented that the client was assessed after he fell from a scale while being weighed. On exam, the client had an open laceration on left side of the forehead measuring approximately 8 cm x 0.25 cm in depth (2.54cm=1 inch). The laceration was described as y-shaped and jagged. The physician examined him and then placed 6 sutures to close the head wound. He was placed on a major head injury protocol and precautions. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000409 State.of California- Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1409-0001859-S Date: 02f01/2005 Time: CLASS AND NATURE OF VIOLATIONS During interview on December 15, 2004 at 11:30 a.m., Staff A stated that she had been working on the unit about one and one-half months. She stated that she had been working on another unit where the weight scale was different from that used on the day of the incident. She added that she received no in-service training on how to use the weight scale and was not aware that the weight scale had brakes. She stated that she and Staff B lifted the client together onto the weight scale. When Staff B informed Staff A that the weight scale was reading error, StaffA lifted the client and repositioned him on the scale. The scale still read error. At this point, Staff B told Staff A that she was touching the weight scale so Staff A, with the client in her arms, stated that she took a step back, Client 1 "jerked a couple of times" and "because I am left handed, I grabbed at his feet and his head fell to the floor between my arm and the weight scale." Staff A stated that the client did "like a flip" landing on the left side of his forehead. Staff Bimmediately told Staff A to apply pressure to the head wound that was bleeding profusely. Staff B went for help. During interview on December 16, 2004 at 3:00 p.m., Staff B stated that prior to the December 4, 2004 injury to Client 1, she had used the weight scale maybe five or six times. She added that she received no in-service training for the weight scale and she was not aware that it had brakes. Staff B stated that on December 4, 2004 at about 3:45 PM, she wheeled the weight scale into the client’s room and positioned it at the foot of the bed. She estimated that the weight scale was "about table height." (Inspection of the weight scale on December 17, 2004 at 12:00 PM revealed that it was 21 inches wide and had adjustable heights. It stood 30 inches from the floor at its lowest height.) Staff B stated that she zeroed the scale and balanced it out. She then walked around to the client and she lifted his lower half and Staff A lifted his upper half and he was placed on the weight scale. Staff B then went back around the scale NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000410 State.of’California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 4 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1409-0001859-S Date: 02101/2005 Time: CLASS AND NATURE OF VIOLATIONS and noted that it read "error." She asked StaffA to reposition the client. Staff A lifted the Client off of the scale and Staff B rebalanced the scale to zero. Staff B stated that the client had to be lifted completely off the scale in order to zero it. She stated that when Staff A placed the client back on the scale he was becoming agitated and he started moving his knees and the scale still read error. Staff A again lifted the client off the weight scale, placing her left arm under his knees and cradled his head in her right arm. As Staff A curled the client towards her body, he stiffened and his head went between her forearm and rib cage and he hit the floor. Staff B stated that she attempted to reach across the weight sc~.le to prevent the fall. Because the breaks were not set, the scale moved. She stated that the client was bleeding from his head but was alert. Administrative staff acknowledged that prior to the December 4, 2004 incident there had been no written training on use ofthe weight Scale and further, weight scale training was not included on the orientation checklist. Neither Staff A nor Staff B was aware that Client 1 had a physician’s order for a three person manual lift and due to lack of training, neither was aware that the weight scale had brakes. Therefore, the facility failed to: 1. Ensure that physician’s orders for a three-person manual lift were carried out as prescribed for Client 1 and 2. Ensure an educational program to provide the necessary skills and knowledge for all facility personnel for accident prevention and safety measures that resulted in a head injury to Client 1. The above violations either jointly, separately, or in any combination had a direct or immediate relationship to NOTE; IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOGAT[ON OF YOUR LICENSE DPH POD 000411 State,of’California- Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 5 of 5 CITATION NUMBER: SECTIONS VIOLATED 17~140g-0001859-S Date: 02101/2005 Time: CLASS AND NATURE OF VIOLATIONS patient health, safety, or security. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000412 ,State of ~alifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 17-1041-0001875-S Date: 08/09/2005 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS State Of Calif. Dept. Of Developmental Services Licensee Name: Address: P. O. BOX 2000 PORTERVlLLE, CA 170000837 License Number: Facitity Name: 93258-2000 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER DIP SNF Address: Telephone: 26501 Avenue 140 . (559) 782-2222 Skilled Nursing Facility 170001876 Facility Type: Facility ID: SECTIONS VIOLATED 72527(a)(9) Incident/Complaint No.(s) : No complaints found Porterville, CA 93257 Capacity: 201 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $500.00 DEADLINE FOR COMPLIANCE 8/23/05 12;00 a.m. CLASS B CITATION-- PATIENT RIGHTS 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 May 23, 2005, an unannounced visit to the facility was conducted to investigate this facility reported event, It was determined the facility failed to ensure the right of Resident R to be free of mental and physical abuse. Resident R was middle aged when admitted January 1978, with diagnoses including Profound Mental Retardation, Epistaxis [bleeding of the nose], and Epilepsy (seizure disorder). Name of Evaluator: Deborah Van Arsdel HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000413 State ofCalifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUI~1BER: SECTIONS VIOLATED 17-104t-000"~875-S Date: 08/09/2005 Time: CLASS AND NATURE OF VIOLATIONS According to Resident R’s Individual Program Plan dated June 7, 2004, the resident is verbal and able to communicate some of his wishes and make some limited choices. The resident was assessed with some cognitive loss due to an impaired short and long-term memory, decision-making ability and difficulty understandingtbeing understood. However, Resident R has the ability to understand basic verbal communication. When reviewed on May 24, 2005, a facility Incident Report dated September 29, 2004, documented an incident involving alleged staff-to-client verbaltmental abuse. According to the facility’s "investigation Disposition Report" dated October 19, 2004, the facility substantiated the allegation. The findings of the facility’s investigation disclosed that on September 27, 2004, on the evening shift, Staff C said to Resident R "Swallow that, that’s stupid behavior, that’s just stupid" and "That’s why your Mama doesn’t like you." These statements were made in the presence of other residents and one other staff member. According to the Senior Special Investigator’s report, an eyewitness to the incident, Staff G, was present during the incident. When interviewed on October 5, 2004 at 3:53 p.m., she stated that during the dinner hour on September 27, 2004, when she entered the residents’ dining room, the residents were already seated. She sat down at a table with residents needing assistance. She stated Staff C was within two feet from her and she (Staff G) was about three feet from Resident R. She stated Resident R was keeping food in his mouth which is his usual behavior then he starts to chew and eat his food. Staff G stated that Staff C turned to Resident R and said, "Look at that, that is just ’stupid’ behavior, and your mama doesn’t like you." Staff G responded to Staff C’s remark by saying, "Wow, am I hearing right[" Staff C then turned to Staff G and said, "Look at it, it is ’stupid’!" Then Staff C said to the resident a second time, "Your Mama doesn’t like you!" Staff G told Staff C to stop NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000414 .,Stat& o~ California - Health and Human Services Agency Department of Public Health SFCTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1041-0001875-S Date: 08109/2005 Time: CLASS AND NATURE OF VIOLATIONS what she was saying. Staff C responded with "Look at him, he is just ’stupid’." Staff G documented a written declaration of what. she had witnessed and gave it to the Shift Lead. The facility interviewed Staff D on October 5, 2004, at 4:31 p.m. She stated Resident R "fully understands what is being said around him, and his mother had just come to PDC to visit with him." She believed the resident was quiet and understood what Staff C said to him. Staff H was also interviewed by the facility on October 5, 2004 at 5:26 p.m. She stated she did not witness the incident. However, she stated Staff C came to her after the incident. She stated Staff C admitted to using the word "dumb" or "stupid" in her interaction with the resident. Staff C mentally abused Resident R while in the presence of other residents and staff during dinner, when she remarked that his behavior was stupid, he was stupid, and his mother didn’t like him. The facility failed to protect Resident R from mental abuse when Staff C verbally degraded the resident in front of peers and another staff member, and caused or under circumstances likely to cause, significan( humiliation, indignity, anxiety, or other emotional trauma. NOTE: tN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000415 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 6 CITATION NUMBER: Date: 10104/2005 Time: 17-1409-0001881-S Type of Visit : Incident/Complaint No.(s) " No complaints found YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS State Of Catif. Dept. Of Developmental Services Licensee Name: Address: P. O. BOX 2000 170000837 License Number: .Address: Telephone: 26501 Avenue 140 (559) 782-2222 Skilled Nursing Facility Facility Type: Facility ID; 72311{a)(2) 72527(a)(26) 4502(h) 72637(c) Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER DIP SNF Facility Name: SECYIONS VIOLATED PQRTERVlLLE, CA 93258-2000 Porterville, CA 93257 Capacity: 201 170001876 PENALTY ASSESSMENT $20,000.00 CLASS AND NATURE OF VIOLATIONS DEADLINE FOR COMPLIANCE 10It8105 12:00 a.m. CLASS A CITATION -- PATIENT RIGHTS 72311. 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. 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: (26) Other rights as specified in Welfare and Institutions Name of Evaluator: W~thout admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Nancy Alvarez Evaluator Supervisor Signature : Name : Evaluator Signature ¯ Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000416 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 6 CITATION NUI~IBER: SECTIONS VIOLATED 17-1409-0001881-S Date: 10/04/2005 Time: CLASS AND NATURE OF VIOLATIONS Code Sections 4502, 4503 and 4505 for patients who are developmentally disabled as defined in Section 4512 of the Welfare and Institutions Code. 72637. General Maintenance. (c) All buildings, fixtures, equipment and spaces shall be maintained in operable condition, 4502. 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. The facility failed to: 1. Implement Resident l’s care plan according to the methods indicated to prevent fractures by always using a two-person transfer. 2. Ensure that Resident l’s equipment, a reclining wheelchair frarne, the Gunnefl Tilt cart, was maintained in NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000417 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 6 CITATION NUI~IBER: SECTIONS VIOLATED 17-1409-0001881-S Date: 10/04/2005 Time: CLASS AND NATURE OF VIOLATIONS operable condition with anti-tip bars. 3. Ensure that Resident 1 was free from harm. Resident 1 is a 42 year-old male who was admitted to the facility with Diagnoses that included Profound Mental Retardation, Spastic Quadriplegia, and Hydrocephalus. The resident had limited head and trunk control and was by medical history, prone to fractures. Review of an annual "Minimum Data Set" (MDS), dated March 16, 2005, revealed that Resident 1 was totally dependent for transfers and required a two plus person physical assist for all transfers. An interdisciplinary note (IDN) written April 28, 2005, at 11:45 a.m. revealed that staff was aware that Resident l’s "wheelchair easily tipped down at the head area when weight is not exactly centered." The IDN indicated that as Staff A 3laced the resident in his wheelchair, the chair tipped and he fell to the floor. Licensed staff documented that upon arrival in the resident’s room, his wheelchair was tipped back with head area of the wheelchair on the floor. The resident’s lower extremities were on the wheelchair and his upper torso was on the floor. StaffA supported his head from contact with the floor. A physician’s progress note dated April 28, 2005 at 11:45 a.m. noted that a full body examination was done with no apparent sites of injury. The physician documented that he did not believe that the resident had struck his head during the incident. It was later determined, by licensed staff, that the resident had two skin breaks to his left ear, each approxima!ely 0.5 cm (2.54 cm = 1 inch) in size. The physician also noted that inspection of the wheelchair indicated that the wheelchair would have a tendency to tip easily. Physician’s orders written on April 28, 2005 at 11:55 a.m. included an Occupational Therapy Consultation to NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000418 Stale of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 6 Ci’I’ATION NUI~BER: SECTIONS 17-1409-0001881-S Date: 10t04/2005 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED evaluate the wheelchair and bed rest for’five days. An IDN written April 29, 2005 at 10:30 p.m. noted that the resident’s face, lips, and nail beds were pale. Pulses were faint and the blood pressure was 108/72. The physician was contacted and new verbal orders were written at 10:50 p.m. for an apnea monitor to be utilized until seen by the physician the following morning. Throughout the night of January 30, 2005 the resident’s blood pressure continued to drop to a low of 76t42. On January 30, 2005 at 6:00 a.m., the resident developed a low grade fever and the blood pressure continued to fall. At 8:30 a.m. on January 30, 2005 an I.V. was attempted times three but was unsuccessful. The blood pressure had dropped to 70 over palpable, the heart rate was 105 and the respiratory rate was 30. A portable chest x-ray taken on April 30, 2005 showed "no acute or active process." On April 30, 2005 at 8:35, the physician ordered the resident to be transferred via ambulance to an acute hospital for "probable dehydration and/or pneumonia." Findings at the acute hospital where the resident was first taken on April 30, 2005, revealed that he had a hemoglobin of 2.5 (norm 13.5 - 17.5) and a hematocrit of 7.1 (norm 4153). A CT scan of the head ordered on the same day for severe anemia after trauma to the head revealed a "Large acute hemorrhage posteriorly on the left and in the midline and a possible small acute hemorrhage anteriorly on the right as well." Between 1:50 p.m. and 8:35 p.m. on April 30, 2005, the resident was given three units of packed red blood cells and then, at 8:50 p.m., he was sent out to another acute hospital for Neurosurgical intervention. The preoperative history and physical completed at the NOTE:.IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000419 Stat,e ef California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 5 of 6 CITATION NUMBER: SECTIONS VIOLATED 17-1409-0001881-S Date: 10t04/2005 Time: CLASS AND NATURE OF VIOLATIONS second acute hospital noted that prior to the resident’s fall two days prior; he was able to track visually. However, after the fall he did not open his eyes nor track as he had previously done. Diagnoses included a Sub Acute Epidural Hemorrhage (bleeding into the brain) and a Left Parietal Skull Fracture. The resident, who was determined by the physician to be not stable for surgery, received supportive care. On May 1, 2005, the physician noted that the resident was starting to open his eyes but did not track. On May 2, 2005, the resident was transferred back to his long term care facility. During interview on May 18, 2005 at 10:30 a.m., StaffA admitted that although she was aware that the resident required a team lift and was aware that the w.heelchair tended to tilt backward, on April 28, 2005, she lifted Resident 1 into his wheelchair alone, it tipped backward and she and the resident went to the floor. During interview on April 18, 2005, at 2:35 p.m., Staff B, the Occupational Therapist, stated that she had designed Resident l’s wheelchair and she was surprised that when she inspected it after the incident on April 28, 2005, that the anti-tilt .bar was not on the wheelchair. Review of an Occupational Therapy Evaluation on April 22, 2002 revealed that the resident’s seating modifications had been completed to include a new Gunnell Tilt cart ... with anti-tip bars to prevent the wheelchair from tipping backwards. The facility failed to implement Resident l’s care plan according to the methods indicated to prevent fractures by always using a minimum two-person transfer and the facility failed to ensure that Client l’s equipment, a reclining NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000420 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 6 of 6 CITATION NUMBER: SECTIONS VIOLATED 17-I409-0001881-S Date: 1010412005 Time: CLASS AND NATURE OF VIOLATIONS wheelchair frame, the Gunnell Tilt cart, was maintained in operable condition with anti-tip bars. These facility failures presented either (1) imminent danger that death or serious harm to the patient or resident of the long-term health care facility would result therefrom, or (2) a substantial probability that death or serious physical harm to the patient or resident of the long-term health care facility would result therefrom. NOTE: iN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000421 Slate of California - Health and Hu.man Services Agency Department of Public Health ’SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 17-1361-0001882-S Date: 10/11/2005 Time: Type of Visit ¯ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE IncidenttComplaint No.(s) : No complaints found CALIFORNIA STATUTES AND REGULATIONS O.R APPL CABLE FEDERAL STATUTES AND REGULATIONS State Of Calif. Dept. Of Developmental Services Licensee Name: Address: P. O.,BQX 2000 170000837 License Number: Facility Name: 26501 Avenue 140 (559) 782-2222 Skilled Nursing Facility 170001876 Facility Type: Facility ID: 72523(c)(2)(A) 72313(a)(2) Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER DIP SNF Address: Telephone: SECTIONS VIOLATED PORTERVlLLE, CA 93258-2000 Porterville, CA 93257 Capacity: 201 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 11/7/05 12:00 a.m. CITATION--.MEDICATION 72523. Patient Care Policies and Procedures. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (2) Nursing services policies and procedures which include: (A) A current nursing procedure manual. 72313. Nursing Service--Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. The facility failed to: 1. Implement the facility’s nursing services policy related to medication administration, and 2. Administer medications as prescribed to Resident A, causing a significant drop in blood pressure as a result of Name of Evaluator: Resurrecio Del Castillo HFE-N Without admiiting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evafuator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000422 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1361-0001882-S Date: 10f11/2005 Time: CLASS AND NATURE OF VIOLATIONS receiving a double dose of his anti-hypertensive medication (Amlodepine/Benazepril) and a double dose of his antianxiety agent (Hydroxyzine). Resident A is a small built non-ambulatory, non verbal male admitted to the facility on April 15, 1957. He has an open medical problem of hypertension, which is managed by medications like Amlodepine Besylate, Atenolol, Clonidine and Enalapril. His blood pressure is stable. He also receives Hydroxyzine, an anti-anxiety medication to decrease his behavior of scratching his perineal area. Resident A receives these medications twice a day at 8:00 a.m. and at 6:00 p.m. StaffA disclosed that on June 29, 2005 (Wednesday) she took the 1800 hours (6:00 p.m.) anti-hypertensive medication (Amlodepine/Benazepril) and the anti-anxiety medication (Hydroxyzine) for Resident A from the medication drawer. She admitted that she did not check the cassette drawer from where she took the medications. Resident A’s blood pressure was 142/88. Staff A administered the medications. At 8:00 p.m., StaffA observed that Resident A’s 6:00 p.m. medications were still in the Wednesday cassette. She immediately administered the medications. Resident A’s blood pressure was 180140. Upon reviewing the MAR (Medication Administration Record) and medication cart at 10:00 p.m., Staff A discovered that she had erroneously administered two doses of both medications to Resident A. Staff A had inadvertently taken the 6:00 p.m. medications from the Friday cassette drawer instead of the Wednesday drawer. As she was reviewing the Wednesday drawer and saw the medications still in the drawer, she immediately gave the two medications without checking the Friday drawer. Resident A’s blood pressure dropped to 72/42. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000423 State o.f California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3. CITATION NUI~IBER: SECTIONS VIOLATED 17-1361,0001882-S Date: 10/11/2005 Time: CLASS AND NATURE OF VIOLATIONS Nursing Procedure No. 7.3. Oral Administration of Medications indicated that the person administering the medications must know the five rights: (right drug, dose route, time, client) reason for giving the medication, the desired effects, possible side effects, special precautions and contraindications. During administration, the medication person should check the label on the medicating package against the MAR. The medication will be removed from the unit dose drawer for designated time and check against the Medication and Treatment record before opening. Using the empty packets to chart from, document medication immediately after administration. The medication person will then check resident’s unit dose drawer to assure all medications have been given for that designated time. The medication person should record immediately using the empty medication packets after giving medication to each resident. The facility failed to implement the facility’s nursing services policy related to medication administration, and failed to administer medications as prescribed to Resident A, causing a significant drop in blood pressure [72/42, (normal 120/800] as a result of receiving a double dose of his anti-hypertensive medication (AmlodepinetBenazepril) and a double dose of his anti-anxiety agent (Hydroxyzine). These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAI=TEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000424 State oLCalifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUI~IBER: 17-1041-0003117-S Date: 08t17/2006 Time: Type of Visit: Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS State Of Calif. Dept. Of Developmental Services Licensee Name: Address: P. O. BOX 2000 Facility Name: Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER D/P SNF Address: Telephone: 26501 Avenue 140 (559) 782-2222 Skilled Nursing Facility 170001876 Fa.cility Type: Facility ID: SECTIONS VIOLATED .72527(a)(11) PORTERVlLLE, CA 93258-2000 170000837 License Number: 72307((a)) 72311 (a) (3) (B) tncidentJComplaint No.(s) ’ CA00070939 Porterville, CA 93257 Capacity: 201 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 8/31/06 12:00 a.m. CITATION-- PATIENT CARE 72307 (a) Each patient admitted to the skilled nursing facility shall be under the continuing supervis[on of a physician who evaluates the patient as needed and at least every 30 days unless there is an afternate schedule, and who documents the visits in the patient health record. 72311 (a)(3) (B) (a)Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden andlor marked adverse change in signs, symptoms or behavior exhibited by a patient. 72527(a)(i 1) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On February 14, 2005, an unannounced visit to the facility was conducted to investigate a facility reported event. It was determined the facility failed to ensure: 1. Resident K was under the continuing supervision of a physician who evaluated the resident as needed, after a fall where the resident complained of pain. Name of Evaluator: Deborah Van Arsdel HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evalualor Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SA~=TEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000425 State of Cafifornia - Health and Human Services Agency Department of Public Health ~£CTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED I7-1041-0003117-S Date: 08/17/2006 Time: CLASS AND NATURE OF VIOLATIONS 2. Nursing services promptly notified Resident K’s physician of the resident’s adverse change in symptoms, i.e., a fall with increasing pain. 3. Resident K’s right to be treated with consideration, respect and with full recognition of dignity when staff told the resident that she had to be quiet before the physician would be notified. Resident K was a 56 year old female admitted December 30, 1963 with diagnoses including morderate mental retardation; autistic disorder; schizophrenia; osteoporosis; hemiplegial hemiparesis; epilepsy; and history of fracture. Per a facility Incident Report dated January 23, 2006, a staff member was assisting Resident K to use the bathroom. When the staff member tried to assist the. resident to her wheelchair, the resident did not stand very well and started falling down. The staff member tried to catch her and ease her to the floor but she felt anyway. It was documented that later the resident refused to go to bed, complain!rig of pain to her left leg. When reviewed on February 15, 2006, the incident was documented in the resident’s clinical record Interdisciplinary Notes (!DNs.). The resident had complained of significant pain on January 23, 2006 at 10:00 PM and refused to bear weight. She told staff she needed to go to the doctor because her "leg was broke." She continued to verbalize about the pain. In response, Staff D told her the doctor would come to look at her "if she was quiet." However, there was no documentation of physician notification by Staff D. An hour and fifteen minutes later, Staff D notified the unit nurse. The unit nurse assessed the resident at 11:30 PM and the resident again complained of left hip and leg pain. The Medical officer on duty was called. An order was given for Tytenol 650 mg as needed for pain but the resident was not examined by the physician. Instead, the issue was posted for the next day’s physician attention. In addition, according to the IDNs, the only pain medication provided to the resident during the incident was regular Tyleno[ at 11:30 PM’, 6:15 AM and 10:15 AM When assessed by staff at 7:15 AM, the resident cried out when her left leg was "touched." When examined by the physician at 9:15 AM on January 24, 2006, over 14 hours after her injury, the resident "vocalized loudly" throughout the exam. At 10:15 AM the client was yelling, appeared to be in pain with facial grimacing and when asked, stated she was in pain. She was again medicated only with Tylenol. At 10:40 AM, 15 hours and 40 minutes after her injury, she was taken to the x-ray department while continuing to complain of pain and discomfort. The x-ray was positive for a left hip fracture and the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000426 State, of, California - Health and Human Services Agency Department of Public Health ~EOTION 1424 NOTICE Page 3 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 17-1041-0003117-S Date: 08/17/2006 .Time: CLASS AND NATURE OF VIOLATIONS resident was transferred to a community hospital emergency room 17 1t2 hours after the injury. The facility failed to ensure: 1. Resident K was under the continuing supervision of a physician who evafuated the resident as needed, after a fall where the resident complained of pain. 2. Nursing services promptly notified Resident K’s physician of the resident’s adverse change in symptoms, i.e., a fall with increasing pain. 3. Resident K’s right to be treated with consideration, respect and with full recognition of dignity when staff told the resident that she had to be quiet before the physician would be notified. The violations had a direct or immediate relationship to the health, safety, or security of a long term healthcare facility patient. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS tS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000427 State of California - Health and Human Services Agency Department of Public Health ., SECTION 1424 NOTICE Page 1 of 2 CITATION NUMBER: 17-1041-0001839-S Date: ’04f15/2002 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS IncidenttComplaint No.(S) : 170023048 State Of Calif. Dept. Of Developmental Services Licensee Name: Address: P. O. BOX 2000 170000837 License Number: Facility Name: PORTERVILLE, CA 93258-2000 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER DIP ICFDD 2650.1 Avenue 140 Porlerville, CA 93257 Address: Telephone: Intermediate Care FacilitylDevelopmentally Disabled Facility Type: Facility ID: Capacity: 512 170001878 SECTIONS VIOLATED CLASS AND NATURE OF VIOLATIONS CLASS B 76525(a)(20) PENALTY ASSESSMENT $700.00 trebled to $2,100,00 DEADLINE FOR COMPLIANCE 4122/02 12:00 a.m. CITATION .- PATIENT RIGHTS The facility failed to ensure that Client S was free from harm.. Complaint 16-10710 was investigated during an unannounced visit on May 2, 2001. Client S was a 38-year-old female admitted to the facility on September 9, 1980 with diagnoses that included profound mental retardation and attention deficit hyperactivity disorder. A nursing assessment dated October 14, 2000, documented that the client was independently ambulatory with good balance and coordination, had adequate vision and was non-verbaL The November 15, 2000, Individual Program P.lan documented the client’s minimal safety awareness. Interdisciplinary notes (IDN’s) dated March 13, 2001 at 8:45 a.m., documented that Client S had been ambulating through a passageway, tripped and fell over some furniture. She sustained a 3cm long forehead laceration, a 2cm long puncture wound inside the mouth, and a small abrasion of the right elbow. The IDN’s documented further that the forehead Name of Evaluator: Deborah Van Arsde] HFEN Wif, hout admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature ¯ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000428 State of California - Heallh and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 2 CITATION NUI~IBER: SECTIONS VIOLATED 17-1041-0001839-S Date: 04t15/2002 Time: CLASS AND NATURE OF VIOLATIONS laceration required suturing with six staples. The Individual Plan Coordinator documented complications, with the wound re-opening when the staples were removed on March 22, 2001. Just prior to the accident, IDN’s documented at 8:00 a.m. that Client S was ’jumping around, lunging at [people]’ and was not responding to prompts to sit down. Per the facility Incident Report, Client J witnessed the fall. He stated that Client S came down the hallway when she tripped over a glider-rocker and then fell to the floor. On September 19, 2001, the hallway and a glider-rocker were observed on the unit where the accident had occurred, The unit had three main hallways that intersected at the center of the unit. The hallways were the only way to move from one area of the unit to another. The glider-rocker measured approximately four feet high, by two feed wide, by two and one-half feet deep. The glider-rocker had been peaced directly in one hallway creating a safety hazard to clients, particularly hyperactive clients with impaired mental capabilities and poor safety awareness. The facility failed to provide an environment free of safety hazards. This led to the failure to ensure Client S was free from harm. This failure had a direct or immediate relationship to the health, safety or security of Client S and therefore constitutes a Class ’B’ Citation. NOTE: tN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000429 State ef~ California - Health and Human Services Agency Department of PubIic Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUI~BER: 17~1041-0001842~S Date: 05/21/2002 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS State Of Calif. Dept. Of Developmental Services Licensee Name: Address: P. O.BOX 2000 170000837 License Number: Facility Name: PORTERVILLE, CA 93258-2000 Type of Ownership: State Agency PORTERVlLLE DEVELOPMENTAL CENTER D/P ICFDD Address: Telephone: Facility Type: Facility ID: 26501 Avenue 140 Porterville, CA 93257 Intermediate Care FacilitytDevelopmentally Disabled Capacity: 512 1700O1878 SECTIONS VIOLATED 76525(a)(7) IncidenttComplaint No.(s) " 170023261 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $10,000.00 DEADLINE FOR COMPLIANCE 5/21/02 12:00 a.m. CLASS A CITATION -- PATIENT RIGHTS The facility failed to ensure that Client L was free from physical abuse. Complaint 16-13295 was investigated during an unannounced visit to the facility on September 26, 2001. Client L was a 46-year-old male admitted to the facility on .April 14, 1998, with diagnoses including schizophrenia, underweight, and mild mental retardation. Client J was a 21-year-old male admitted to the facility July 20, 1999, with diagnoses including impulse control disorder, .conduct disorder, sexual disorder, and mild mental retardation. Interdisciplinary notes dated September 22, 2001, at 3:30 p.m. documented that Client L reported to facility staff that Client J ’committed sodomy’ on him, forced him to perform oral copulation and threatened to suffocate him if he refused. He complained of rectal pain at that time and was treated by his physician with pain medication. Name of Evaluator: Deborah Van Arsdel HFEN Without admitting guilt, I hereby ackqowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature ¯ Title: NOTE; IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000430 State of. California - Health and Human ServicesAgency Department of Public i4ea]th SECTION t424 NOTICE Page 2 of 3 CITATION NUhIBER: SECTIONS VIOLATED 17-1041-0001842-S Dale: 05121/2002 Time: CLASS AND NATURE OF VIOLATIONS When interviewed on September 26, 2001, Quality Assurance staff stated that Client L had been sent to an acute care hospital for a Sexual Abuse Response Team (SART) examination on September 22, 200i. It was stated that Client J had been removed from the unit he had resided on with Client L. According to the facility Incident Report dated September 22, 2001, a facility registered nurse examined Client L. At the time of the exam, Client L stated that he ’hurt way down deep in there.’ It was also documented that Client L was ’very frail and unable to fight off stronger peers.’ Client J was moved to Unit 15 ’to provide protection’ and to ’prevent further sexual attacks.’ Documented staff interviews on September 24, 2001, determined that Client L thought the incident had occurred on Friday night, September 21, 2001, in the bathroom. Client L and Client J shared a bedroom for two weeks, which had a ’connected’ bathroom. Staff received a verbal report from the SART indicating that there was positive evidence of trauma to Client L. The police Crime Report dated September 22, 20001, contained a vivid description by Client L of a violent rape during which he was grabbed by the neck and threatened with suffocation by Client J. Client J admitted to having sex with Client L but alleged Client L had asked for the sex. Client J stated that Client L had asked him to stop but he did not stop until he heard staff approaching. The official September 22, 2001, SAIRT examination report documented extensive physical trauma to Client L’s peri-anal area and internal anal area and concluded that the physical findings were consistent with the history of the incident given by Client L. The facility failed to ensure that Client L was free from NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS I=OR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000431 State of California - Heaffh and Human Services Agency ’SECTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Departmenl of Public Health Page 3 of 3 17-1041-0001842-S Date: 05121/2002 Time: CLASS AND NATURE OF VIOLATIONS physical and sexual abuse. This facility failure had a substantial probability of death or serious physical harm to Client L and therefore, constitutes a Class ’A’ Citation. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000432 State of california - Health and Human Services Agency Department of Public Health 8ECr’IOI~ 1424 NOTICE Page 1 of 3 CITATION NUI~BER: 17-1139-0001841-S Date: 05t21t2002 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility tD: SECTIONS VIOLATED 76525(a)(20) Incident/Complaint No.(s) ¯ 170023288 State Of Calif. Dept. Of Developmental Services P, O. BOX 2000 170000837 PORTERVILLE, CA 93258-2000 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER DIP ]CFDD 26501 Avenue 140 Porterville, CA 93257 Intermediate Care FacilitytDevelopmenf~ally Disabled 170001878 CLASS AND NATURE OF VIOLATIONS . PENALTY ASSESSMENT $10,000.00 Capacity: 512 DEADLINE FOR COM PLIANCE 5/21/02 12:00 a.m. CLASS A CITATION -- PATIENT RIGHTS The facility failed to protect Client A’s right to be free from harm when Client B injured Client A by attempting to strangle him for the second time in Iess than two months. Complaint 16-13329 was investigated during an unannounced visit to the facility on October 17, 2001. Client A was an 18-year-old male admitted to the facility January 15, 1998. His diagnoses included mild mental retardation and post traumatic stress disorder. He had a history of maladaptive behaviors that included physical assaults, verbal threats, spitting in the faces of others and suicidal threats. He had no insight into his behaviors and took little or no responsibility for his actions. He was ambulatory, communicated verbally without difficulties and was able to perform all activities of daily living. Client B was 33-year-old male admitted to the facility April 18, 2000. His diagnoses included moderate mental retardation, anti-social personality disorder and neurotic depression. He had a history of maladaptive behaviors that Name of Evaluator: Margy Dismukes H,F.E,N.. Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000433 State of California - Health and Human Services Agency Department of Public Hea;th 8EOTiOI~11424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1139~0001841-S Date: 05t2112002 Time: CLASS AND NATURE OF VIOLATIONS included assault, threats, obscene phone calls, assault with a deadly weapon and suicide attempts. Client B ambulated without assistance. He communicated verbally. He was able to perform all activities of daily living. Clients A and B resided in the same residence. On October 17, 2001, during the investigation of Complaint 16-11276, Client A was observed to have a small, red, bleeding abrasion at the outer edge of the left upper eye lid. There were multiple horizontal, red bruises on the [eft side of his neck. The bruises had the shape of fingers. When asked how and when he received the injuries, Client A stated he made a derogatory remark to Client B about Client B’s mother. Client B punched him and tried to strangle him with his hands. Client A was able to pull Client B’s hands away from his neck. He said Client B attempted to strangle him in September with a Shoestring. Staff 1 was unable to locate any documentation of this incident, tt was not reported to the Department. During an interview on November 16, 2001, Client B denied being involved in any incident with Client A. He denied hitting or strangling him at any time. Staff 3 stated Client B did attempt to strangle Client A on September 1, 200l. Staff 3 provided an investigative report that documented the special investigator’s findings that Client B attempted to strangle Client A with a shoestring leaving a deep, red mark around his neck. The incident was referred to the district attorney because the method of strangulation was consistent with attempted murder. Both clients remained on the same residence where they had easy access to each other. This incident was the second time in less than two months that Client A was injured by Client B. Review of the facility’s investigative report for the October 17, 2001 incident documented that Clients A and B had an argument in their residence at 1600 hours. The NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS .FOR SUSPENSION OR REVOCATION OF= YOUR LICENSE DPH POD 000434 State of California - Health and Human Services Agency Department of Public Health .SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER." SECTIONS VIOLATED 17-’1139-00018~1-S Dale: 05/2112002 Time: CLASS AND NATURE OF VIOLATIONS argument led to an altercation resulting in what was identified as scratches to the outer corner of the left eye and left side of the neck of Client A. There was no documentation of injuries to Client B. The facility’s failure to protect Client A from harm presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Client A and therefore constitutes a Class ’A’ Citation. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAF’fEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000435 State of California - Health and Human Services Agency Department of Public Health ’SEcTIoN 1424 NOTICE Page 1 of 3 CITATION NUMBER: 17-1139-0001840-S Date: 05t21t2002 Time: Type of Visit: YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE ¯ CALIFORN IA STATUTES AND REGULATIONS OR APPLICABLE Incident/Complaint No,(s) : 170023355 FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility tD: SECTIONS VIOLATED 76525(a)(20) State Of Calif. Dept. Of Developmental Services P, O, BOX 2000 170000837 PORTERVILLE, CA 93258-2000 Type of Ownership: Stale Age~qcy PORTERVILLE DEVELOPMENTAL CENTER DIP ICFDD 26501 Avenue 140 Porterville. CA 93257 Intermediate Care FacilitytDevetopmenta]ly Disabled 170001878 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $8,000.00 Capacity: 512 DEADLINE FOR COMPLIANCE 5121/02 12:00 a.m. CLASS A CITATION -- PATIENT RIGHTS The facility failed to protect Client A’s right to be free from harm when Client B injured Client A by attempting to strangle him with a shoelace. Complaint 16-13415 was investigated during an unannounced visit on October 17, 2001. Client A was observed with bright red bruises on his neck and a bleeding abrasion at the outer edge of his left eyelid. He stated Client B attacked him earlier in the day and attempted to strangle him. According to Client A, this was the second time Client B had attempted to strangle him. Sometime in September, Client B had attempted to strangle him by putting a shoestring around his neck and tightening it. Client A stated he could not breathe. He hit and kicked Client B several times causing Client B to release him. He reported the incident to staff. Staff I had no knowledge of the incident and was unable to locate documentation of the September incident. During an interview on December 18, 2001, Staff 2 stated he was aware of the September incident and provided a copy of Name of Evaluator: Margy Dismukes H.F.E.N. Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000436 State of California - Health and Human Services Agency Department of Public Health :SEC3:ION I424 NOTIC£ Page 2 of 3 CITATION NUt~BER: SECTIONS VIOLATED 17-1139-0001840-S Date: 05t21t2002 Time: CLASS AND NATURE OF VIOLATIONS the facility’s investigative reporL The report documented the incident occurred on September 1, 2001. The surveyor reported this incident to the Department, which was then documented as Complaint 13415. The investigation of Complaint 13415 was completed December 18, 2001. The crime/incident report completed by Staff 4 documented statements Staff 4 took from witnesses of the incident: Staff 3, Client A, Client B, Client C and Client D. Client B stated he put the shoestring around Client A’s neck and attempted to choke him. Staff 3, Client C and Client D all stated they witnessed Client B go behind Client A, place a shoestring around his neck and tighten it. Staff 4 recommended in the conclusion of the crime/incident report that Client B should be charged with assault witha deadly weapon due to witness statements, visible marks on Client A’s neck, and Client B’s admission that he tried to choke Client A. Review of Client B’s clinical record documented he was admitted to thefacility on April 18, 2000. His Comprehensive Rehabilitation Therapy Evaluation dated May 1, 2000 documented he had a history of multiple problems with aggression and assault with a deadly weapon. There was no evidence of an Individual Program Plan (IPP) was developed or implemented for aggression or assault. Review of Client A’s clinical record showed he was admitted to the facility January 15, 1998. His IPP dated February 5, 2001 documented he had a history of assaults, verbal threats, spitting in the face of others and suicidal threats. He had no insight into his behavior and took little or no responsibility for his actions.. The facility made no changes to his IPP. On September 1,2001, Client B attacked Ciient A from the rear. Client B placed a shoestring around the neck of NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOIJR LICENSE DPH POD 000437 State of California - Health and Human Services Agency Department of Public Health SEOT’ION 1424 NOTICE Page 3 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 17-1139-0001840-S Date: 05/21/2002 Time: CLASS AND NATURE OF VIOLATIONS Client A and tightened it in an upward motion. Client A was injured when the shoestring caused a deep, red indentation around the neck of Client A. Client A was unable to breathe while Client B tightened the shoestring around his neck. The facility’s failure to protect Client A from harm presented imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result to Client A and therefore constitutes a Class ’A’ Citation. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAtLURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000438 State of California - Health and Human Services Agency Department of Public Health SEc’rION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 17-1139-0001843-S Date: 07/26/2002 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGOLATIONS Licensee Name: ¯ Address: License Number: Facility Name: Address: TeIephone: Facitity Type: Facility ID:. SECTIONS VIOLATED 76525(a)(20) IncidenttComplaint No.(s) : 170023085 State Of Calif. Dept. Of Developmental Services P. O. BOX 2000 170000837 PORTERVILLE, CA 93258-2000 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER DIP ICFDD 26501 Avenue 140 Porterville, CA 93257 Intermediate Care FacilitylDevelopmentally Disabled 17OOO 1878 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $8,000.00 Capacity: 512 DEADLINE FOR COMPLIANCE 7/26/02 12:00 a.m. CLASS A CITATION -- PATIENT RIGHTS The facility failed to protect Client A’s right to be free from harm when she was hit on the top of her head and injured by a metal stool thrown by Client B. This class ’A’ Citation is a result of the investigation of Complaint 16-11132. Client A was a 48 year-old female admitted to the facility in 1971. Her diagnoses included profound mental retardation and attention deficit hyperactivity disorder. Client A was non-verbal. She communicated with staff by using facial expressions, making vocal noises and gesturing. Client A enjoyed sitting on the sofa in her residence alone. She was a passive participant in most activities, preferring to sit and watch her peers. She was five feet, three and one-half inches tall and weighed 145 pounds. Client B was a 39 year-old male admitted to the facility on April 2, 2001, from a community based home. His admitting diagnoses included severe mental retardation and intermittent explosive disorder. He had a history of Name of Evaluator: Margy Dismukes H.F.E.N. Without admitting guilt, hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name: Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000439 State of California - Health and Human Services Agency Department of Public Health SECTION I424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1139-0001843-S Date: 07/26/2002 Time: CLASS AND NATURE OF VIOLATIONS multiple community placements and returns to developmental centers because of his behaviors of throwing furniture, attacking peers and staff, and hitting his head. He was almost six feet tall and weighed 200 pounds. During an interview on June 6, 2001, at 1615 hours, Staff 1 stated that on June 1, 2001 at 1100 hours, Client A was sitting in the activity area of her residence when Client B became upset with staff because he wanted to put his water bottle in his locker right away and was told to wait for additional staff. Client B attacked a water fountain on the wall by.kicking it and pulled it completely off the wall. He picked up a stool, threw it and hit Client A on the top of her head causing a 7centimeter (cm) laceration. The stool was round with a padded center, a wide metal band around the outside of the seat, heavy metal legs and a heavy metal band around the legs. As Client A bled profusely from the laceration, she screamed and fought staff that attempted to stop the bleeding. Interdisciplinary notes dated June 1,2001, at 1115 hours, documented that Client A sustained a deep laceration approximately 6cm long. Depth was not measured because Client A was resistive, screaming and fighting. Physician’s progress notes dated June 1, 2001, at 1130 hours, documented that the laceration was actively bleeding. Client A was very resistive, screaming and thrashing about. She was given Versed (a sedative) 5 milligram (mg) intramuscular (IM) and placed on a papoose board (restrained on a board to limit movement) to stabilize her head for sutures. She continued to be resistive thrashing her head about causing suture material to touch her hair repeatedly. Because the procedure was not sterile, the physician ordered Keflex 500mg (an antibiotic’) four times a day for ten days. Client B had an objective to maintain hitting his head at zero incidents per month for six consecutive months by May 31, 2002. Under training method, number 17 documented if NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000440 State of California - Health and Human Services Agency Page 3 of 3 ,,SEC’rl0N 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health 17~1139-000!843-S Date: 07/2612002 Time: CLASS AND NATURE OF VIOLATIONS Client B continued to escalate and it is thought he is about to engage in target behaviors of biting his hand, hitting his head, andtor throwing furniture, quickly remove the other nearby clients from the room to a safer place. Staff failed to remove Client A to a safer place resulting in her being hit on the head by a metal stool thrown by Client B causing a 7cm laceration that required six sutures to close. Client A was given Versed to calm her, Keflex for ten days and physically restrained to be sutured because of her screaming and thrashing about due to the pain and shock of being hit. The facility failed to protect Client A from harm. The facility’s failure to protect Client A from harm 3resented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Client A and therefore constitutes a Class ’A’ Citation. ¯ NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000441 State o! California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 1 of 5 CITATION NUI~BER: 17~1139-0001844-S Date: 11104/2002 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Incident/Complaint No,(s) : 170023027 FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type; Facility iD; SECTIONS VIOLATED 76525(a)(20) State Of Calif. Dept. Of Developmental Services P, O. BOX 2000 170000837 PORTERVILLE, CA 93258-2000 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER DIP ICFDD 26501 Avenue t40 Porterviile, CA 93257 Intermediate Care FacilitytDevelopmentally Disabled 170001878 CLASS AND NATURE OF VIOLATIONS GLASS B Capacity; 512. PENALTY ASSESSMENT $1,000.00 trebled to $3,000.00 DEADLINE FOR COMPLIANCE "tl/11/02 12:00 a.m, CITATION -- PATIENT RIGHTS The facility failed to protect Client A’s right to be free from harm when she received a six inch laceration and a ¯ twelve inch laceration on the right side of her torso from persons or objects unknown, Client A was an active, social woman in her forties who was tall, of large stature, and obese. She ambulated freely and was able to communicate her. needs verbally. Her diagnosis included moderate mental retardation and grand mal status epileptic. The facility’s incident report dated January 20, 2001, documented that a staff person found Client A at 6:45 p,m., lying on her back on the floor of her bedroom, She was bleeding from two lacerations on her right side. The lacerations were very deep and Client A was non-responsive. The facility’s emergency response team was called. Client A became agitated and uncooperative with the emergency response team hindering their treatment. An ambulance was called to transport her to the acute hospital. Client A’s agitation and resistance escalated with the arrival of the Name of Evaluator: Margy Dismukes H.F.E.N, Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signalure ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000442 Stale of, California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 5 C~TATION NUMBER: SECTIONS VIOLATED 17-1139-0001844-S Date: 11t0412002 Time: CLASS AND NATURE OF VIOLATIONS ambulance. She fought with the ambulance attendants who decided to transfer her without a neck brace. Staff I documented in the report that the nursing person in charge along with the nurse of the day (NOD) checked the room to see if maybe there was a piece of furniture or other objects Client A could have fallen against to cause her injuries. The only blood that was found in the room was where Client A had been iying on the floor. A review of the incident was conducted of this incident by the facility on January 23, 2001. There was no evidence of any thorough investigation. The facility documents that Client A has a long history of sustaining lacerations and included the following care plans: Eczema-free of skin lesions, bruising of upper/lower extremities, hypocalcemiano more than one spontaneous fracture, overweight-will tose weight until desired range is reached, Epilepsy-seizures wilt remain at the current status, leg edema-free from complications. Client A was interviewed on January 23, 2001, in the facility’s acute hospital. She was unable to describe how she was injured. During an interview on January 20, 2001, at 1:45 P,m., Staff 2 stated Client A suffered from monoclonal gammapathy of and lgM Kappa, a blood disease manifested by an abnormal elevation of these proteins in the blood. This disease caused an increase in the viscosity (thickness) of the blood and multiple tumors. Staff 2 stated this disease caused changes in all tissues and splitting of skin could be a result. He stated the lacerations were spontaneous when Client A fee When asked if the lacerations could have been caused by any other means, he responded he did not know. He stated he was not the doctor on the scene. This was what the doctor on the scene told him. A review of Client A’s clinical record did not show a NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000443 State of California ~ Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1139-0001844-S Date: 11/04/2002 Time: CLASS AND NATURE OF VIOLATIONS history of spontaneous lacerations. The facility’s Level One Review written by Staff 3 documented the following lacerations: October 31, 2000, Client A had a three quarter inch laceration on her right ankle. She stated she felt in the shower. October 26, 1999, Client A had a laceration under her right upper arm while at a Halloween carnival. Client A was unaware of the injury. This laceration required sutures to close. June 28, 1999, Client A had a five inch long, one half-inch deep laceration On her right arm. She rubbed her arm against a screw on the outside of a facility tram while she was waving causing this laceration. This laceration required seventeen sutures to close. May 29, 1999, Client A had a laceration on her knee that was 4.8 cm long and 3 cm deep. She stated she fell on cement. There was no evidence that these injuries were spontaneous. Staff 3 documented, that approximately two years ago, Client A had a large laceration on her buttocks. There was no supporting documentation of this submitted by the facility. Client A’s Individual Program Plan (IPP) including objectives did not document a problem with spontaneous lacerations of the skin. The hematologist follow up note dated December 14, 2000 documented that Client A’s serum viscosity, lgA, IgG, and tgM were within normal limits. Staff4 was interviewed May 3, 2001 at 9:15 a.m., She stated she was the medical officer of the day (MOD) January 20, 2001, when Client A was discovered injured. She observed the two lacerations on Client A’s right side. Both lacerations were deep and the adipose (fatty) tissue was NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000444 Slate of California - Health and Human Services Agency ¯ SECTION 1424 NOTICE ~ITATION NUMBER: SECTIONS VIOLATED Department of Public Health Page 4 of 5 17-1139-0001844-S Date: 11/04/2002 Time: CLASS AND NATURE OF VIOLATIONS exposed. The edges were smooth and easily approximated. Because Client A was agitated and fighting the staff, Staff 4 was not able to get a really good look at the lacerations. She looked at the bed and did not believe falling against it could have caused the lacerations. Staff 4 provided a written declaration. On May 6, 2001 at 3:00 p.m., the treating emergency room physician at the acute hospital was interviewed. He stated he remembered Client A’s injuries because they were so horrendous. He remembered the lacerations were completely through all layers of the skin. It took fifty external sutures and he did not remember exactly how many internal stitches to close the wound nor was it documented in the emergency room record. He said the wounds were clean and could have been made by a sharp object. He had never seen wounds like that caused spontaneously. A review of the literature on Monoclonal Gammapathy of IgG and IgM Kappa did not indicate spontaneous lacerations as a manifestation of the disease. One doctor did not believe the lacerations were spontaneous and another had never seen spontaneous lacerations of such magnitude. Facility staff concluded there was nothing in the room that Client A fell against to cause the lacerations because blood was only on the floor where she was found. Client A was seriously injured when she received two large lacerations on the right side of her body from sources or persons unknown. These lacerations were completely through all layers of skin exposing the adipose tissue requiring more than fifty stitches total internaf and external. The facility failed to protect Client A from serious injury. The facility’s failure to protect Client A from harm NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAI=TEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000445 State of California - Health and Human Services Agency "SECTION ’1424 NOTICE CITATION NUI~BER: SECTIONS VIOLATED Departmenl of Public Health Page 5 of 5 17-113£-0001844-S Date: 11104/2002 Time: CLASS AND NATURE OF VIOLATIONS presented a direct or immediate relationship to the health, safety or security of the client and constitutes a ’B’ citation, NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000446 State of California - Health and Human Services Agency Department of Public Health Page 1 of 3 SECTION 1424 NOTICE CITATION NUIVIBER: 17-1139-0001845~S Date: 01t14t2003 Time: Type of Visit : Y.OU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) IncidentfComplaint No.(s) " 170023025 State Of Calif. Dept. Of Developmental Services P. O. BOX 2000 170000837 PORTERV~LLE, CA 93258-2000 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD 26501 Avenue 140 Porterville, CA 93257 Intermediate Care Facility/Developmentally Disabled 170001878 CLASS AND NATURE OF VIOLATIONS CLASS B Capacity: 512 PENALTY ASSESSMENT $1,000.00 trebled to $3,000.00 DEADLINE FOR COMPLIANCE 1/21/03 12:00 a.m. CITATION-- PATIENT RIGHTS This Class ’B’ Citation is a result of an investigation of Complaint 16-10368. The facility failed to protect Client A’s right to be free from harm when Client A received multiple bruises on his body and multiple cuts in the anal mucosa that caused rectal bleeding. The cause of these injuries was unknown. Client A was an active male in his forties who ambulated freely. He had a speech impediment that caused him to slur his words making it difficult to understand him at times. Client A was short in stature, rotund with short arms and legs. He was able to make his needs known. Client A had a history of scratching and hitting himself. The facility reported on January "I2, 2001, that staff noticed that Client A had blood in his stool on January 8, 2001. Staff observed multiple bruises on his body. During an interview on January 19, 2001, at 12:05 p.m, Client A gave conflicting stories of how he received his Name of Eva~uator: Margy Dismukes H.F.E.N. Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature : Tille : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000447 State of California - Health and Human Services Agency Department of Public Health SECTION ’I424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1139-0001845-S Date: 01/14/2003 Time: CLASS AND NATURE OF VIOLATIONS injuries.. He first stated staff pushed him down then said another client ’beat his ass.’ He was unable to identify the staff or client. He was observed scratching a rash on his chest and hands. He stated he scratched because he itched and denied scratching his anus. He demonstra6ted he was unable to reach his anus from either the front or the rear. His fingernails were noted to be extremely short. Client A’s injuries were viewed with his permission. The injuries observed were the same as those reported by facility staff. When asked again how he received the injuries, Client A became agitated and ended the interview. During an interview on February 23, 2001 at 2:00 p.m., Staff 2 provided photographs of Client A’s injuries taken by the facility police. Photograph A showed a red linear mark down the center of Client A’s back. It was approximately the same size as a ballpoint pen held against his back for reference in photograph B. Photograph C showed a fading bruise on the right side of his lower back near the waistline. Photograph D showed multiple red lines on his left hip. Photograph E showed Client A bending over a bed with white briefs pulled down below his hips. There was a large dark red bruise rimmed in black on the right side of his coccyx extending into between his buttocks. Dark red stains were visible in the white briefs. Staff 2 stated Client A gave him conflicting stories of how he received his injuries when he interviewed him. Staff 2 stated he believed Client A’s roommate assaulted him. The roommate denied this and when he asked Client A, he became agitated and refused to answer. Qn Ma~:ch 13, 2001, at 2:00 p.m., another attempt was made to interview Client A to clarify how he received his injuries. When asked if he was sexually assaulted by anyone, he became anxious and agitated. He paced the room shaking his head. His speech was more slurred than during the previous interview making him very difficult to understand. He said his roommate always watched him when he used the bathroom, NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000448 State of California - Health and Human Services Agency Department of Public Health SEC"I’ION 1424 NOTICE Page 3 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 17-1139-0001845-S Date: 01/14t2003 Time: CLASS AND NATURE OF VIOLATIONS he did not like living at the facility and wanted to go home. When asked again how he was injured, he became more agitated and the interview was ended. At 2:30 p.m. on March 13, 2001, Staff 3 stated that Client A reported the rectal bleeding to her. He took her to the bathroom to look into the toilet. There was so much blood the water was bright red. Client A was taken to the emergency room of the local acute hospital for treatment. On May 23, 2001, another attempt was made to interview Client A. He would only say he wanted to go home. Record review showed the facility staff called the acute care hospital before taking Client A to the emergency room. The hospital’s referral record documented the facility staff identified Client A’s problem as bloody hemorrhoids. The emergency room examination record revealed the bleeding was due to shallow cuts in the anal mucosa. The recommended treatment was to treat as hemorrhoid bleeding for the next few days with frequent bathing. Facility staff documented these cuts were due Client A scratching himself. Because of Client A’s rotund body and short extremities, he could not reach into his anus to scratch and cause the described injuries. Client A had no history of scratching inside his anus. Client A was harmed when he received a 9cm x 4cm bruise to his buttocks on the coccyx, a linear red bruise in the middle of his back, multiple bruises to his left and right hips, and multiple cuts to the anal mucosa that caused rectal bleeding. These injuries were from sources or persons unknown. The facility failed to provide care and treatment for Client A that protected his right to be free from harm. The above violations had a direct or immediate relationship tot he health safety and security of Client A. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFrEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000449 State of California - Hea{th and Human services Agency Department of Public Health 8ECTI.ON’ 1424 NOTICE Page 1 of 3 CITATION NUMBER: 17-1041-0001871-S Date: 06/28t2005 Time: Type of Visit ¯ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS State Of Calif. Dept. Of Developmental Services Licensee Name: Address: P. O. BOX 2000 170000837 License Number: Facility Name: PORTERVILLE, CA 93258-2000 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER D/P ICFDD Address: Telephone: 26501 Avenue 140 Porterville, CA 93257 intermediate Care FacilitytDevelopmentally Disabled 170001878 Facility Type: Facility ID: SECTIONS VIOLATED 76315(b) 76525(a)(20) ¯ IncidenttComplaint No.(s) ¯ No complaints found CLASS AND NATURE OF VIOLATfONS CLASS B Capacity: 512 PENALTY ASSESSMENT $500.00 DEADLINE FOR COMPLIANCE 7/12/05 12:00 a.m. CITATION -- PATIENT RIGHTS 76315. Developmental Program Services--Individual Program Plan, (b) The individual program plan shall be implemented as written. 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. On March 16, 2005 an unannounced visit to the facility was conducted to investigate a facility reported event. It was determined the facility failed to: Name of Evaluator: Deborah Van Arsdel HFEN Without admitting guilt, i hereby acknowledge receipt of this SECTION 1424 NOTICE Signature" Name ¯ Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000450 State of CaFifornia - Health and Human Services Agency Department of Public HeaJth SECTION 1424 NOTICE Page 2 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 17-104t-0001871-S Date: 06128/2005 Time: CLASS AND NATURE OF VIOLATIONS 1. Implement Client D’s individual program plan as written. 2. Protect Client D from harm. Client D 63 year old female admitted to the facility on October 26, 1953 with diagnoses that included Profound Mental Retardation; PICA (a pattern of eating non-edible substances); Osteoarthritis and a history of foreign body in pharynx (December 29, 1992, September 15, 1987, and July 22, 1987). According to a facility Incident Report (IR) dated February 17, 2005, this fR was a follow-up of an incident that occurred on January 18, 2005, when Client D was sent to the ¯local community hospital for evaluation. The IR indicated the client had signs of distress, coughing up mucous and emesis leading to the hospital transfer. It was also documented the client had a history of PICA behavior and has had numerous resulting surgeries in the past. The incident was documented in the clinical record Interdisciplinary Notes (IDNs) on January 18, 2005 at 6:15 p.m. Staff observed clear secretion coming out of the client’s mouth. The secretion persisted so the client was suctioned. Later, the client was observed with a. wet shirt and "small coughing episodes" that brought up small particles of food. When she was unable to take her medications staff called the unit Registered Nurse for an assessment. After emesis, and falling oxygen saturation readings, oxygen was administered via mask and the physician called. The client was transferred to the acute care community hospital via ambulance. An Esophagogastroduodenoscopy (EGD scope visualizing throat and stomach) procedure done on January 21, 2005, at the acute care hospital was positive for foreign body ingestion. According to the EGD, Client D’s esophagus was filled with thick fluid, food particles and paper towel in both the client’s esophagus and stomach. The esophagus was suctioned NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000451 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1041-0001871-S Date: 06/28/2005 Time: CLASS AND NATURE OF VIOLATIONS and the foreign body was removed by "piece meal." The "long foreign body" in the stomach had to be removed with a "snare." The EGD also showed, multiple irregular ulcers in the lower third of the esophagus oozing blood. Appearances were Necrotic ulcers due to foreign body impaction. The client remained hospitalized for several days. The client was also treated for pneumonia during the hospital stay. The client’s April 19, 2004 Individual Program Plan (IPP) identified her PICA behavior. The IPP Approaches and Strategies document "PICA: Provide close supervision at all times to prevent ingestion of edibles." Plan B-1.1 dated April 19, 2004, was in place. Interventions included close supervision "at all times" during waking hours. The facility failed to closely supervise Client D at all times per the Individual Program Ptan and failed to prevent harm from the ingestion of foreign bodies. The client was able to ingest enough paper towels to obstruct her esophagus and necessitate an invasive procedure to remove the paper towel, These failures had a direct or immediate relationship to the health, safety, or security of Client D. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE . DPH POD 000452 State of California - Health and Human Services Agency Departmenl of Public Health SECTION I424 NOTICE Page 1 of 5 CITATION NUI~BER: 17-1129-0001874-S Date: 08/04/2005 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALl FORN~A STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Nam4: Address: License Number: Facility Name: Address: -Felephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(7) 76315(b) Incident/CompIaint No.(s) ’ No complaints found State Of Calif. Dept. Of Developmental Services P. O. BOX 2000 170000837 PORTERVlLLE, CA 93258-2000 Type of Ownership: State Agency PORTFRVILLE DEVELOPMENTAL CENTER DIP ICFDD 26501 Avenue 140 Porterville, CA 93257 Intermediate Care Facility/Developmentally Disabled 170001878 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $1,000.00 Capacity: 512 DEADLINE FOR COMPLIANCE 8/22!05 12:00 a.m. CLASS B CITATION -- PATIENT CARE 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. 76315. Developmental Program Services--Individual Program Plan. (b) The individual program plan shall be implemented as written. On March t, 2005, an unannounced visit was made by the Department of Health Services to investigate a facility self reported event. The investigation found that the facility failed to: Name of Evaluator: Velle Mere Wemke HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000453 State of California - Health and Human Services Agency ¯ Department of Public Health SECTION 1424 NOTICE Page 2 of 5 CITATION NUN1BER: SECTIONS VIOLATED 17-1129-0001874-S Date: 08t04t2005 Time: CLASS AND NATURE OF VIOLATIONS 1. Ensure the rights of two severely developmentally disabled clients to be free from verbal and physical abuse, and 2. To implement the clients Individual Program Plans for maladaptive behaviors. On October 2, 2004 at 7:00 a.m. while three Psychiatric Technician Students in-training observed client care they observed and reported verbal and physical abuse by Staff 1, a Psychiatric Technician. On October 2, 2004, Staff 1 warned all three students, "Whatever you see here stays here, don’t tell your teacher. Sometimes weird stuff happens here and sometimes we have to use physical force, don’t tell them anything. We try to be )rofessional but it just doesn’t work with these guys." Client 1 was a male with diagnoses Of severe mental retardation and intermittent explosive disorder. Client 1 has open health, care pfans for osteopenia at risk forspontaneous fractures because of weak/fragile bones), bruising and body aches and pains. Client 1 is vulnerabfe to harm from physical abuse because of the danger of spontaneous fractures. Review of Client l’s Individual Program Plan for maladaptive behaviors included "harm to others". The reactive plan noted Client 1 is more likely to become aggressive when the staff used physical guidance. Student t stated on the declaration dated October 12, 2004. Student 1 observed Staff 1 pull Client 1 "back" into the living room by his shirt and yell at him. Staff 1 directed Client t to sit down and, "Staff 1 put up his fists like he [Staff 1] was going to "charge" Client 1". Student 1 also documented "1 observed him [Staff 1] pushing and shoving NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000454 State,of California - Health and Human Services Agency Depart, ment of Public Health SECTION 1424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS VIOLATED 17-1129-0001874-S Date: 08/04/2005 Time: CLASS AND NATURE OF VIOLATIONS Client 1. He was using physical force to redirect him to sit down onto his seat.". ..... "He [Staff 1] then told this writer [Student 1 ] and two classmates" [Student 2 and 3], "Whatever you see here stays here, don’t tell your teacher. Sometimes...we have to use physical force that don’t, kill them or anything. We try to be professional but it just do~esn’t work with this guy (Client 1 and peers)". Student 2 stated on a declaration dated October 12, 2004, "starting at approximately 7:00 a.m., I witnessed several occasions where he [staff 1] had been physically rough with some of the clients. He came in and was trying to help me get my client [Client 2] ready. He kept grabbing Client 2 by the arm and shoving him around roughly. After the clients were all dressed and sitting in the living room, there was an individual [Client 1 ] who would keep standing up. He [Staff 1] would go and shove him back into his seat, this happened repeatedly". .... "After breakfast, we returned to the living room where more roughness occurred with him " [Staff I] shoving clients down". "Some students [Student 1 and 3] and I were talking to him [Staff 1] when he made a comment "What you see here, stays here, don’t tell your instructor". "After that we (the students and I) went to break ...... we informed our instructor". Interview with Student 3 on March 4, 2005, revealed Student 3 observed Staff 1 pull Client 1 back into a chair by the client’s shirt and saw Staff 1 physi.calfy push the Client into the chair by his shoulders from behind. Staff I raised his arm and continued to raise his arm while in a standing position, as if to backhand client 1. In a written declaration dated 10t24t04, Student 3 documented "1 observed Staff 1 forcefully grab him [Client 1] by his shirt and pull him into a chair. At breakfast, Staff 1 continued to grab his [Client l’s] shirt pulling him into a chair and at one time physically grabbing his shoulders from behind and shoving him into the chair". NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS ~S GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000455 State of California - Health and Human Services Agency Department of Public Health ~ECTION 1424 NOTICE Page 4 of 5 CITATION NUI~BER: SECTIONS VIOLATED 17-1129-0001874-S Date: 08f04/2005 Time: CLASS AND NATURE OF VIOLATIONS Client 2 has diagnoses of severe mental retardation, unsteady gait (which requires close shadowing by staff to prevent falls), inappropriate sexual behavior and aggressive type personality change. Client 2, who walks with a shuffling gait, has had several falls resulting in injuries because of his unsteadiness on his feet. A gait belt (wide belt worn by the client to give caregivers something to hold on to in order to stabilize and support the client when he walks) was recommended by physical therapy but the client adamantly refuses to wear it and becomes very aggressive when staff try to persuade him to use it. Review of Client 2’s Individual Program Plan for maladaptive behaviors included, "aggression to others" and inappropriate sexual behavior, rubbing against others in a sexual manner. Known antecedents to Client 2’s behaviors included being " rushed or over-prompting; proaciive plans included giving Client 2 time to respond, when redirecting, calf him by his favored pet name, and reactive plans included using the word "stop" or redirection to another activity. Review of the declaration dated October 12, 2004, by Student 1 stated Staff 1 was observed to say to Client 2, ’Are you gay or are you "faggot", you’re a "faggot" [client’s name]," when Client 2 began to rub another client’s lap. Interview with Student 2 on March 8, 2005 at 10:26 a.m. revealed Staff 1 was observed getting physically rough with Client 2. Student 2 was assisting Client 2 to get dressed and Staff 1 came into the room and tried to hasten the client’s dressing by grabbing Client 2 by the arm and shoving Client 2 around. Student 2 heard Staff 1 say to this client, "Hey [name] are you a faggot, you must like that". Three students observed Staff 1 use either physical force or NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000456 State,of,California - Health and Human Services Agency Department of Public Health SECTION "[424 NOTICE Page 5 ef 5 CITATION NUMBER: SECTIONS VIOLATED 17-1129-0001874-S Date: 08t04t2005 Time: CLASS AND NATURE OF VIOLATIONS verbal abuse to force Client 2 to comply with his instructions. Student 2 reported that Staff 1 came into Client 2’s room; shut the door as Staff 1 talked to his cell phone. While Student 2 was assisting the client to dress, Staff 1 got physically rough with the client, grabbed the client by the arm and shoved him around, presumably to speed the dressing process. Client 1 was shoved and pushed multiple times, pulled.by the shirt and intimated when Staff 1 raised his hand as if to backhand Client 1. Client 2 was subjected to physical abuse when Staff 1 grabbed Client 2’s arm and shoved him around and subjected to humiliation, verbal abuse when called "faggot". There was no observation by all three students of any attempt to use Client 1 of 2’s IPP by Staff 1. The facility failed to ensure Clients 1 and 2 were free from harm when Staff 1 was mentally and physically abusive to Clients I and 2, and the facility failed to implement the Individual Progr&m Plans for maladaptive behaviors for Clients I and 2. The violations were determined to cause or under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Clients 1 and 2, and had a direct or immediate relationship to the health, safety, or security of long term health care facility patients or residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000457 State, of, California - Health and i-luman Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 4 CITATION NUN1BER: 17-1706-0001883-S Date: 1011212005 Time: Type of Visit: YOU ARE HEREBY FOUND tN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facil;ty Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(7) Incident/Complaint No.(s) : CA00059315 State Of Calif. Dept. Of Developmental Services P. O..BOX 2000 PORTERVlLLE, CA 93258-2000 170000837 Type of Ownership: State Agency PORTERVILLE Dt~VELOPMENTAL CENTER DIP ICFDD 26501 Avenue 140 Porlerville, CA 93257 Intermediate Care FacilitytDevelopmentally Disabled 170001878 CLASS AND NATURE OF VIOLATIONS CLASS B Capacity: 512 PENALTY ASSESSMENT $1,000.00 trebled to $3,000.00 DEADLINE FOR COMPLIANCE 1t/8/05 12:00 a,m. CITATION -- PATIENT RIGHTS 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the folfowing rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. The facility failed to ensure Client 1 remains free from physical abuse when they failed to: a. Provide close supervision and monitoring to prevent Client 1 from being repeatedly assaulted which resulted in repeated bodily injury to Client 1. b, Arrange alternate living arrangements to a "Safer, less stressful environment where the (~lient would be Less at risk for harm from peers." Name of Evaluator: LYNN JANOSCO HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature ¯ Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000458 State.. of, California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1706-0001883-S Date: 10112/2005 Time: CLASS AND NATURE OF VIOLATIONS Client 1 is a 35 year-old who was admitted to the facility with a diagnosis that.included Moderate Mental Retardation. An individual Program Plan (IPP), dated September 29, 2004, identified Client 1 as verbal, speaks in short sentences, capable of interaction with staff and peers and of making her wants and needs clearly known. The client was further identified as able to tell staff if she feels sick or if a peer appears to be sick. The client can walk, but most of the time remains in a wheelchair. An incident report dated August 22, 2005 at 1:15 p.m. revealed that while Client 1 was on the unit, in the foyer area, Client 2 ran over and grabbed Client l’s hands and pulled Client 1 out of the wheelchair. Client 1 felt and hit her head on the floor sustaining a 1 centimeter laceration over the left eyebrow. Client 2 was admitted with diagnoses that included Profound Mental Retardation and Paranoid Schizophrenia with a history of assaulting staff. Review of the ERNE (Emerging Risk Notification note) dated March 2, 2005; indicated Client 1 was a Potential target of aggressive peers on Residence 26. A formal request dated March 29, 2005 was made for alternate living arrangements to a "Safer, less stressful environment" where Client 1 would be less at risk of harm from her peers. On March 6, 2005, Individual Program Plan review noted that Client 1 sustained several injuries including fracture of the right distal Fibula and incidents of bruising. It was noted that the source of the injuries "is not completely clear." The Team recommendation was for Client I to receive "Closer Supervisiontmonitoring on the residence and at her training site." Risk factors included Potential for fractures, self-inflicted injuries, and seizures. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000459 State, of, California- Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 4 CITATION NUf~BER: SECTIONS VIOLATED 17-1706-0001883-S Date: 10112/2005 Time: CLASS AND NATURE OF VIOLATIONS Further review of Client l’s record revealed that Client 3 harmed Client 1 on five separate occasions: Client 3 was admitted to the facility with diagnosis that included Mild Mental Retardation, and Schizoaffective Disorder. A nursing care plan dated January 13, 2005, included behaviors described as "Agitating peers by yelling ... or attempting to hit them." On December 29, 2004 Client 3 slapped Client I and on January 12, 2005, an ERNE was held to discuss the incident. Documentation following the team revealed [Client 1 and Client 3] had a "Rocky" relationship. It further stated that both clients were very intelligent and independent but Client 3 seemed to dislike Client 1. The Team recommendation indicated; "Continue to follow [Client 3’s] plans ... Staff would provide client supervision when these two parties are in the same vicinity." Client 3 continued to victimize Client l four more times after the team made the recommendation. Dates of the incidents included: January 23, 2005, February 21, 2005, May 15, 2005, and July 16, 2005. Further review of the ERNE notes revealed that Client 4 slapped Client 1 on the face, on two separate occasions: on May 15, 2005 and July 7, 2005. Review of Client 4’s IPP dated September 22, 2004, identified behaviors that included hitting others and property destruction. Review of the behavioral training plan revealed, "When fragile clients are around, monitor closely and redirect Client 4 away from the area to an alternate activity of the client’s choice." Interview with Administrative Staff on September 7, 2005 at 3:00 p.m. revealed that the recommendation made by the team in March 2005 (6 months earlier), to place Client 2 in a safer, less stressful, alternate living environment .... NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000460 State pf California - Health and Human Services Agency Deparlment of Public Health SECTION 1424 NOTICE Page 4 of 4 CITATION NUMBER; SECTIONS VIOLATED 17-1706-0001883-S Date: 10/12/2005 Time: CLASS AND NATURE OF VIOLATIONS "Had not been formally addressed." The facility failed to protect Client 1 from physical abuse when they failed to transfer Client 1 to an alternate living arrangement and failed to closely monitor Client 1 from being assaulted on multiple occasions, while on the residence. This violation had a direct relationship to the health and safety, or security of the client. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000461 State of.California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 2 CITATION NUMBER: 17-1041-0003284-S Date: 08/17/2006 Time: Type of Visit- Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORN IA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS State Of Calif. Dept. Of Developmental Services Licensee Name: Address: P. O. BOX 2000 170000837 License Number: Facility Name: PORTERVILLE, CA 93258-2000 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER DIP ICFDD Address: Telephone: 26501 Avenue 140 Porterville, CA 93257 Intermediate Care Facility/Developmentally Disabled 170001878 Facility Type: Facility [D: SECTIONS VIOLATED 76525(a)(20) I ncidenttCompIaint No.(s) :,CA00073412 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $1,000.00 Capacity: 512 DEADLINE FOR COMPLIANCE 8/31/06 I2:00 a.m. CLASS B CITATION -- PATIENT RIGHTS 76525(a)(20) Clients’ Rights (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. On March 6, 2006, an unannounced visit to the facility.was conducted to investigate a facility reported event. It was determined the facility failed to ensure: 1. Client D’s right to be free from harm when Staff S attempted to slide the client’s lap-tray onto her wheelchair and the client’s fifth finger 0f the right hand got caught between the lap tray and the armrest resulting in a fracture. Client D was a 67 year old female admitted November 16, 1995 with diagnoses including mild mental retardation; schizoaffective disorder, borderline personality disorder and history of fracture. Client D’s Individual Program Plan (IPP) dated June 10, 2005, documented a health plan for "Potential for Fracture." Plan Step No. 4 included use of a wheelchair and possible use of a lap tray as a mechanical support. According to a facility Incident Report (IR) dated February 22, 2006, on February 21, 2006 at 1:15 pm, Staff S reported to the facility Family Nurse Practioner (FNP) that Name of Evaluator: Deborah Van Arsdel HFEN Without admitting guilt, I hereby acknow]edge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000462 State of, California- Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 2 CITATION NUMBER: SECTIONS VIOLATED 17-1041-0003284-S Date: 08t17t2006 Time: CLASS AND NATURE OF VIOLATIONS Client D was agitated during her afternoon care. She had caught her right little finger in her lap tray causing some redness. The client was assessed at that time by the FNP and no’injury was noted. However, during rounds on February 22, 2006 at 6:30 am, bruising and swelling of the client’s right hand was noted. It was posted for the unit physician’s attention and an x-ray was ordered. The x-ray was positive for fracture of the right little finger. The IR Level 1 Review documented an interview with Staff S on February 24, 2006 at 11:00 am. Staff S stated she had just positioned the client in her wheelchair after assisting her with her personal care. She was sliding the client’s lap-tray on to the wheelchair for positioning/support when she heard a noise and felt some resistance. Client D had gotten her fifth finger of the right hand caught between the lap tray and the armrest. The client’s IPP "Approaches and Strategies" were updated February 24, 2006. to include the following: "Staff to make sure that Diane’s arms are clear of way before putting the lap tray. If unable to position lap tray, stop to ask for help." When Staff S went to attach the lap tray to Client D’s wheelchair without making sure the client’s fingers were clear before sliding on the tray, the client was injured with a fracture of her right little finger. The facility failed to ensure: 1. Client D’s right to be free from harm when Staff S attempted to slide the client’s lap-tray onto her wheelchair and the client’s fifth finger of the right hand got caught between the lap tray and the armrest resulting in a fracture. This violation had a direct or immediate relationship to health, safety or security of Client D, a long term healthcare facility patient. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000463 Stale of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUI~IBER: 17-1561~0006485-S Date: O8/25/2009 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Statd Of Calif. Dept. Of Developmental Services Licensee Name: Address: P. O. BOX 2000 170000837 License Number: Facility Name: PORTERVlLLE, CA 93258-2000 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER DIP ICFDD Address: Telephone: 26501 Avenue 140 Porterville, CA 93257 Intermediate Care FacilitytDevelopmentally Disabled 170001878 Facility Type: Facility ID: SECTIONS VIOLATED 76315(b) IncidenllComplaint No.(s) : CA00156452 PENALTY ASSESSM ENT $1,000.00 CLASS’AND NATURE OF VIOLATIONS CLASS B Capacity: 512 DEADLINE FOR COMPLIANCE 9/2/09 12:00 a.m. CITATION -- PATIENT CARE 76315 (b) The Individual Program Plan Shall Be Implemented As Written failed-to comply with the above regulation by failing to: Implement Client A’s Individual Program Plan which stated that Client A choked easily due to an esophageal-(canal opening from the throat about 24 centimeters into the stomach) stricture tortuous (twisted) and receives a puree (baby food consistency) diet. However, on 7!9f08 at 5:45 p.m., Client A was served and ate formed .consistency food which .resulted in food lodging in the esophagus and the client undergoing a hospital procedure twice to remove the food. Review of the clinical record on 7/21/08 at 1:40 p.m., indicated that Client A, age 62, was admitted on 5t25t95. Current diagnoses includes esophageal stricture. Review of the Interdisciplinary Notes dated 7/9t08 at 5:45 p.m., indicated that while the client was in the dining room, staff observed that the client was served the wrong plate and wrong consistency of food. It was noted that the client ate one bite of chopped potatoes before the plate was removed by staff. The client coughed up some food along with phlegm (sputum). The client was observed to rub on his throat. Name of Evaluator: Marion Leatherwood HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name: Evaluator Signature ¯ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000464 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 17-1561-0006485-S Date: 08/25t2009 Time; CLASS AND NATURE OF VIOLATIONS Review of the Interdisciplinary Notes dated 719108 at 6:15 p.m., indicated that the RN (registered nurse) assessed the client and noted that the lung sounds revealed rhonchi (rumbling sound) in both upper lung lobes. Stridor (high pitched sound) was noted to the trachea. The physician was notified and an order was obtained for inhalation treatment as needed for wheezing. Review of the Interdisciplinary Notes dated 7f10/08 at 5:30 a.m., indicated that the client’s oxygen saturation was at 85%. The staff received an orde~ to administer oxygen per nasal cannula at 5 liters/minute to maintain the client’s oxygen level above 90%. At 6:00 a.m., the client’s oxygen saturation level was at 95% and at 7:30 a.m., the oxygen saturation level was at 99% while the client was receiving oxygen at 3 liters/minute. Review of the Interdisciplinary Note dated 7t10t08 at 9:00 a.m., indicated that the RN assessed the client at 8:25 a.m. and noted that the client was being fed thickened fluids. The client then started coughing and spitting up some food particles. Review of the Physician’s Progress Notes indicated that the client was seen by the physician on 7/10/08 at 9:25 a.m. The physician noted that the client had scattered rales (bubbling sound) in both lungs. It was further noted that when the client was off of oxygen the client’s oxygen saturation level dropped to the 80 percent. At t0:00 a.m., the client was ordered to be transferred to the community acute hospital. Review of the acute care hospital discharge summary, indicated that the client was admitted on 7110/08 and discharged on 7tl 5/08. The client’s admitting diagnoses included foreign body with retained food material in the upper esophagus and possible aspiration pneumonia. The client underwent an esophagogastrod.udodenoscopy (a procedure in which a scope is inserted through the esophagus into the stomach to visualize and remove foreign bodies). Multiple attempts were made to remove foreign bodies in the upper side of the esophagus and many pieces of "meat and vegetables" were removed. It was noted that not everything could be removed and a second procedure was done using "rigid" esophagoscopy to remove all of the food particles. During .an interview with the Dietary Director on 7t24/08 at ’10:30 a.m., she stated that the dietary staffs on the units were responsible for preparing the plates using a diet card. Client A’s diet card, approximately 5x7, noted that the client was on a Puree Small Anti-Reflux diet’, Life Threatening Choking Risk. NOTE: IN ACCORDANCE WITH OALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000465 State of,California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1561-0006485-S Date: 08/25/2009 Time: CLASS AND NATURE OF VIOLATIONS During an interview with the Unit Supervisor on 7/24/08 at 10:45 a.m., she stated that the unit staff had a similar card which had training objectives and precautions, but no diet order. The Unit Supervisor stated that the dietary staffs were responsible for placing prepared meal trays on a cart and passing the trays to the client tables during the dinner meal. The Unit Supervisor stated that unit staff, who sat at the table with the client (s), was responsible for checking the client’s meal tray with the diet card. Pre-licensed Staff I stated that he did not check the plate for the ordered diet prior to the dietary.staff member sitting the tray (client’s prepared meal) in front of the client. Pre-licensed Staff 1 stated that he did not think that the unit staffwas responsible for checking the tray against a diet card. Pre-licensed Staff "1 stated that the unit staff had cards with information regarding the clients’ eating needs, but no diet order was on the card. Review of the physician’s orders dated 6/5/08, indicated that the c.lient was prescribed a pureed diet with nectar thickened beverages. Review of the Individual Program Plan,. dated 615108, Physical/Medical, N-23.1, stated: "Due to an esophageal stricture (tortuous esophagus), client receives a puree diet. Client r0ust be closely supervised to assure he does not eat foods not on his diet." Client Chokes Easily. Review of the Approaches and Strategies dated 6/5/08, indicated, Alerts: "Adhere to puree diet as he has a life threatening esophageal stricture-High Risk of Choking". The facility failed to comply with the above regulation by failing to implement Client A’s Individual Program Plan which stated that Client A choked easily due to an esophageal stricture and receives a puree diet. These actions had a direct or immediate relationship to the health, Safety or security of long-term health care facility patients or residents. NOTE: 1N ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS 1S GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000466 State ef California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 4 CITATION NUMBER: 17-1893-0007180-S Date: 03t25/2011 Time: Type of Visit: Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND.REGULATiONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76315(b) 76329(a)(4) 76329(a)(6) Incident/Complaint No.(s) - 0A00221743 State Of Calif. Dept. Of Developmental Services P. O. BOX 2000 170000837 PORTERVlLLE, CA 93258-2000 Type of Ownership: State Agency PORTERVILLE DEVELOPMENTAL CENTER D!P ICFDD 26501 Avenue I40 Porterville, CA 93257 Intermediate Care Facilil.ytDevelopmentally Disabled 170001878 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $25,000.00 Capacity: 512 I DEADLINE FOR COMPLIANCE 4/11/11 12:00 a.m. CLASS AA CITATION-- PATIENT CARE 763t5(b) Developmental Program Services - Individual Program Plan (b) The individual program plan shall be implemented as written. 76329(a)(4) Developmental Program Services- Application of Restraints (a) In the use of physical restraints, each of the following requirements shall be met: (4) A client placed in restraint shall be checked at least every 30 minutes by program staff to assure that the restraint is properly applied. A record shall be kept of these checks. 76329(a)(6) Developmental Program Services - Application of Restraints (a) In the use of physical restraints, each of the following requirements shall be met: (6) Clients shall be restrained only in an area that is under direct observation of staff and shall be afforded protection from other clients who may be in the area, During the investigation of a reported event it was determined that the facility failed to: 1. Ensure that the client’s individual program plan was implemented when Client 1 was placed in a wheelchair restraint for reasons not documented, without the lap tray being placed on the wheelchair that resulted in Client 1 slipping down and strangling on the Name of Evaluator: Margaret Johnson HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION I424 NOTICE Signature : Name: Evaluator Signature " Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000467 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1893-0007180-S Date: 03/25f2011 Time: CLASS AND NATURE OF VIOLATIONS seatbelt of the wheelchair. 2. Ensure that Client 1 was checked at least every 30 minutes to assure that the restraint was properly applied. 3. Ensure that Client 1 was under direct supervision of staff while she was in the wheelchair restraint. Client 1 was a 62 year old female who was admitted to the facitity’with diagnoses of severe mental retardation and psychosis. ¯ The client had a history of talking in a loud and shrill voice when she became agitated. She would also flop down on the floor and scream when she was agitated or reluctant to do something. These behaviors also became apparent when she did not get a good night’s sleep or when she was bothered by her peers. A review of Client l’s IPP (Individual Program Plan) revealed that she had one behavior plan for reducing episodes of agitation that included the use of a wheelchair with seatbelt and lap tray. The lap tray would further secure the client and prevent the client from sliding down in the wheelchair. The client could be placed in the wheelchair restraint when all other causes of the agitation had been ruled out, the agitation was escalating and the client was a danger to herself. This intervention of a wheelchair restraint with seat belt and lap tray was listed on Client l’s 1PP and dated 6/18/09. The Approaches and Strategies revealed that Client 1 speaks in 1-2 word phrases, but at times speaks too softly to be understood. When the client is agitated, she speaks in a high pitched voice that is difficult to understand. A review of the Interdisciplinary Notes for 3/13/’10 at 9:00 PM indicated that the physician’s order was noted for the wheelchair restraint with lap tray for agitation. The order was effective for 12 hours. The notes for 3t14/10 at 2:51 AM indicated that Staff A documented that he was informed by staff of an emergency in the female dorm area. The client was found to have "slid down in chair, seat belt was at the neck/chin area." Staff B had removed Client 1 from the chair, placed her on the floor and then informed Staff A. There was no documentation of why the client had been placed in the wheelchair restraint, when she had been placed there or that the client had been observed at any time while in the restraint. In addition, there was no documentation that Client 1 was assessed to determine that she was breathing or had a pulse when she was discovered unresponsive in the wheelchair. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAF"rEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000468 State ,0f California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 4 CITATION NU]VlBER: SECTIONS VIOLATED 17-1893-0007180-S Date: 03/25/2011 Time: CLASS AND NATURE OF VIOLATIONS A review of Nursing Procedure No. 2, Potentially Life Threatening Emergencies, dated 7t20109, indicated that the "person discovering the emergency situation will immediately: Initiate emergency response (i.e., "Dial 181", CPR...etc)". In an interview with Staff A on 3/19/10 at 1:45 PM, he stated that the client was agitated when he came on duty at 10:30 PM on 3/13/10. He assisted the evening shift staff to put her in the wheelchair restraint with the seat belt. He stated he did not place the lap tray on the wheelchair because he "did not think it was needed." He stated that he placed the client back in her room so "she wouldn’t wake up the rest Of the unit." He stated that he then completed unit paperwork and was helping other clients with personal hygiene until about 1:30 AM, when Staff B came and told him about Client 1. (The time discrepancy is due to the time change to Daylight Savings Time that weekend at 2:00 AM.) He stated that he saw Client 1 on the floor, went back to the tech station to call in the emergency, then returned to the client and started CPR. CPR was not successful. On 3/22/10 review of Facility Bulletin No. 104, Behavior Management, dated March, 2009, indicated that "individuals in restraint must be under continuous visual supervision by staff and must be released from restraint as soon as they are calm..o" It also indicated that "nursing staff...will evaluate the efficacy of the procedure as well as health and safety concerns every 55 minutes the individual is in restraint and make a determination as to the appropriateness of continuing the restraint..." In an interview with Staff B on 3t22/10 at 11:20 AM, she stated that she started her shift on 3/13/10 at 11:00 PM. She worked on client laundry and audits until about 12:30 AM on 3/14/10. She stated that she had not been told by StaffA that Client I was in restraints and she acknowledged that anyone in restraints should have 1:1 supervision. Then she started her rounds on the clients at about 1:30 AM. She provided personaf care to two other clients and then entered Client 1 ’s room. When she saw Client I, she had slid down in the wheelchair, the wheelchair was tipped forward and Client 1 was hanging by the seatbelt around her neck. The lap tray was not on the chair. The client was limp and warm; she called her name and received no response, so she got the client out of the wheelchair and onto the floor. Then she went and got Staff A. An interview was conducted on 3/22/10 at 9:55 AM with Staff C - the physician on call on 3tt4/10 and in charge of the resuscitation effort for the client. She stated that CPR was in progress when she arrived. Upon her arrival, StaffA told her that Client 1 was found with her wheelchair tipped forward and the client was caught by the seatbelt around her neck. She stated that the client’s left arm was flexed stiffly, her eyes were wide open and the pupils were fixed and dilated. She stated that rigor morris (the stiffness that NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VlOt_ATtONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000469 Sta, te.of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS VIOLATED 17-1893-0007180-S Date: 03/25/2011 Time: CLASS AND NATURE OF VIOLATIONS occurs in dead bodies) was already occurring and that rigor mortis happens in about 3-4 hours after death. She stated that there were indentations exactly 4 inches apart on the client’s lower jaw; the measurement of the seatbelt buckle was exactly 4 inches. There were marks on the client’s neck 1 1/2 inches wide, which is the exact width of the seatbelt. Staff C believed the seatbelt and buckle around the client’s neck were the cause of the patient’s death. She stated that if the lap tray had been used the client probably would not have been able to slide down in the wheelchair and have the seatbelt up around her neck. A review of the final autopsy report, dated 4/1/10, indicated the cause of death to be positional asphyxia, Therefore, the facility failed to: 1. Ensure that the client’s individual program plan was implemented resulting in strangulation of the client by a wheelchair restraint. 2. Ensure that the client was under direct supervision while in restraints. 3. Ensure that staff checked that the restraints every 30 minutes and were applied properly, allowing the client to slide down in the wheelchair and strangle on the seatbelt and buckle. These facility failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and were a direct proximate cause of death to the client. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000470 State of C,alifomia - Health and Human Services Agency Department of Public Health SECTION "~.424 NOTICE Page 1 of 4 CITATION NUMBER; 15-1569-0001966-S Date: 02/1312003 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE Inciden~Complaint No.{s) ¯ 150015034 CALIFORNIA STATUTES AND REGULATIONS OR APP LICABLE Licensee Name: Address: License Number: State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA Type of Ownership: State Agency Facility Name: Address: Telephone: SONOMA DEVELOPMENTAL CENTER DIP ICFDD Facility Type: Facility ID: Intermediate Care Facility/Developmentally Disabled 150000230 SECTIONS VIOLATED 76525(a)(20) 15000Arnold Dr Eldridge, CA 95431 CLASS AND NATURE OF VIOLATIONS CLASS A 95814 PENALTY ASSESSMENT $8,0OO.OO Capacity: 581 DEADLINE FOR COMPLIANCE 2/18f03 12:00 a.rn, CITATION -. PATIENT RIGHTS 76525. CJients’ Rights. (a) Each client has the rights listed in (a) of this sectionwhich shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. An unannounced visit was made to the facility on 07/10/02 at 3:50 p.m. to investigate an unusual occurrence report #150015034 regarding Client 1 and Client 2. During the investigation information was obtained that resulted in a citation pertaining to patient care services and patient’s rights. The facility failed to ensure that Client 1 was free from sexual abuse. Name of Evaluator: Cathy Ruebusch HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000471 State qf California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS VIOLATED 15-1569-0001 £66-S Date: 02/13/2003 Time: CLASS AND NATURE OF VIOLATIONS The violation of the regulation resulted in Client 1 experiencing sexual assault by Client 2 on 04/19102 at 12:30 a.m. Client 1 was a 48-year-old man admitted to the facility on 10tl 1/83 and had current diagnoses that included stereotypic movement disorder and profound mental retardation. His medical record revealed the Individual Program Plan (IPP) for services last updated on 06/30194 identified Client 1 as requiring total assistance for bathing, dressing, hygiene, and eating. This list identified Client 1 as being trained to toilet himself. The behavior plan dated 06/27/02 ¯ identified the problem of "dropping to the ground by sudden crouching" as the only behavior requiring intervention. Client 2’s medical record revealed he was a 41-year-old man admitted to the facility on 05/16/86 and had current diagnoses that included obsessive-compulsive disorder, moderate mental retardation, Down’s Syndrome, and "hepatitis B carrier." The hepatitis status was determined on 04110195. Review of Client 2’s laboratory test results revealed he had a test for hepatitis C and was n&gative for this on 04/29/02. He also had a test for hepatitis B on 04/26/02 that documented his continued carrier status. The IPP dated 05/08/02 for Client 2 documented, "inappropriate physical contact with peers: kissing, stroking, rubbing his body against others, touching breasts, buttocks, or genitals, or any sexual contact" as one of his problem behaviors. A discontinued IPP dated 01!10/02 also identified this behavior. The "overview" to the plan for this behavior on both IPP stated, "[Client 1] is sometimes sexually aggressive with other clients. He has sometimes targeted less capable individuals who are passive and unable to defend themselves. His pattern has been to begin with more superficial forms of contact and quickly progress to more intimate and intrusive interaction. It is necessary to NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODEr FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000472 State qf California - Health and Human Services Agency Department of Public Health ,SECTION 1424 NOTICE Page 3 of 4 CITATION NUMBER; SECTIONS 15-1569-0001966-S Date: 02/13/2003 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED protect other individuals from unwanted physical affection, sexuaf contact, exploitation, and disease. "The physician and nurse practitioner have indicated that [Client 2] cannot be permitted to have unprotected sex with anyone due to his hepatitis status and the risk of him infecting others. Since [Client 2] has made it clear in the past that he will not use a condom, this means that it is not permissible for him to engage in sexual relations with any other clients. "All of the other individuals at his residence must be protected from exploitation as they are unable to give informed consent in this area (the failure of a client to resist sexual advances does not constitute consent). The }nterdisciplinary Team has therefore concluded that none of the behaviors described above should be permitted." The "Proactive & Preventive Strategies" tisted in the 01/10/02 plan included "1. [Client 2] must remain under staff supervision. He should not be permitted to roam around the halls or remain by himself away from staff, other than when he is in his own bedroom. Staff must be aware of his whereabouts at all times... 2. Staff should switch on the motion detector alarm in [Client 2’s] bedroom when he goes to bed at night... If he gets up during the night, staff should immediately go to see if he needs assistance and to ensure he does not bother other individuals." On 04/19/02 at 12:30 a.m., Client 1 was found in Client 2’s bed with Client 2’s penis penetrating his anus. The facility incident report stated that Client 1 could not consent to sexual activity and that Client 2 had a history of sexually inappropriate behavior. The report stated that "there are alarms on [Client 2’s] door due to previous incidents, however, the alarm did not go off." The report identified that when the battery was changed on the door alarm, the alarm became functional. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLA’lIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000473 State qf California - Health and Human Serv]q;es Agency Department of Public Health SECTION "~424 NOTICE Page 4 of 4 ClTA’rlON NUI~IBER: SECTIONS 15-1569-0001966-S Date: 02113/2003 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED Interview with the Unit Supervisor at 1:55 p.m. revealed that she was the supervisor for the unit where Clients I and 2 lived at the time of the incident. She was familiar with the incident and stated that the battery failed on the alarm unit on the night on 04/18102- 04/19/02 when Client 2 assaulted Client 1. She stated that it was the procedure before the incident for all alarms on the unit to be checked once each month by an assigned staff member. She stated that she believed that the assigned staff member made the check but that the battery became nonfunctional between the time it was checked and the date of the incident. The plan also included moving Client 2 to a different room away from Client 1 with eventual placement on a unit "where clients can accept his sexual advances." She stated that she was concerned because Client 2 was reported as still on the unit with Client 1. She stated that the delay in transfer plans was "unacceptable." The facility correctly identified a significant risk: (1) there was an aggressive sexual predator in the facility who had and could again force sex on other men, (2) the facility had vulnerable residents who were incapable of giving consent for sex and were incapable of defending themselves to prevent undesired sex, and (3) the sexual predator.was infected with hepatitis B, which is a potentially fatal disease, that could likely be transmitted to his unwilfing victims. The facility had developed the intent and a plan to protect its vulnerable residents. However, the facility failed to recognize a predictable flaw in their plan, the failure of the alarm du’e to an exhausted power supply (dead battery). Therefore, the facility failed to ensure that Client 1 was free from sexual abuse. The facility’s violation presented either imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. NO3"E: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000474 State of Califor~ia - Health and Human Services Agency Department of Public Health °SECTION 1424 NOTICE CITATION NUMBER: Page 1 of 4 15-1022-0002029-S Date: 02tl 8/2004 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR Incidenl/Complaint No,(s) ¯ 150019376 APP LICAB LE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS State of CA Dept of Developmental Services ¯ 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D!P ICFDD Eldridge, CA 95431 15000 Arnold Dr Intermediate Care FacilitytDevelopmentally Disabled CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $500.00 trebled to $1,500.00 VIOLATED 76525(a)(20) Capacity: 581 150000230 CLASS B DEADLINE FOR COMPLIANCE 2t27/04 12:00 a.m. CITATION-- PATIENT RIGHTS 76525. CIients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to ensure Resident A’s. right to be free from harm, including abuse as manifested by being slapped on the side of his head by PTT 1 while she was providing direct care to the resident. The facility initiated an Incident Report on 11/21/03 that documented the following information from PT 1: Name of Evaluator: Jose Figueroa HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name: Evafuator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000475 Stale of California - Health and Human Services Agency .SECTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health Page 2 of 4 15-1022-0002029-S Date: 021~18t2004 Time: CLASS AND NATURE OF VIOLATIONS "Approximately 0720, I witnessed a staff, Psychiatric Technician Trainee I (PTT 1), slap Resident A against the left side of his face with her right hand. I witnessed this act as I’was pulling back the drape hung for privacy in the client’s bathroom. I told PTT 1 "you can’t do that, I’m going to report you." I also told her to leave the bathroom and wait in Family Room 2 where there were no clients. I immediately checked Resident A for injury. I observed that his cheek and left side of head were reddened. I comforted and reassured Resident A, and notified shift lead who did a full body check and then notified appropriate personnel." At 0725, Resident A was examined by the unit physician who documented: "No sign of injury at this point. Client appears to be himself. No treatment indicated." After being removed from client contact PTT 1 waited in the office of the IndiVidual Program Coordinator who submitted the following written statement: "When I walked into my office ] noticed a stranger sitting at.the table. I asked her who she was and she preceded to tell me "I’m the one who hit the kid" and she began to cry. While she was crying she said, "1 don’t know what came over me, I am so sorry for hitting him...She said Resident A hit her in the nose while she.was bent over buttoning his PJ’s and the next thing she know her arm was moving up and she slapped his face at the exact moment a staff person walked in. She said, "I’ve been working here (I assumed she meant the registry) since October and have been hit, pinched and scratched and I never reacted at all, but my nose, if he hadn’t hit my nose." I asked her if it was an accident, was she batting his hand away, she said "no". I asked her if it was a reflex and she said "yes, but that’s no reason, I feel so awful..." NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000476 State of California - Health and Human Services Agency Page 3 of 4 ,SECTION 1424 NOTICE CITATION NUMBER; sEcTIoNS VIOLATED Depadment of Public Heatth 15-1022-0002029-S Date: 02/18/2004 Time: CLASS AND NATURE OF VIOLATIONS Subsequent to the Incident Report, A Crime incident Report was also filed by the facility followed by an investigation of the alleged physical abuse against a client by a staff person. A summary of the investigation and the results of the investigation were completed by the Case Investigator on 12/12t03 and included the following information: "...SDC Police Officer responded to Hill Cottage to take a report of the alleged abuse at approximately 0725 hours. PT 1 identified PTT 1 as the perpetrator. PT 1 told the Police Officer that when she walked into bathroom where PTT 1 was assisting Resident A, she observed PTT 1 slap Resident A across the face. The Police Officer interviewed PTT 1 after reading her the Miranda Rights. PTT 1 voluntarily admitted to the Police Officer that she slapped Resident A. PTT 1 swung her right hand in a lateral movement as a demonstration of what she did... Senior Psychiatric Technician 1 told me (Caselnvestigator) that while she escorted PTT 1 to the Nurse’s Station, PTT 1 said to her without solicitation, "1 can’t believe i did that."... The Individual Program Coordinator told me (Case Investigator) that at approximately 0820 hours she entered her office located at Hilt Cottage and found a woman later identified as PTT 1 inside. Individual program Coordinator asked her who she was and PTT 1 said, ’Tin the one who hit the kid." The Individual program Coordinator asked her if it was an accident and PTT 1 said, "No."... Staffing Supervisor, told me (Case Investigator) that PTT 1 was escorted back to her office for reassignment. Staffing Supervisor said that PTT 1 told her that she was bending over to tie Resident A’s shoes when he hit her in the nose. PTT I told Staffing Supervisor that she "flew up" with her arms and hands and that one of her hands hit Resident A on the side of the head... NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000477 State of California - Health and Human Services Agency r~SEC~IO’N 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Heal{h Page 4 of 4 15-1022-0002029-S Date: 02/18/2004 Time: CLASS AND NATURE OF VIOLATIONS On 1/21/04, at 09:00 a.m., PTT 1 was interviewed by the Health Facilities Evaluator Nurse investigating the allegation. PTT 1 stated: "...I was bending over trying to pull his pajama bottoms up as he was standing in the bathroom. He came up with his right hand and hit me hard on the side of my face and nose. I thought i was too close as f came head level to him. At that moment as t was raising up my arms to protect myself, my hand came across his head and struck back of his head because I was turning to see the staff person coming into the room." PT 1 was interviewed by the Health Facilities Evaluator nurse on 1/24/04, at 6:30 a.m. PT 1 stated: I work the NOC shift and PTT 1 came on in the day shift. To my knowledge she had never worked on the unit (Hill) before and I did not see her before our encounter during the incident...I was walking by the bathroom and the curtains were closed. As I pulled back the curtains I saw her (PTT 1) intentionally slap Resident A on the side of his head with her right hand...After I asked her what she was doing she said ’Tm sorry", over and over again. The facility failed to ensure that Resident A’s rights to be free of harm, including abuse, were protected, and he was subsequently slapped by a caregiver. These facility violations had a direct relationship to the health and security of Resident A. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000478 State of Oatifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUI~IBER: t 5-1284-0002031-S Date: 05f04/2004 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE Incident’Complaint No.(s) : No complaints found CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: State of CA Dept or Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P tCFDD 15000 Arnold Dr Eldridge, CA 95431 Telephone: Facility Type: FaciJity ID: SECTIONS Intermediate Care Faciiity/Developmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS P ENALTY ASSESSM ENT $1,000.00 trebled to $3,000.00 VIOLATED 76525(a)(20) CLASS B Capacity: 581 I DEADLINE FOR COMPLIANCE 5/12104 12:00 a.m. CITATION -- PATIENT RIGHTS 76525..Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to implement established procedures to ensure that each client is afforded the right to be free from harm. The driver of a facility van and the clients’ escort did not fmplement the facility procedures to do an outside check of the vehicle and give the "all clear" signal before departure. As the van moved forward, the attached trailer injured Client 1 who was standing between the van and trailer. Name of Evaluator: Linda Lucey HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signatul’e : Name: Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS 18 GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000479 State of California - Health and Human Services Agency Department of Public Health SECTION I424 NOTICE Page 2 of 3 CITA’I’ION NUI~IBER: SECTIONS 15-1284-0002031-S Date: 05/04/2004 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED On 7t24/03, the facility reported that Client 1 was injured when he stepped unseen behind the recycling van and was passed over by the attached trailer when lhe van pulled away. An incident report dated 7/24/03 indicated the van driver (Staff Member A) unloaded the passengers, looked in both side mirrors, and then proceeded to pull away from the curb. When she heard Staff Member C yelling, Staff Member A immediately stopped and, in the side mirror, saw Client 1 sitting on the ground surrounded by dirt and flowers. Interdisciplinary notes of 7/24/03 documented abrasions on Client l’s right shoulder, left inner knee, right forearm, and left upper buttock. There were lacerations on the left upper buttock and a bump on the top of the head with swelling. Notes indicated Client 1 was highly agitated and expressed feelings of anger and fear. Later notes indicated he was limping and had a swollen left ankle with bruising. An X-ray on 7/25103 revealed a fractured left fibula. On 7t25/03, the escort (Staff Member B) stated he and Staff Member A were unloading clients and Client 1 stayed in the van to talk with the driver. Staff Member B heard Staff Member C yelling from the door of the home and looked back to see Client 1 under the trailer face down. Staff Member C saw Client 1 scramble out from under the trailer. Staff Member B stated Client 1 usually goes to the back of the van to get his flowers at the end of the day. On 7/25/03, Client 1 indicated he went behind the van to get his flowers as usual. He indicated the van started moving and he tried to move out of the way but the trailer hit him in the back, knocked him down and made him roll. Client 1 exhibited an expression of anger on his face. Client 1 indicated the staff members were not paying attentiori. On 8/27/03, Staff Member C stated he was holding the door NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS I=OR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000480 State q,f C, alifornia- Heallh aad Human Services Agency Department of Public Health SEC’[ION 1424 NOTICE Page 3 of 3 cI’rATION NUMBER: SECTIONS "15-1284-0002031-S Date: 05t04f2004 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED open for the returning clients when he noticed Client 1 between the van and the trailer getting flowers out of the back. The van started rolling forward and Client 1 started taking little steps to keep up. Staff Member C yelled, "STOP[ STOP!" but in the next instant Client 1 was roLling under the trailer. The facility document entitled, "TRANSPORTATION SAFETY" documented the role of the driver including, "Prior to departure, drivers will do an outside check around vehicles." The role of the escort included, [Before departure of a vehicle, the escort will advise the driver of safe conditions by saying, "ALL CLEAR"]. On 1t29/04, when question about a procedure for unloading clients, Staff Member A stated her understanding that when the clients are off the van, the escort is responsible for them. Staff MemberA did not indicate knowledge of the transportation safety procedures. On 4t’22/04, when questioned about a procedure for ur~loading clients, Staff Member B stated usually the driver turns off the van and gets out to help the escort unload. Staff Member B stated the day of the incident was different because the driver was in a hurry to get to a meeting. Staff Member B did not indicate knowledge of the transportation safety procedures. The staff members responsible for the safety of the clients did not implement the established procedures to check around the facility van and signal an "ALL CLEAR" prior to departure. The trailer attached to the van passed over Client 1 causing multiple facerations, multiple abrasions, bruising and a fractured leg. Client I was upset and angry after the incident. The above violation had a direct or immediate relationship to the health, safety, or security of client. NOTE: IN ACCORDANCE wI’rH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000481 State ~f California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 5 CITATION NUMBER: Date: 05/26/2004 Time: 15-1022-0002229-S Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE lncidenl/Complaint No.(s) : No complaints found CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name; Address: Telephone: Facility Type: Facility IO: SECTIONS State of CA Dept of Developmental Services 1600 9TH STREET, RM, 340 150000089 SACRAMENTO, CA 95814 State Agency Type of Ownership: SONOMA DEVELOPMENTAL CENTER DiP ICFDD Eldridge, CA 95431 15000 Arnold Dr Intermediate Care FacilitylDevetopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS Capacity: 581 PENALTY ASSESSMENT VIOLATED $!,000.00 trebled to $3,00O.00 ¯ 76525(a)(20) 76525(a)(14) CLASS B DEADLINE FOR ICOMPLIANCE f611/04 12:00 a.m. CITATION -- PATIENT RIGHTS The facility failed to ensure Resident A’s right to dignity and be free from harm, including abuse as manifested by being kicked in his left hip by Psychiatric Technician Assistant I(PTA 1) while he was providing direct care to the resident. On 4/9/04 the facility initiated an Incident Report (IR) stating that an Individual Program Coordinator I (IPC 1) reported that he had observed PTA 1 kick/push Client A in the left hip area. ’1 was walking towards the nurse’s station and glanced to my right. Through the window of the double doors I could see Client A standing in the hall with his back to me. PTA 1 was standing to the client’s left, and, just as I glanced at them, PTA 1 delivered a kick to the client’s left hip area. I proceeded to the nursing station. (PTA 1 had seen me and stopped hurting the client). He approached me and apologized." The IR also documents a physical examination of Client A by Dr.K. "At 1940 client ambulating at baseline according to level of consciousness stable - he has mild limp to left Name of Evaluator: Jose Figueroa HFEN Without admitting guilt, J hereby acknowledge receipt of Ihis SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE; IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTIFy CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000482 State ef California - Health and Human Services Agency Department of Public Health SEGTION 1424 NOTICE Page 2 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1022-0002229-S Date: 05/2612004 Time: CLASS AND NATURE OF VIOLATIONS (described as baseline) very cooperative with exam. In no apparent distress lower left extremity mo evidence erythema, eccymosis or soft tissue swelling, no apparent tenderness. His physical exam of lower left extremity was unremarkable. Observetunit M.D. can re-assess 4/9/04." A review of the Interdisciplinary Notes (IDN) documents that on 4/9/04 at 1 ’150 the IPC 1 entered the following information: "Late entry for 4/8/04. Yesterday at about 1855 hrs, I was walking down the hall and glanced through the window of the door to the Family B hall. There I saw Client A standing in the hall next to a staff member. Just as I glanced at them, I saw the staff member deliver a swift kick to Client A’s left hip area. The staff member saw me looking at him. He followed me into the nursing station and began apologizing repeatedly. I said "Don’t apologize to me, I’m not the person you kicked." Then I reported the incident to the Senior Psychiatric Technician. I went to my office to review the policy on abuse so I could make sure I was responding correctly. The staff member came to my office and started saying things like "1 didn’t do it on purpose. I don’t usually do that kind of thing." etc. I told him it’s never OK to kick a client and that I had to report it. I called the SDC police and answered the police officers questions when he arrive here." The IPC 1 was interviewed on 4f23/04, at 9:30 a.m. The IPC 1 verified the information he entered in the IDN and identified the "staff member" as PTA 1. The Unit Supervisor 1 (US 1) of Judah was fnterviewed on 4/23/04 at 11:45 a.m. She stated that there had not been any other reported incidents of abuse regarding PTA 1, and that Client A did not have any behavior problems. On 5/5/05 at 15:30 p.m, PTA 1 was interviewed regarding the incident. He stated that he had worked on Judah Unit for approximately five years. In the afternoon of 418f04, at NO~E: tN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000483 State ef California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS 15-1022-0002229-S Date: 05/’26/2004 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED around 18:00 through 19:00 p.m., he was working with B group. His co-worker was doing the client showers. The coworker decided to go to lunch and PTA 1 went to check to see if anyone was still in the showers. As he was leaving the room, he saw "...Client A behind me, he (Client A) saw BM (feces) on the floor. With my body ; was not able to stop him from going after it. I reached out with my other leg and tripped him to stop him. While I was doing this I saw person in the window. I took Client A back to B group and then cleaned up BM with towel. I went to the nursing station to talk with IPC to tell him that I was sorry about howl had handled Client A," The facility failed to ensure that Resident A’s rights to dignity and to be free of harm, including abuse, were protected, when PTA 1 kicked him. These facility violations either jointly, separately or in any combination had a direct or immediate relationship to client health, safety or security. facility failed to ensure Resident A’s right to dignity and be free from harm, including abuse as manifested by being kicked in his left hip by Psychiatric Technician Assistant 1 (PTA 1) while he was providing direct care to the resident. On 4/9/04 the facility initiated an Incident Report (IR) stating that an Individual Program Coordinator 1 (IPC 1) reported that he had observed PTA 1 kicktpush Client A in the left hip area. "1 was walking towards the nurse’s station and glanced to my right. Through the window of the double doors I could see Client A standing in the hall with his back to me. PTA 1 was standing to the client’s left, and, just as I glanced at them, PTA 1 delivered a kick 1o the client’s left hip area. I proceeded to the nursing station. (PTA 1 had seen me and stopped hurting the client). He approached me and apologized." The IR also documents a physical examination of Client A by NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000484 Sta,te ef California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 5 CITATION NUMBER: SECTIONS ,15-1022-0002229-S Date: 05t26t2004 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED Dr.K. "At 1940 client ambulating at baseline according to level of consciousness stable - he has mild limp to left (described as baseline) very cooperative with exam. In no apparent distress lower left extremity -no evidence erythema, eccymosis or soft tissue swelling, no apparent tenderness. His physical exam of lower left extremity was unremarkable. Observe/unit M.D. can re-assess 4/9/04." A review of the Interdisciplinary Notes (IDN) documents that on 4t9/04 at 1150 the IPC 1 entered the following information: "Late entry for 4/8/04. Yesterday at about 1855 hrs, I was walking down the hall and glanced through the window of the door to the Family B hall. There I saw Client A standing in the hall next to a staff member. Just as I glanced at them, I saw the staff member.deliver a swift kick to Client A’s left hip area. The staff member saw me looking, at him. He followed me into the nursing station and began apologizing repeatedly. I said "Don’t apologize to me, I’m not the person you kicked." Then I reported the incident to the Senior Psychiatric Technician. I went to my office to review the policy on abuse so I could make sure 1 was responding correctly. The staff member came to my office and started saying things like "1 didn’t do it on purpose. I don’t usually do that kind of thing." etc. I told him it’s never OK to kick a client and that I had to report it. I called the SDC police and answered the police officers questions when he arrive here." The IPC 1 was interviewed on 4/23/04, at 9:30 a.m. The IPC 1 verified the information he entered in the IDN and identified the "staff member" as PTA 1. The Unit Supervisor 1 (US 1) of Judah was interviewed on 4/23/04 at 11:45 a.m. She stated that there had not been any other reported incidents of abuse regarding PTA 1, and that Client A did not have any behavior problems. On 5/5f05 at 15:30 p.m, PTA 1 was interviewed regarding the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH ANB SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000485 Sta!e of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 5 of 5 CITATION NUMBER: SECTIONS 15-1022-0002229-S Date: 05t26t2004 Time: CLASS AND NATURE OF ViOLATiONS VIOLATED incident. He stated that he had worked on Judah Unit for approximately five years. In the afternoon of 4/8/04, at around 18:00 through 19:.00 p.m., he was working with B group. His co-worker was do{ng the client showers. The coworker decided to go to lunch and PTA 1 went to check to see if anyone was still in the showers. As he was leaving the room, he saw "...Client A behind me, he (Client A) saw BM (feces) on the floor. With my body I was not able to stop him from going after it. I reached out with my other leg and tripped him to stop him. While I was doing this I saw person in the window. I took Client A back to B group and then cleaned up BM with towel. I went to the nursing station to talk with IPC to tell him that t was sorry about how I had handled Client A." The facility failed to ensure that Resident A’s rights to dignity and to be free of harm, including abuse, were protected, when PTA 1 kicked him. These facility violations either jointly, separately or in any combination had a direct or immediate relationship to client health, safety or security. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000486 State of California - Health and Human Services Agency Department of PuNic Health 8ECTIOI~ 1424 NOTICE Page 1 of 4 CITATION NUMBER: 15-1634-0002232-S Date: 08117/2004 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABEE Incident!Complaint No,(s) ¯ 150019472 CALIFORNIA STATUTES AND REGULATIONS OR APP LICABLE Licensee Name: Address: Ucense Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAME~NTO, CA Type of Ownership: 95814 State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD 15000Arnold Dr Eldrid.qe, CA 95431 Intermediate Care FacilitylDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $10,000,00 Capacity: 581 DEADLINE FOR COMPLIANCE 8/20/04 12:00 a.m. 76521(a) CLASS .A CITATION.. MEDICATION 76347(b) The facility failed to ensure that medications were administered as prescribed when the Medical Officer of the Day (MOD) dispensed Morphine Sulfate Sustained Release rather than the immediate release formulation of Morphine Sulfate (MS) that had been prescribed. Three licensed staff administered three incorrect doses. The Client fias experienced a significant decline subsequent to the failure to administer the correct formulation of MS. Review of the clinical record revealed a 52 year old who was admitted to the facility in 1958. Current medical diagnoses include Portal Vein Enlargement, Splenomegaly, Cirrhosis, Hepatitis B positive and Hepatitis B carrier. His Individual Program Plan (IPP) dated 12/23/03 (prior to the medication error) described him as "able to ambulate and can move around famiJiar environments independently. He is able to make his needs and wants known by gestures, body language, facility expressions and small vocalization. On 01101f04, the Client was observed to be crying from ear Name of Evaluator: Treya Auge HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name . Evaluator Signature Tille : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODEI FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000487 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 4 CITATION NUMI~ER: 15-1634-0002232-S Date: 08/1712004 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: L..icense Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76521(a) 76347(b) Incident/Complaint No.(s) " 150019472 State of CA Dept of Developmental Services t600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: Slate Agency SONOMA DEVELOPMENTAL CENTER DIP ICFDD Eldridge, CA 95431 15000 Arnold Dr Intermediate Care Facility/Developmentally Disabled Capacity: 581 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $10,000.00 DEADLINE FOR COMPLIANCE 8120/04 12:00 a.m. CLASS A CITATION -- MEDICATION The facility failed to ensure that medications were administered as prescribed when the Medical Officer of the Day (MOD) dispensed Morphine Sulfate Sustained Release rather than the immediate release formulation of Morphine Sulfate (MS) that had been prescribed. Three licensed staff administered three incorrect doses. The Client tias experienced a significant decline subsequent to the failure to administer the correct formulation of MS. Review of the clinical record revealed a 52 year old who was admitted to the facility in 1958. Current medical diagnoses include Portal Vein Enlargement, Splenomegaly, Cirrhosis, Hepatitis B positive and Hepatitis B carrier. His Individual Program Plan (IPP) dated 12/23t03 (prior to the medication error) described him as "able to ambulate and can move around familiar environments independently. He is able to make his needs and wants known by gestures, body language, facility expressions and small vocalization. On 01t01/04, the Client was observed to be crying from ear Name of Evaluator: Treya Auge ¯ HFEN Without admitting guilt, t hereby acknowledge receipt of this SECTION "[424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000488 State of California - Health and Human Services Agency Department of Public Health S.ECTION 1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS VIOLATED 15-1634-0002232-S Date: 08/17/2004 Time: CLASS AND NATURE OF VIOLATIONS pain, The MOD was notified of the Client’s pain. The Client had a long-standing history of liver disease, so the Vicodin (pain medication) which had been ordered, was discontinued by the MOD and MS 15mg. (milligrams) PC (by mouth) every 6 hours PRN (as needed) x (times) 24 hours and then review, was ordered by the MOD. The medication was obtained by the MOD from the facility’s acute care unit medication cart and delivered to the Client’s unit by the Assistant to Coordinator of Nursing Services (ACNS). Licensed Psychiatric Technician (LPT) 1 received the medication on the unit at 12:05 p.m. He gave the first dose to the Client at that time, The Client .received a second dose at 6:30 p.m. from LPT 2, LPT 2 documented that this dose.was ineffective, At 8:15 p.m. the physician on call was notified that the Client had experienced no relief and a telephone order was given for MS 15mg PC STAT (immediately) lx (time) only and then to give MS PC every 4 hours PRN x 24 hours for pain. LPT 3 administered this dose. At 10:15 p.m. tl~e Client was still restless so the physician was again notified and a telephone order was given for Lorazepam (a short acting benzodiazepine tranquilizer) 1 rag. NOW for restless agitation. This medication was administered at 10:20 p.m, The Client received 45 mg. of Morphine Sulfate long acting instead of the immediate release formulation of Morphine Sulfate and 1 mg. of Lorazepam PC within an 8 hour period. The last two dose of MS (long acting) were 2 hours apart. The American Hospital Formulary Service Drug Information 2003 handbook states, "Administration of large single doses of Morphine Sulfate as extended release tablets may lead to acute over dosage." This Client received 45 mgs.of MS extended release over an 8 hour period. On 01102/04, at 7:50 a.m. (11 hours later), the Client was found in bed unresponsive, with severe respiratory distress (4 respirations per minute) and falling blood pressure (BP) NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000489 State of California ~ Health and Human Services Agency Department of Public Health ~ECT]’ON 1424 NOTICE Page 3 of 4 CITATION NUI~BER: SECTIONS VIOLATED 15-1634-0002232-S Date: 08f17/2004 Time: CLASS AND NATURE Of: VIOLATIONS of which the numbers were not recorded. A medical emergency was called. An Intravenous (IV) line was star~ed and Narcan and Romazicon (antagonists) were given in an attempt to reverse the effect of the MS and Lorazepam. The Client showed transient response to the Narcan but none to the Romazicon. The Client was then transported to the general acute care (GAC) section of the facility with diagnosis of MS induced respiratory distress. At the GAC, the Client improved with the Narcan but still demonstrated no response to the Romazicon. He then re-sedated at 12:30 p.m. and became obtunded (unresponsive), with a systolic BP of 77. Additional Narcan was given with some improvement but no change in BP. The Client was then transported to Sonoma Valley Hospital (SVH). He was returned from SVH on 01/02104 at 7:30 p.m. after receiving 0.4 mgs. of Narcan x 4 and stabilization of BP. On 01/03/04 at 4:45 a.m., his blood pressure again decreased to 73/35 with poor response to stimuli. He was again given Narcan 0.5 rags. IV with BP response to 90 systolic and observed movements and response to stimuli. At 8:30 a.m. on 01/03t04, he was observed sleeping but responsive with a BP of 102/50. On 01/05/04, the Clinical Nurse Supervisor (CNS) initiated an investigation into the event that had occurred. It was determined that the MOD had dispensed the wrong medication. He had dispensed MS Sustained Release not the immediate release formulation of MS. Since the above incidents, the Client has experienced a permanent decline in functioning and decreased level of independence. Facility policy and procedure titled: "MEDICATION AND TREATMENT ADMINISTRATION" stated: "PURPOSE: to ensure completion of physician’s orders by providing the 5 rights: Right client, Right time, Right route, Right medication and Right dose." "Section 11 4: " Read medication label 3 times." NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT V~OLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000490 State of California - Health and Human Services Agency Department of Public Health S, ECTI’O~ 1424 NOTICE Page 4 of 4 CITATION NUI~BER: SECTIONS VIOLATED 15-1634-0002232-S Date: 08t17t2004 Time: CLASS AND NATURE OF VIOLATIONS Decline of the Client’s status was documented in the clinical records as follows: Review of the IPP dated 05/04/04; "Remains exceedingly fragile since his illness earlier this year. It is felt that he may soon be confined to a wheelchair and using Attends (adult diapers). Self-care skilis have declined and he is not participating in Activities of Daily Living (ADL’s). Desire to participate in leisure activities has declined and he refuses most of the time." The failure of the facility staff to give the Client the medications as prescribed and to follow proper administration procedure placed the Client at risk for serious harm and lead to the decline in ADL function for this Client. These violations presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000491 State of California - Health and Human Services Agency Department of Public Health S~EcTION 1424 NOTICE Page 1 of 4 CITATION NUMBER: 15-1284-0002238oS Date: 11/04/2004 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76315(b) 76525(a)(20) Incident/Complaint No.(s) ¯ No complaints found State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA Type of Ownership: 95814 State Agency SONOMA DEVELOPMENTAL CENTER D!P ICFDD 15000Arnold Dr Eldridge, CA 95431 Intermediate Care Facility/Developmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $800.00 trebled to $2,400.00 Capacity: 581 DEADLINE FOR COMPLIANCE tl/15/04 12:00 a.m. CITATION-- PATIENT CARE The facility violated the above regulations due to its failure to ensure implementation of a client’s written behavior plans and failure to ensure a client’s right to be free from the harm of unnecessary physical restraint and verbal abuse. Instead of responding as directed in the written behavior plans, a staff member reacted to a client’s inappropriate behaviors with unnecessary physical restraint and verbal abuse. An individual program plan (IPP) dated 4/14/04 documented Client 1 has severe mental retardation, is nonverbal, and communicates wants, needs, and preferences with facial expressions, vocalizations, and physical gestures. A behavior plan dated 1/23/04, indicated Client 1 has aggressive behaviors including hitting, kicking and pushing others as well as socially inappropriate behaviors, , including spitting on others. The document indicated Client 1 tends to focus the aggression toward staff. A 7/30/04 plan revision indicated Client l’s socially inappropriate Name of Evatuator: Linda Lucey HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000492 State qf C~alifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 4 CITATION NUlYlBER: SECTIONS VIOLATED 15-1284-0002238-S Date: 11t04/2004 Time: CLASS AND NATURE OF VIOLATIONS behaviors recently escalated in frequency and intensity in the classroom and included intentional vomiting on the floor and on others. The behavior plans described prevention strategies that included avoiding power struggles. The plans indicated staff members should make sure that further intervention is really necessary when Client 1 becomes resistive. The plan indicated staff members should take her hand with their hand and lead her when Client 1 refuses to go to activities. The plans indicated staff members should not struggle with Client 1 if she resists, The plan indicated staff members should help Client 1 to calm down by offering a reassuring tone of voice. The planned response to vomiting included redirecting Client 1 to an activity or to the patio outside the classroom. The plans indicated staff should use a physical escort (have four people carry her) and take her to a quiet area away from others when Client 1 presents a danger to herself or others, During interview on 10t26/04, and in a signed statement dated 8/12104, Staff Member V. described observations of Staff Member T and Client 1 in the classroom on 8tl 1/04. Staff Member V indicated Client I was trying to run away after an incident of vomiting. Staff Member T used one hand to grab Client 1 by the back of the neck. Staff Member T physically steered Client 1 to the eating area with. his hand on the back of her neck. Staff Member V indicated Client 1 drank a container of soy milk a~d wanted to drink the second one that was in her lunch. Staff Member T pushed a plate of food toward Client 1 stating something like Client 1 needed to eat before having another container of soy milk. Staff Member V stated Staff Member T and Client 1 were pushing the plate of food back and forth between them when Staff Member T abruptly stood up and said something like, "She hit me. She spit on me." Staff Member V stated Client 1 ran to the couch where she usually sits to calm down. Staff Membei" T went after Client 1 and grabbed her around the front of the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000493 State qf California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 4 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0002238-S Date: fllt04t2004 Time: CLASS AND NATURE OF VIOLATIONS throat with his left hand. Staff Member T hovered over the seated Client 1 yelling something like, "if you weren’t a client, iV you were out in the real world, I’d kill you... I’d beat you into the ground... I’d beat you to death." At this point the teacher entered the room and interrupted Staff Member T. An incident report dated 8/12/04 documented the classroom teacher observed Staff Member T standing over Client I and talking to the Client I in an inappropriate manner. Attached to the incident report were handwritten notes signed by additional staff members present during the incident. The staff members stated they overheard Staff Member T using a strong tone of voice toward Client 1 and saying things something like, "If you (were) a normal person, (I’d) beat you to death... If you were someone on the street and spit and hit me I would beat you... (and) You better get it together or else I take you home (to the unit), and then you will behave for me." During interview on 9/15/04, Staff Member T incorrectly stated Client 1 is a, "hands-on client" and that means, "Hands on both shoulders". When questioned about Client 1% behavior plans, Staff Member T stated when she hits; you try not to get hit. When she spits, you get a towel. When asked for the written behavior plan for hitting, Staff Member T said, "You tell her it’s not appropriate." When questioned about a behavior plan for vomiting, Staff Member T stated he did not know of a plan for.vomiting. Staff Member T stated he was briefed On how Client 1 will bite and scratch. When asked about the behavior plan for scratching and biting, Staff Member T stated he didn’t know of any. Staff Member T said, "You got to deal with it." Therefore, the facility failed to ensure implementation of the written behavior plans and violated Client l’s right to be free from the harm of unnecessary physical restraint and NOTE: 1N ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000494 State of California - Health and Human Services Agency Departmeiqt of Public Health SECTION t424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS VIOLATED I5-1284-0002238-S Date: 11/04/2004 Time: CLASS AND NATURE OF VIOLATIONS abuse. The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to clients. NOTE: ~N ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000495 State of California - Health and Human Services Agency Department of Public Health SECTION 7424 NOTICE Page 1 of 3 CITATION NUMBER: 15-1284-0002242-S Date: 01f26/2005 Time: Type of Visit ¯ YOU ARE HEREBY FOUND 1N VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(14) 76521 ]ncidentlCompIaint No.(s) ’ No complaints found State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP ICFDD 15000 Arnold Dr Eldrid.qe, CA 95431 Intermediate Care FacilitylDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $700.00 trebled to $2,100,00 Capacity: 581 DEADLINE FOR COMPLIANCE 2/7/05 12:00 a.m. CITATION .- PATIENT RIGHTS The facility failed to ensure implementation of administrative policies and procedures and failed to ensure clients’ rights-to dignity and respect. When a client displayed inappropriate sexual behaviors toward peers, staff members did not follow facility procedures designed to ensure protection of all clients’ rights to dignity and respect. Findings include: The facility document entitled, "ABUSE/M ISTREATMENT/N EGLECT/PREVENTION & REPORTING" defined sexual abuse as, "Any act of sexual assault or other sexual impropriety.., which may or may not cause harm, pain, or humifiation.., including.., fondling ..." The policy documented, "All incidents of abuse will be immediately reported ..." The facility document entitled, "CLIENT PROTECTION & PREVENTION FROM HARM" indicated, "The Program Director is responsible to ensure client protection .... from harm Name of Eva]uator; Linda Lucey HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS }=OR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000496 State. of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0002242-S Date: 01f2612005 Time: CLASS AND NATURE OF VIOLATIONS by... taking action on any issue, trend, or pattern that is identified... The event is logged in the 24-Hour Log and an interdisciplinary note (IDN) is written. An Incident Report (1R) is written if it meets the criteria." The facility document entitled, INCIDENT REPORTING(IR) & INVESTIGATION SYSTEM" documented an incident report is to be written for, "All Allegations Or Suspicion Of Client Abuse (Including Sexual Abuse...)". Male Client 2’s interdisciplinary notes of 8/01t04 documented Client 2 was in the women’s restroom at 6:55 PM. Staff heard a female client yell," (Client 2) Stop!" Staff observed Client 2 rubbing up against the unidentified female client sexually. Notes indicated Client 2 escalated and required containment in five point restraints. Female Client 3’s interdisciplinary notes of 8/02t04 at 6:40 PM indicated Client 2 was found in her bed simulating sex with her. The notes indicated Client 3 stated she hadn’t wanted Client 2 to do that. Female Client 1 ’s interdisciplinary notes of 8t02t04 at 10:00 PM documented staff heard Client 1 yell for another to stop and found Client 2 simulating sex against Client 1 ’s leg in the women’s’ bathroom. During interview on 12/10/04, Client 1 stated she was in the women’s’ bathroom, seated on the toilet when Client 2 came into the stall. Client 1 stated Client 2 had his pants down. Client l said, "1 pushed him 5ff me. I told him look, I don’t like that." During interview on 11t10/04, Staff Member D stated inappropriate sexual activity required documentation in the 24-Hour Log and completion of an incident report. Staff Member D checked the 24-hour log and found a notation indicating (Client 2) was found simulating sex with Client 3 on 8t02/04 at 6:40 PM. Staff Member D could not find documentation of the incident between Client 2 and the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000497 State of California - Health and Human Services Agency Department of Public Health SECTION .1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15~1284-0002242-S Date: 0112612005 Time: CLASS AND NATURE OF VIOLATIONS unidentified female on 8/01/04 or the incident between Client 2 and Client I on 8/02/04. During interview on 11110/04, the Program Direcior could not identify the female client assaulted on 8/01t04 and could not provide evidence of incident reports documenting the three episodes of inappropriate sexual behavior. The Program Director provided Client Protection Committee (CPC) meeting notes that indicated a team discussion after Client 2 simulated sex with Client 3 on 8/02/04 at 6:40 PM. The notes indicated Client 3 was, "not complaining." The notes did not indicate any further action. The Program Director could not provide evidence the CPC discussed the other two known incidents. Duringinterview on 11/15/04, the Associate Governmental Programs Analyst (AGPA) stated the quality assurance office of the facility received an incident report regarding the restrictive intervention of Client 2 on 8/01t04. That report noted Client 2 was rubbing against a female client in the women’s’ bathroom. The report did not identify the female. There was no separate incident report regarding the femafe client. The quality assurance office did not receive incident reports documenting Client 2’s inappropriate sexual behaviors toward Clients 1 and 3 on 8/02/04. There was no evidence the three incidents were thoroughly investigated. There was no evidence the facility responded with measures to protect the other clients. Therefore, the facility failed to implement its abuse policies and procedures and failed ensure clients’ rights to dignity and respect. The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to clients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000498 State of California - Health and Human Services Agency Department of Public Health SECTION"1424 NOTICE Page 1 of 3 CITATION NUI~IBER: 15-t 106-0002237-S Date: 11/04t2004 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(14) Incident/Complaint No.(s) ¯ No complaints found State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD Eldddge, CA 95431 15000 Arnold Dr Intermediate Care Facility/Developmentally Disabled Capacity: 581 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $800.00 trebled to $2,400.00 DEADLINE FOR ICOMPLIANCE t11/9/04 12:00 a.m. CITATION -- PATIENT RIGHTS The facility failed to comply with the above regulations by failing to ensure Client M was treated with dignity, respect and humane care as follows: Findings areas follows: Client M has a diagnosis that includes Profound Mental Retardation and was admitted to the facility on 2t3/03, Client M is non-verbal. On 7t22/04 at approximately 5:15 PM Staff N reported that a student, Staff S, had seen Staff P kick Client M in the ankle that morning at 7:30 or 8 am in the dinning room. The special incident report states Client M was checked for injuries immediately after the report. A large bruise was found on his right bicep, which was greenish yellow in color and appeared to be an old injury. Staff S stated only Staff P and Client M were in the room at that time. At approximately 1:30 or 2 PM on 7/22/04 Staff N told the Name of Eva~uator: Christine Young Health Fac. Evaluator Nurse Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name ; Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000499 State of California - Health and Human Services Agency Departmenl of Public Health S.,ECT]ON1424 NOTICE Page 2 of 3 CITATION NUMBER: SECT;ONS VIOLATED 15-1106-0002237-S Date: 11/04/2004 Time: CLASS AND NATURE OF VIOLATIONS unit supervisor she was moving the students off her unit as she felt there was tension between the students and the unit supervisor, The unit supervisor stated she felt therewas a correlation between the students and Client M’s increase in agitation. She felt it was a correlation between Client M’s attention seeking and the students inexperience with this type of client. The unit supervisor had previously asked that the students not interact with Client M and focus on their own clients. The unit supervisor stated in the report she felt the conversation went well and things would improve the next time the students were on the unit. She further wrote that she felt the teacher met with the students and discussed the conversation as she said she would do and it was at this time she believes the allegation was made. Review of Client M’s record shows he has behaviors that include harm to others, he will attack peers and staff, kicking, spitting and hitting others,. He also has a behavior of biting himself. IDN’s (interdisciplinary notes) dated 7/18/04 and 7/22/04 note incidences of aggression toward others. One of Client M’s behaviors is to throw himself on :the floor when agitated. The US (unit supervisor) stated in an interview on 9/15/04 that she has worked with Staff P for 4 years. She further stated she had told Staff S that she did not want her interacting with Client M as his behavior was becoming more aggressive and she felt it was correlated to the interactions she was having with him. The US stated Staff S appeared Upset and went to lunch at this time. The US further stated she did not know why she had not been told before 5 PM that day when the incident happened at 8 or 9 am that morning. Staff Pstated in an interview on 9/17/04 that she did not kick Client M or yell at him, She stated the client was "agitated" and going after other clients in the dinning room so she stood in front of him so he would not hurt anyone. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLAT!ONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000500 State of California - Health and Human Services Agency Department of Public HeaIth SECTI,ON,I424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1t06-0002237-S Date: 1110412004 Time: CLASS AND NATURE OF VIOLATIONS She said she has worked with Client M for a long time and he will listen to her so she was not afraid of him and did not feel he would hurt her. Client M "attacked" another client 3 times while in the dinning room. Staff S stated in an interview, on 9/2ti04 that she was in the dinning room with Staff P Client M and a client she was working with that day. Staff P, told Client M that he needed to eat and set the tray in front of him. Client M pushed the tray away. Staff P then kicked Client M in the leg, pointed her finger at him and said "god damn you". He was not trying to attack anyone at any time; he was just sitting at the table. Client M left the dinning room after being kicked. Staff S stated she told Staff N at approximately 8 or 9 am about the incident and was then assigned to another unit along with another student. Staff S stated she had no contact with the US after that incident. Staff N stated in an interview on 9/21/04 that Staff S had told her about the incident at around 10 am, She then spoke with another instructor and several other people about what should be done. At 4 PM she called the Unit Supervisor and told her of the incident. Staff N felt Staff P was being honest about the incident and had always been honest and straightforward with her. The facility’s failure caused humiliation, indignity and possible anxiety to Client M. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SA]=TEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000501 State of California - Health and Human Services Agency Department of Public Health SECTION .1424 NOTICE Page 1 of 2 CITATION NUMBER: 15-1116-0002245-S Date: 03/08/2005 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facili(y ID: ’ SECTIONS VIOLATED 76525(a)(20) incidenttComplaint No.(s) ’ No complaints found State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care FacilitytDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B Capacity: 581 PENALTY ASSESSMENT $900.00 trebled to $2,700.00 DEADLINE FOR COMPLIANCE 3t17!05 12:00 a.m. CITATION -- PATIENT RIGHTS The facility failed to comply with the above regulation by failing to ensure the rights of Client 1 to be free from harm and abuse, as follows: Client 1 is 31 year old with diagnoses which include severe mental retardation, anxiety disorder, infantile autism, epilepsy, self injurious behaviors, and assaultiveness. Client 1 was admitted to the facility on 06/20/1988. Review of the Client’s Individual Program Plan (IPP) revealed that the Client requires either prompting or assist from one person to accomplish activities of daily living on his own. .Further review of Client l’s record showed that there was follow up to an incident that occurred on 01/12t02005 where the Client was being checked for bruising on his abdomen. Interdi~cilinary Team Note (IDT) date 01t12/05 at 1330hours (1:30 pm) states, "Due to an aggres.~ive act there seems to be some bruise formation present on his hip and armpit c (with) chest scratches." Interview with staff on Client’s Name of Evaluator: Gregory Hannah HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000502 State of California - Health and Human Services Agency Department of Public Health SEOTI8N 1424 NOTICE Page 2 of 2 CITATION NUMBER: SECTIONS VIOLATED 15-1116-0002245-S Date: 03108t2005 Time: CLASS AND NATURE OF VIOLATIONS unit, Judah, revealed that there had been an incident on 01/12t2005 at the Client’s vocational program job site. It was observed that Staff Member had punched Client 1 in the stomach two times. Interview with Staff Member B on 01/14/2005 revealed that she heard Client 1 making loud vocalizations. When she opened the door and went into the room she observed Staff Member A hit Client 1 with a closed fist in the stomach two times. She then ordered Staff Member A away from Client 1 and checked the Client over for injury and gave him comfort care for agitation. Review of Staff Member A’s record revealed that he had been hired by the facility on 06/15f2000 to work in food service in the main kitchen. Further revealed that he passed his exam for Nurse Assistant Certification on 03/2712003. Per the faciity personnel department Staff Member A was hired as a Psychiatric Technician Assistant (PTA) and assigned to Program 4 on 10/19/2004. An appointment for an interview with Staff Member A was arranged by the facility for 01/21t2005 at 8:30 am. Staff Member A did not show up for the interview. Other attempts to i.nterview him also failed. The facility failed to ensure that Client l’s right to be free from harm or abuse by Staff Member A were maintained. The failure had a direct or immediate relationship to the health, safety, or security of Client 1. NOTE,’ IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000503 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 2 CITATION NUMBER: 15-1116-0002256-S Date: 11/04t2005 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility SECTIONS VIOLATED Incident/Complaint No.(s) " No complaints found State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care FacilitytDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS Capacity: 581 PENALTY ASSESSMENT $1,000.00 trebied to $3,000.00 76525(a)(20) CLASS B DEADLINE FOR COMPLIANCE 11t21/05 12:00 a.m, CITATION-- PATIENT RIGHTS Based on client and facility record review, and staff interview, the facility failed to ensure that Client 1 was not subjected to the abuse of being hit in the head twice with a sugar dispenser by StaffA. Findings include: The facility failed to comply with the above regulation by failing to ensure that Client 1 was not subjected to the abuse of being hit in the head twice with a sugar dispenser by Staff A, as follows: Review of Client l’s record revealed that he was admitted to the facility 08/21/1984 and has diagnoses which include profound mental retardation, history of seizures, tonicclonic epilepsy, self aggressive behavior, intermittent explosive disorder, and blindness due to retrolental fibroplasia, Review of Client l’s record, facility documentation, and staff interview revealed that on 07/04/2005, at Name of Evaluator: Gregory Hannan HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name: Evalualor Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000504 State of California - Health and Human Service~ Agency Department of Public Health SEC’~ION "1424 NOTICE Page 2 of 2 CITATION NUMBER: SECTIONS VIOLATED 15-I 1 lS-0002256-S Date: 11/04/2005 Time: CLASS AND NATURE OF VIOLATIONS approximately 8 a.m. in the dining room, Staff B and Staff C witnessed the following: Client 1 hit StaffA in the leg, Staff A then told Client 1 "1 told you not to hit me". Staff A then hit Client 1 in the back of the head with a plastic sugar container. Staff A then brought it over Client l’s head and hit him in the forehead with a downward motion. "l:he Unit Supervisor was notified and Staff A was removed from client contact. Client 1 was examined by the unit Health Services Supervisor (HSS) and his Physician and no obvious signs of injury were noted. Client 1 was observed during the course of the day and no signs of distress or change in his usual routine or behavior were noted. Interview with administrative staff revealed that the facility had substantiated the claim of abuse and Staff A was awaiting administrative action. Was unable to interview StaffA as she is out on disability (NDI) and the facility is unsure when she will be returning. Review of Staff A’s record revealed that there was another incident of client abuse in August 2001 where she was seen to pinch a client in the back if the neck. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000505 State of California - Health and Human Services Agency Department of Public Health SE..CTION ’f424 NOTICE Page 1 of 3 CITATION NUMBER: Date: 06t24f2005 Time: 15-1022-0002250-S Type of Visit ¯ IncidenltComplaint No,(s) ’ No complaints found YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Faci;ity Type: Facility ID: SECTIONS VIOLATED 76525(a)(14) State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA Type of Ownership: 95814 State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care FacilitylDevelopmentally Disabled 150000230 PENALTY ASSESSMENT $700.00 trebled to $2,100.00 CLASS AND NATURE OF VIOLATIONS CLASS B Capacity: 581 DEADLINE FOR COMPLIANCE 6/30/05 12:00 a.m. CITATION-- PATIENT RIGHTS The facility failed to comply with the above regulation by failing to ensure Client A’s right to dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs by walking her in the facility hallway while she was unclothed, as follows: On 5t2105, the facility initiated an Incident Report (IR) regarding an Individual Program Coordinator’s (IPC) allegation that at around 1445 hours she had observed a naked female client in the hallway who needed assistance. The IPC helped her (Client A) into a private room and then went to find staff for assistance. The IPC approached Psychiatric Technician Assistant 1 (PTA 1) who directed her to PTA 2. PTA 2 went with the IPC to the room with Client A and proceeded to take Client A, still unclothed, back into the hallway, pushing her from behind to the family room where PTA 1 was supervising other clients. These two staff people proceeded to argue responsibility for assisting the client. Following the argument both individuals walked Client A, who was still unclothed, back up the hallway to her room where they got clothing for Client A to put on. Name of Evaluator: Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Jose Figueroa HFEN Signature: Name : Evaluator Siflnature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000506 State of California - Health and Human Services Agency Department of Public HeAlth SECTION 1"424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED .15-1022-0002250-S Dale: 06/’2412005 Time: CLASS AND NATURE OF VIOLATIONS The IPC reported the incident to the Unit Supervisor and filled out the JR. The Sonoma Developmental Center Office of Protective Services completed an investigation of the incident on May 19, 2005. A summary of the investigation included: On Tuesday, May 3, 2005 at about 1250 hours, I interviewed the IPC regarding the neglect of Client A. IPC stated on 5t2t’05 at about 1445 hours, she observed Client A walking down the hallway on the Lathrop unit with only a sports bra, socks and shoes (no underwear/pants). She stated Client A was not wearing the sports bra correctly and was exposing her breast and genital area. IPC directed Client A into a nearby peer’s room so she could get assistance from fellow staff members. ]PC asked PTA 1 for assistance, but was told she couldn’t help because she was busy with clients in a family group. PTA 1 suggested PTA 2 might be able to assist her with Client A. IPC asked PTA 2 for assistance with Client A. IPC stated she showed PTA 2 which room Client A was in and observed PTA 2 get apair of gloves and push (medium pressure described by IPC) Client A (still unclothed) to the family group where PTA 1 was and heard him say, "Here." IPC then heard PTA 1 state, "1 can’t take care of her." IPC stated both individuals began to argue for about one or two minutes while Client A was standing in the family room unclothed. IPC said after the brief argument both individuals walked Client A back to her room. IPC stated she notified her Unit Supervisor immediately after the incident... IPC stated that the incident took place during shift change and she felt that both PTA 1 and PTA 2 were tired and wanted to go home and did not want to be responsible for Client A. On 5t20/05 at 0845 hours, the IPC was interviewed regarding the incident she reported. The IPC stated that she was at NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000507 State of California - Health and Human Services Agency Department of Public Heallh SEC’fION "1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1022-0002250-S Date: 06/24/2005 Time: CLASS AND NATURE OF VIOLATIONS the Nursing Station and she saw Client A wearing only a bra, which was not on correctly and it exposed her breast. The IPC took Client A into the nearest private room. The IPC asked PTA 1 to get some clothing for Client A. PTA 1 said that she could not do it but she would ask PTA 2 to get clothes. PTA 2 walked back with the tPC to the private room and brought Client A out of the room into the hallway. The IPC said she told PTA 2 "You can’t be doing this’" (taking a naked client down the hall). But PTA 2 pushed her into the family room full of people. PTA 1 and PTA 2 got into an argument over who was responsible for Client A and then they walked her back to her room. PTA 1 and PTA 2 both seemed frustrated because the shift change was later than usual and they wanted to go home. The facility failed to ensure that staff maintained Client A’s rights to be treated with dignity and provide privacy for her while she was in a state of undress. The above violation had a direct relationship to the health and security of the client. NOTE: IN ACCORDANCE WiTH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000508 State of California - Health and Human Services Agency Departmenl of Public Health SECTION 1424 NOTICE Page I of 3 CITATION NUMBER: 15-1022-0003074-S Date: 05102/2006 Time: Type of Visit ¯ Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) IncidentfComplaint No,(s) " CA00071852 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care FacilitytDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 trebled to $3,000.00 Capacity: 581 DEADLINE FOR COMPLIANCE 5/11/06 6:00 a.m. CITATION -- PATIENT RIGHTS 76525(a)(20) Clients’ Rights (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to follow the above regulation by not ensuring that a .client was free from neglect when the Psychiatric Technician Assistant 1 (PTA 1) assigned to monitor Client A and prevent him from pulling out his oxygen, heart monitor and internal jugular central lV line, fell asleep, which resulted in all of these lines being pulled out by Client A. Findings: On 2t6/06, Sonoma Developmental Center (SDC) initiated an Incident Report (tR) describing the following event: Client A was at Sonoma Valley Hospital (SVH) for treatment of (Congestive Heart Failure) CHF. HefShe had been assigned a one-on-one (1:1) stafffrom Sonoma Developmental Center (SDC). A restraint order was written to use restraints when agitated to prevent removing hislher intravenous (IV). The morning of February 6, 2006, Roadruck Unit received a telephone call from SVH that the 1:1 staff was found asleep, during which time Client A had managed to pull off his/her heart monitor leads, pulled out Name of Evalualor: Jose Figueroa HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000509 State of California - Health and Human Services Agency Department of Public Health SECT4ON 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1022~0003074-S Date: 05t02t2006 Time: CLASS AND NATURE OF VIOLATIONS his/her IV, and crawled to the bottom of his/her bed. The central line and IV’s were reinserted without complications." The Sonoma Valley Hospital (SVH) Registered Nurse 1 (RN 1) who initially reported the incident later provided a full written description of what he had observed as follows: "On 02/06/06, at 03:50 AM, I noticed that the leads were off on this patient. Upon going into room, patient was found sitting at the end of the bed. Oxygen (02) line off, leads off, and more importantly, the left internal jugular (LIJ) central line was out, dressing completely soaked and blood running down front of patient. The gown was off as welt. SDC staff person found dozing in chair, aroused to assist with clean up..." PTA 1 also provided a written description which included a statement that, "...At the time I sit (sic). down, 3:30 AM, watching TV, accidentally closed my eyes and then nurse tap (sic) my shoulder. I see (sic) the client sitting down, he had pulled out all the stuff in his body. So I help (sic) the nurse to clean him and he (sic) still agitated..." The facility Office of Protective Services completed an investigation of the incident on February 15, 2006. The Investigation Report contained written statements from PTA 1 and Registered Nurse 1 from SVH. The investigation Report included the following information: On 2t6/06, at approximately 0800 hours, Officer S. was advised by Senior Psychiatric Technician from Roadruck Unit, that PTA t was found asleep while assigned to a one-on-one with Client A at Sonoma Valley Hospital ... Officer S. received a typed statement from RN 1, employed by SVH, and PTA 1, the staff person from SDC assigned as the 1:1 for Client A. RN 1 reported that on 2/6/06, at approximately 0350 hours, he noted that Client A’s leads, 02 line and LIJ central line, were removed and his dressing was soaked with blood. RN 1 noted that PTA 1 who was present, was found "dozing" in a chair. Client A was noted to be hostile to RN 1 and staff. A new IV line was placed in Client A’s right hand. Officer S received a copy of a hand written statement, not dated, from PTA.1. PTA 1 stated that at approximately 0330 hours, she sat down to watch television and NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000510 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 15~I022-0003074-S Dale: 05/02/2006 Time: CLASS AND NATURE OF VIOLATIONS "accidentally" closed her eyes. PTA 1 said that the staff nurse tapped her on the shoulder. PTA 1 said that she observed that Client A had pulled out all his lines. On 2/14/06 at approximately 0850, Officer S. interviewed PTA 1 Officer S. asked PTA 1 if she knew what she was accused of and she said "neglect". Officer S. asked PTA 1 if she admitted or denied the allegation. PTA 1 said, ’I don’t deny it". Officer S. asked PTA 1 to read her written statement aloud. He asked PTA 1 if the statement was true and correct and she said, "yeah, it’s true". I asked her if she had anything else to add and she told me, "No, that’s it". I asked her if there was a reason why she fell asleep and she said, ’Tin not pretty (sic) sure. I was just watching TV, and I don’t know what happened". I asked her if she had enough sleep the night before and she said, "Yes". She told me that she was working a regular shift that night. I asked PTA 1 if she admitted falling asleep and she said, "Yeah. That’s what happened. I cannot deny it". Therefore, the facility failed to ensure that Client A, who was in the acute care for treatment of CHF and in restraints, was not neglected when the 1:1 staff assigned to Client A fell asleep while on duty with the Client. The Client then pulled out his central venous line, and took of his monitor electrodes and oxygen and was found at the end of his bed. This facility failure had a direct and immediate relat onsh p to the health, safety, or security of long-term health care facility patients or residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000511 State of California - Health andHuman Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-1594-0003193-S Date: 07/1212006 Time: Type of Visit : Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATI(~NS OR APPLICABLE Licensee Name: Address: License Number: Facility Name; Address: Telephone: Faciiity Type: Facility iD: SECTIONS VIOLATED 76525(a)(20) IncidenttComplaint No.(s) : CA00080434 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care FacililytDevelopmentally Disabled Capacity: 581 150000230 CLASS.AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $900.00 DEADLINE FOR COMPLIANCE 7/26/06 6:00 a.m. CITATION -- PATIENT RIGHTS 76525(a)(20) Clients’ Rights (a) Each client has the rights fisted in (a) of this section which shall not be denied or withheld.except as provided in (c) of this section. Each facility shall establish and. implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to comply with the above regulation by failing to implement written policies and procedures to ensure Client 1 was free from harm when Client 1 sustained an unwitnessed fall from bus steps resulting in a fractured left clavicle and fractured feft rib, Review of the annual medical summary, dated 10/25/05, revealed Client l’s diagnoses included osteopenia (mild thinning of the bone mass) and a seizure disorder. The Individual Program Plan (IPP) notes, dated 11tt7/05, revealed that Client I was at risk for falling, bruising, and injury due to seizure medications and periodic ataxia and lethargy. Client 1 walked steadily, though sometimes tentatively, and seemed to have good balance and coordination in his activities. Further documentation revealed that Name of Evaluator: CAROL DEVITA HFEN Without admitting guilt, t hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000512 State of California - Heafth and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUI~IBER; SECTIONS VIOLATED 15-1594-0003193-S Date: 0711212006 Time: CLASS AND NATURE OF VIOLATIONS there were times when he seemed a bit unsteady, got tired after longer distance walks, and, at times, experienced ataxia, putting him at risk for fails. He seemed to have more difficulty over uneven surfaces, especially stairs. Further documentation revealed that the client should be observed while walking to help him avoid falls or injury due to uneven surfaces, getting set off balance in crowded situations, missing steps, or other hazards. The facility incident report revealed on 5/08/06 at 1330, a staff member and driver were preparing to lift a client in a wheelchair and were distracted when Client 1 walked out of the gate and went to board the bus. The driver was facing the bus door while operating the lift and the other staff member was on the other side of the lift with his back to the bus doors. The driver reported seeing Client 1 walk by but did not register the situation until he and the escort heard a thud. Both turned around and saw the client lying on the ground. Client 1 fell backwards off the first and possibly second step of the bus. He landed on his "behind" and struck his head on a chain fink fence. The client sustained a small superficial cut approximately 11/2 to 2 inches on his head. The code team was called and the client was transported to x-ray for a cervical spine series. Client Protection Process (CPP) documentation, dated 5/16/06, revealed upon Client l’s return to the unit, he was examined by the Family Nurse Practitioner (FNP) and Health Services Supervisor (HSS) and no injuries were noted. He was given Acetaminophen and warm Showers to ease the ache and soreness. On 5/09/06, staff documented Client 1 was cheerful and ambulatory with no bruising noted, but appeared to be sore, grimacing when he raised his arms. On 5/10/06 at 1045, he was examined by the HSS and was noted to be responsive to questions and to have good bilateral grips. At 1315, HSS documented that Client 1 was complaining of pain, refusing to lift, and was. protective of his left arm. X-rays were taken and revealed a non-displaced left clavicle (collarbone) fracture and slightly displaced fracture of the left first rib. The "Transportation Safety" policy included the following: 1. Driver will assist ambulatory passengers entering and exiting buses from the top or bottom of the stairs, depending on the passenger. Driver will.coordinate with escort who will be at the top or bottom of steps to best protect passengers. Driver will say to entering/exiting passengers, "Watch your step." 2. Escort will assist with loading and unloading all passengers. 3. Escort will assist ambulatory clients in entering and exiting buses from the top or bottomof the stairs, depending on the passenger. The escort has to make a safety judgment of which passengers will be escorted on and off the vehicle first based on the number of support staff available and the current situation. Escort will coordinate with the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000513 State of California - Health and Human Services Agency Department of PubIic Heafth SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1594-0003193-S Date: 07/12/2006 Time: CLASS AND NATURE OF VIOLATIONS driver about who will be at the top or bottom of steps to best protect passengers, Escort will say to entering/exiting passengers, "Watch your step". During an interview with the bus driver on 6/05/06 at 3:30 p.m., he stated that on the day of the incident, he and another staff (escort) were loading another client onto the van using the wheelchair lift. The bus driver stated that the staff (escort) was new to the unit and to new to the routine and that he (the driver) usually loaded the clients in wheelchairs by himself. While using the lift, he stated that he heard a thump and observed that Client 1 had fallen out of the bus. He further stated, "There was no one at the bottom." During an interview with the escort, Staff C, on 6,’i3/06 at 3:15 p.m., he stated at the time of the incident he was not facing the door of the bus, as he was assisting another client onto the wheelchair lift. He stated that he was aware of the transportation safety policy but had only worked on the unit for one month and "needed orientation" for "coordination and teamwork". The facility’s failure to ensure that written policies were implemented to keep Client 1 free from harm resulted in this client sustaining an unwitnessed fall from bus steps, a non displaced left clavicle fracture, and a slightly displaced fracture of the left first rib. The violations above had a direct relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000514 State of California - Health and Human Services Agency Department of Public Health SEC’~ION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 1.5-1022-0003308~S Date: 08/24/2006 Time: Type of Visit ’ Complaint investig, YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: ¯ Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(7) Incidenl/Complaint No.(s) ¯ CA00079909 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care Facility/Developmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMEN’T $6OO.OO Capacity: 581 DEADLINE FOR COMPLIANCE. 8/30/06 6:00 a.m. CITATION -- PATIENT RIGHTS T22 DIV5 CH8 ART4-76525(a)(7) - CLIENTS’ RIGHTS (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement Written policies and procedures to ensure that each client admitted is afforded the following rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. The facility failed to follow the above regulation by not preventing a facility staff person from inflicting psychological abuse upon Client A, whose fear of water was used by the staff person as aversion therapy to motivate Client A into compliance with staff request. Findings: Complaint number 79909 stated that on May 2, 2006, Client A was with her Education Services Group on grounds outside King Residence using the vending machine. Client A became upset, lay down on the ground, and began kicking. Staff attempted re-direction to the van per Client A’ s behavior plans with no results. The Primary Teacher ( Teacher M) proceeded to obtain a garden hose, turn on the water, and spray Name of Evaluator: Jose Figueroa HFEN Without admitting guilt, I horeby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000515 State of California - Health and Human Services Agency Department of Public Health SECT.ION 1424 NOTICE Page 2 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 15-1022-0003308-S Date: 08t24t2006 Time: i CLASS AND NATURE OF VIOLATIONS ~ J at the ground near Client A. Client A then jumped up and entered the van. A second Teacher (Teacher P) asked why the water was turned on and was informed that Client A was afraid of water. An investigation of the incident was initiated by the facility’s Office of Protective Services (OPS) on 5/16f06.. The OPS Investigation included an interview with Teacher P, Teacher M, and the Staff Psychologist Y. Teacher P stated that on 5t2/06, at approximately 13:40 hours, during an outing, Client A got out of a state van behind King Unit so she could use a vending machine. Teacher P said that as Teacher M and Client A were returning to the van, she noticed that Client A ran in front of the state van and lay down on the ground. Teacher P said that Teacher M followed behind Client A and was attempting to encourage her, prompt her t0 stand up and get back into the van. Teacher P said that was when Sonoma Developmental Center (SDC) employee Psychiatric Technician Assistant 1 (PTA 1) exited the van so he could assist Teacher M getting Client A back into the van. Teacher P said that when Client A again refused to stand up, she noticed Teacher M walk over to King Unit and grab a water hose and turn the water on. Teacher P said that Teacher M then walked toward Client A’ s location and was spraying the ground which was located around Client A. Teacher P indicated the Teacher M didn’t spray Client A directly and he didn’t get her wet. Teacher P indicated that when she asked PTA 1 what that was all about, he indicated words to the effect, "Client A has a fear of water." Teacher P said that what Teacher M did was a "stupid thing" and that he should have followed her plan and picked her up with the assistance of other staff. Teacher M was asked if he had prior knowledge that Client A had a fear of water. Teacher M said that he didn’t know if Client A had a fear of water but h~ knew that she avoided water and didn’t like to sit in it or be around it. Teacher M said that he knew this because in the past Client A would avoid wet areas and wouldn’t sit in or around wet areas. Teacher M cited examples such as Client A would avoid walking or sitting on wet lawns or would avoid going out to the cou.rtyard if it had been sprayed down with water. Teacher M said that his motivation for using the water hose was that it was a hot day and Client A was sitting on the ground, so he thought by spraying some water around Client A’ s general location would cool down the area and get her to stand up. Teacher M said that he was sorry for what he did and that he would never do it again. Teacher M said that it was a spur of the moment decision and that he just used poor judgment. Staff Psychologist Y said that on 5/2/06 ...he examined Client A. Staff Psychologist Y NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000516 Slate of California - Health and Human Services Agency Department of Public Health SE, C’BON 1424 NOTICE Page 3 of 3 crrAT1ON NUMBER: SECTIONS VIOLATED 15-1022-0003308-S Date: 08t24/2006 Time: CLASS AND NATURE OF VIOLATIONS said that it was pretty obvious that Client A was actively avoiding the stimulus of the water being sprayed around her. Staff Psychologist Y said that this was demonstrated by her standing up and walking away.from t.hat location and into the van. Staff Psychologist Y said in his opinion, Client A was afraid of that event. Staff Psychologist Y said that Teacher M was using "Aversive Therapy. " Essentially, Teacher M was doing something that Client A didn’t like or hated so he could get her to do what he wanted her to do. Staff Psychologist Y said that in his opinion, what Teacher M did was " aversive Therapy " which could be considered abuse. Staff Psychologist Y said, especially if Teacher M knew prior to the incident that Client A was afraid of water... " The violation was determined to cause or Under circumstance likely to cause significant humiliation, indignity, anxiety or other emotional trauma to the Client. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONSIS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000517 State of California - Health and Human Services Agency Depadment of Public Health SIECTtO.N 1424 NOTICE Page 1 of 3 CITATION NUMBER: 154 284-0003046-S Date: 08/23/2006 Time: Type of Visit ’ Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR Incident/Complaint No.(s) : CA00066920 APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, .CA 958.14 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care FacilitytDevelopmental]y Disabled 150000230 CLASS AND NATURE OF VIOLATIONS Capacity: 581 PENALTY ASSESSMENT $1,000.00 trebled to $3,ooo.oo 76525(a)(20) CLASS B DEADLINE FOR COMPLIANCE 9/!/06 6:00 a.m. CITATION -- PATIENT RIGHTS 76525(a)(20) (a) Each.client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to ensure each client’s right to be free from the harm of abuse and neglect. A staff member attempted to administer 12 tablets and capsules at one time to a reclined client with swallowing problems. When the client resisted, the staff member slapped the client on the face. The client had fresh marks on the face and exhibited signs of psychological distress after the incident. Findings: An annual assessment dated 10/19/05 indicated Client 1 liked to sit in a large soft reclining chair. The assessment documented Client 1 was being treated for PTSD (post traumatic stress disorder), was actively fearful of others, and did not like to be touched Name of Evaluator: Linda Lucey HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evalualor Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAF.TEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000518 State of California - Health and Human Services Agency Depadment of Public Health S~:CTION I424 NOTICE Page 2 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 15-1284-0003046-S Date: 08/23/2006 Time: CLASS AND NATURE OF VIOLATIONS or examined, even when done in the calmest, gentlest manner. Client 1 demonstrated discontent through a range of behaviors including harm to self, others and environment. The assessment of 10tl 9/05 documented Client 1 had ne.urogenic dysphagia with a risk of aspiration and choking. During interview on 3/7/06 at approximately 4:30 p.m., a licensed staff member stated Client I sits up to take medications, one pill at a time, mixed with applesauce. During interviews on 3/7/06 at approximately 3 p.m. and on 3t16t06 at approximately 2:45 p.m., Staff Member A stated she prepared all Client l’s medications scheduled for 3 p.m., 6 p.m., during dinner, and after dinner at about 3 p.m. on 11t25t05. Review of Client l’s medication records revealed this totaled 12 tablets and capsules. Staff Member A stated she found Cfient 1 resting in a reciiner, positioned all the way back. Staff Member A stated she did not adjust the recliner to put Client I in a sitting position. Staff Member A stated she gave Client I the tablets and capsules mixed in applesauce all at once because, "You are lucky if (clients) (sic) open their mouth(s). If (the mouth is) open, (you) give (sic) all at once ... (and) ... If you give the whole thing at once, you are done." Staff Member A stated Client 1 swallowed the applesauce, but let the tablets and capsules roll out the side of the mouth. During interview on 2/27/06 at approximately 2 p.m., Staff Member B stated he peeked into Client l’s room looking for the medication nurse around 3:15 p.m. on 11/25/05. Staff Member B stated he observed Client 1 was positioned all the way back in a recliner chair facing the door. The medication nurse, Staff Member A, had her back to ¯ the door and was standing on Client l’s left side. Client l’s head was positioned to the right, facing away from Staff Member A. Staff Member B stated Staff Member A used the left hand to take hold of Client "l’s chin and turn Client l’s face to the left. Then, using the right hand, Staff Member A reached around the rec]iner and slapped Client 1 on the right cheek. Staff Member B stated he heard a loud, "skin-to-skin slap" noise. A police report dated 1/10/06 documented the supervising psychiatric technician reported marks on Client l’s face that were irregular in shape and "blotchy" in appearance iust after the incident. Two certified staff members reported observations of fresh bruising and swelling on the right side of the face just after the incident. The responding police officer documented the presence of 4 marks on Client l’s right cheek appearing as, "fresh abrasions or scratches" and noted Staff Member A had fingernails longer than 1/4 inch. The police report indicated the supervising ~:egistered nurse who examined Client 1 at 4:45 p.m. reported 4 scratches on the right cheek looked fresh, NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000519 State of California - Health and Human Services Agency Department of Public Health SECTI’oN 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0003046-S Date: 08/23/2006 Time: CLASS AND NATURE OF VIOLATIONS perhaps an hour and not a couple of days old. Observation of a photograph provided by the facility police department dated 11/25t05 showed a cluster of four skin openings on the right side of the face near the chin with discoloration on the cheek above the skin openings. Interdisciplinary notes of 1 tt25/05 at 4:20 p.m. indicated the presence of four marks on Client l’s right cheek. Earlier notes did not document any facial injuries. Subsequent interdisciplinary notes do~,umented Client 1 was agitated at 6 p.m. and did not eat much dinner. At 8:30 p.m. Client 1 was striking out at o{hers. At 10 p.m., Client 1 was striking at the furniture and had ripped the sheet up. Therefore the facility failed to ensure Client l’s right to be free from the harm of neglect and abuse. Staff Member A administered a mouthful of 12 tablets and capsules to Client 1 while Client 1 was reclined, increasing the risk of choking. When Client 1 exhibited resistance, Staff Member A slapped Client 1 on the face. Client 1 had fresh marks on the face and exhibited symptoms of distress in the hours after the incident. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000520 Slate of California - Health and Human Services Agency Department of Public Health Page 1 of 3 ¯ SEOTI(~N 1424 NOTICE CITATION NUMBER: t5-1022-0003418-S Date: 10/12/2006 Time: Type of Visit ’ Complaint lnvestig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(7) IncidentlComplaint No.(s) ’ CA00087409 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care Facility/Developmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMEN’T $600.00 Capacity: 581 DEADLINE FOR COMPLIANCE 10/26/06 6:00 a.m, CITATION-- PATIENT RIGHTS T22 DIV5 CH8 ART4 - 76525(a)(7) Clients’ Rights (a) Each client has the rights listed in (a) of this section .which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329, The facility failed to follow the above regulation by not maintaining Client A’s right to be free of physical abuse, when he was punched in the chest by Psychiatric Technician 1 (PT 1).Findings: On 7/18/06, the facility initiated an Incident Report (fR) regarding an allegation by Teacher 1, that on the morning of July 18, 2006 she witnessed PT 1 punch Client A in the chest. Teacher 1 stated in the IR that she was working at the Farrell Training Center. As she came into the classroom, she observed PT 1 hit Client A in the chest. Teacher 1 immediately reported the incident to the Unit Supervisor and the Senior Name of Evaluator: Jose Figueroa HFEN Wilhout admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name: Evaluator Signature Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000521 State of California - Health and Human Services Agency Department of Public Health SEOTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1022-0003418-8 Dale: 10t12/2006 Time: CLASS AND NATURE OF VIOLATIONS Psychiatric Technician (SPT). Teacher 1 stated that the Health Services Specialist (HSS) saw Client A and noted a slight reddened area below the right clavicle. Following the initiation of the IR, the Police and Office of Protective Services (OPS) was afso notified. The IR was reviewed by the Unit Supervisor who added the following information: "Staff from Farrell E paged this writer at 12:00 p.m. to report an allegation of abuse involving a staff person from Farrell E. Information was gathered and notifications were made. The alleged perpetrator was removed from client contact at 12:05 p.m., 7118/06. HSS came to assess Client A at site. Client A was provided with care and emotional comfort. No signs or symptoms of distress or injury were noted. It was reported that Client A had a podiatry appointment this a.m and arrived at Farrefl later than usual. Several staff stated that he was more combative than normal. He did calm down later in the morning and continued his usual routine without further incident ... " A review of Client A’s clinical record indicates that his open conditions include: maladaptive behavior such as; communication through aggression..He suffers from dysphagia, blindness in the left eye, Diabetes Mellitus, and left-sided Hemiplegia (left-sided atrophy and contractures of the left knee and left elbow). He has a physically enforced task compliance component to his behavior plans. This allows any clinicianto hold his hand for up to 2 minutes to complete the task. The Police investigation conducted by the facility’s OPS included interviews with the witness to the abuse, Teacher 1, the alleged perpetrator PT 1 and the HSS who examined Client A. In the Summary of Investigation the OPS investigator included the followi.ng information: "...(Teacher 1 ) told me that on July 8, 2006, at approximately 11:30 hours, she saw (PT ¯ 1) standing behind and a little to the right of (Client A) who was sitting on a couch in classroom F. She said that (PT 1) took his left hand and held (Client A’s) right arm down. (PT 1) then took his right arm and with a closed fist ’slugged’( Client A) across the chest... (HSS) said that on July 18, 2006, she was requested to examine (Client A) for injuries. She said that approximately 1230 hours, she noted a 2centimeter btanchable erthremia (reddened area) below( Client A’ s) right clavicle... NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000522 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15=1022-0003418-S Date: 10t12t2006 Time: CLASS AND NATURE OF VIOLATIONS (PT 1) denied the allegations against him ... " On 9t21/06 a written, signed statement from Teacher 1 was received by the Department which corroborated her initial allegation reported in the IR and her statement she provided to the OPS during the investigation’. On 10/11/06, PT 1 was interviewed at 9:35 a.m by the Department HFEN Investigator regarding the alleged abuse. PT 1 stated the following: "1 had been working with (Client A) for the day. I did not touch .(Client A) in.any violent or agressive way. I recall (Client A) showing resistance; jerking, moving, i was doing finger stick and other treatments during my care of him. When [ finished up with the finger sticks I noticed blood on his hands. I went to get a wash cloth. I explained to (Client A) that ! was going to clean his hands. I took his left hand, washed and dryed the hand and then did the other hand. When I was explaining to him what I was going to do he head butted me on the left shoulder two times. To my understanding, she (Teacher 1) and I were the only ones in the classroom at the time that she alleges incident occured." The OPS investigation substantiated the allegation of abuse. "Based on the information gathered and reviewed, the investigation has determined that there was sufficient probable cause to believe that (PT 1) violated the California Penal Code section 1. 243.25 Battery against a Dependent Adult and SDC Policy # 413; Abuse/MistreatmenttNeglect Prevention and Reporting. The case was referred to the Sonoma County District Attorney’s Office for review and prosecution. The above violation of Patients’ Rights had a direct and immediate relationship to Client A’s health, safety and security. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000523 State of California - Health and Human Services Agency Department of Public Health SECT,1ON 1424 NO’I’ICE Page 1 of 3 CITATION NUMBER: 15-1022-0003404-S Date: 10/12f2006 Time: Type of Visit : Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: .Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(14) Incident/Complaint No.(s) ¯ CA000899t3 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA Type of Ownership: 95814 State Agency SONOMA DEVELOPMENTAL CENTER DIP ICFDD Etdridge, CA 95431 15000 Arnold Dr Intermediate Care FacilitylDevelopmentally Disabled Capacity: 581 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMEN’T $600.00 DEADLINE FOR COMPLIANCE 10t26/06 6:00 a.m. CITATION-- PATIENT RIGHTS T22 DIV5 CH8 ART4-76525(a)(14) CLIENTS’ RIGHTS (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (14) To dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs The facility failed to follow the above regulation by not ensuring Client A’s right to dignity and respect, when PT 3 said to Client A during care for his personal needs, "Why are you such a dummy." Findings: The facility submitted an Incident Report (IR) to the Department on August 11,2006, The IR stated that on the morning of August 10, 2006, while Psychiatric Technician 1 (PT 1) was passing medications she observed Client A engaged in self-injurious behavior (SIB). She overheard PT 2, who was working with Client A say "Why are you such a dummy." Name of Evaluator: Jose Figueroa HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NO]ICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000524 Slate of California ~ Health and Human Services Agency Department of Public Health SECT, ION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1022-0003404-S Date: 10t12/2006 Time: CLASS AND NATURE OF VIOLATIONS Following the reporting of the incident, the facility notified their Office of Protective Services (OPS) and an investigation was initiated. The investigation was concluded on 8/21/06. The final report included statements from two witnesses and the staff person accused of verbal abuse. The investigating officer documented in the OPS report: "On August 10, 2006, at approximately 7:20 a.m.(PT t) was doing medication rounds on Netson D unit. (PT 1) said she walked in to room # 109 (Client A’s bedroom) and saw (Client A) engaging in self-injurious behavior (SIB). (PT 1) said (PT 3) was standing in front of (Client A) and said, ’ Why are you such a dummy.’ (PT)1 said she escorted (Client A) out of the bedroom and calmed him down from his SIB (PT 1) said she reported the incident to her supervisor and filled out an incident report form... On August 10, 2006, at approximately 7:20 a.m., (PT 2) was working on Nelson D unit with (PT 3), inside room # 109. (PT 2) said she heard (PT 3) say, ’ Why are you such a dummy’ to (Client A). (PT 2) said (Client A) was engaging in SIB activity and (PT 3) was attempting to get him changed/dressed when (PT 3) made the statements towards (Client A) ... On August 10, 2006, at approximately 7:20 a.m., (PT 3) stated she was working on Nelson D unit inside room # 109 with (PT 2). (PT 3) said she was attempting to get (Client A) dressed and he was engaging in SIB activity. (PT 3) said she became frustrated and made a spontaneous statement, ’This is dumb, I don’t seem to be getting anywhere.’ (PT 3) said she did not tetl (Client A) he was dumb and that she would never call a client dumb ..." The investigating officer concluded in his report: "Although (PT 3’s) statement appeared to have been said in a spontaneous manner, per SDC Policy #413, which states Verbal Abuse- Any verbalization that is not reasonable and prudent execution of one’ s duties, which is loud, threatening, demeaning, discriminatory, derogatory, or has aggressive content, meets the definition of Verbal Abuse." On 8t30/06, at 10:00 AM, PT land PT 2 were interviewed and made a written statement corroborating what they had reported in the IR and the statements they had given during the OPS investigation, This violation of Patients’ Rights was determined to cause or under circumstance likely NOTE: IN ACCORDANCE WiTH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS 1S GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000525 State of California - Health and Human Services Agency Department of Public Health SECI’ION 1424 NOTICE Page 3 of 3 CITATION NUI~BER: SECTIONS VIOLATED 15-1022-0003404-S Date: 10t12t2006 Time: CLASS AND NATURE OF VIOLATIONS tocause significant humiliation, indignityl anxiety or other emotional trama to the Client, NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT ViOLATiONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000526 State of California - Health and Human Services Agency Department of Public Health Page "i of 4 , SEO,TtON 1424 NOTICE CITATION NUI~BER: 15-1022-0003485-S Date: 11/17/2006 Time: Type of Visit : Complaint investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(7) tncidenltComplaint No.(s) ’ CA00092870 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO. CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD Eldridge, CA 95431 15000 Arnold Dr Intermediate Care FacilitytDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B Capacity: 581 PENALTY ASSESSMENT $700.00 DEADLINE FOR cOMPLIANCE 12/1/06 6:00 a.m. CITATION -- PATIENT RIGHTS T22 DIV5 CH8 ART4 - 76525(a)(7)PATIENT RIGHTS (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. The facility failed to follow the above regulations by not ensuring that Client A was free from physical abuse as manifested by Senior Psychiatric Technician 1 (SPT 1) hitting Client A on the shoulder with Client A’s shoe. Findings: On the morning of September 12, 2006, Client A was in the unit family room and was exhibiting aggressive behaviors by throwing his shoes at staff and attempting to strike out at staff. The Senior Psychiatric Technician (SPT 1) was attempting to calm Client A Name of Evaluator: Jose Figueroa HFEN Withoul admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000527 State of California - Health and Human Services Agency . SECTION 1424 NOTICE CITATION NUI~IBER: SECTIONS VIOLATED Department of Public Health Page 2 of 4 15-1022-0003485-S Date: 11/17/2006 Time: CLASS AND NATURE OF VIOLATIONS with the assistance of the Unit Psychologist. The SPT 1 asked the Psychologist to leave the room because he felt Client A was becoming more agitated and "putting on a show" in front.of her. The Psychologist left the room but was observing the interaction from outside of the room. The Psychologist states she saw SPT 1 attempting to get the client to put on his shoes. She further states she saw SPT 1 strike Client A two times on the arm with the shoe while demanding he put the shoe on. The Psychologist immediately intervened and prevented any further interaction between the two and summoned the Unit Supervisor for assistance. On 9t12/06, the Unit Psychologist initiated an Incident Report (IR) stating that she had witnessed SPT 1 strike Client A on his left shoulder with Cfient A’ s shoe. The IR also documents that Client A was examined by the Health Services Specialist (HSS) and the Unit Physician following the allegation of abuse by the Psychologist: "...No observable injury noted at this time...Nothing new/fresh. No redness or areas of bruising observed. Denies pain or discomfort, full ROM ..." The Sonoma Developmental Center (SDC) Police Department (Office of Protective Services) was notified of the allegation and they initiated an investigation which was completed on 10123/06. The information obtained from interviews with the Psychologist on 9/12106 at 12:20 PM and the SPT 1 on 9t12t06 at t4:10 PM,was documented on the "Crime Incident Report" dated 10123/06 as follows: The Psychologist indicated that on or about 9t12t06, at approximately 09:30 hours, she was in the Corcoran Unit hallway when she heard a client, later identified as Client A, throwing things and making vocalizations in the farnily room. The Psychologist indicated that she walked over to the family room so she could see what was going on. At some point she observed SPT 1 walk up and she asked him if he knew why Client A was being so agitated. According to SPT 1 Client A had been picking on his face that morning so unit staff members had decided to keep him back in the unit rather then (sic) send him to his work site. The Psychologist indicated that SPT 1 entered the family room and said to Client A words to the effect, "... Sit down. Don’t be hitting people..." The Psychologist said that Client A then took his shoe off and SPT 1 said to Client A words to the effect, "... Put it back on..." The Psychologist said that Client A then cowered a bit, slid the shoe on, and then slid the shoe back off. She said that SPT 1 then repeated himself by again saying words to the effect, "... Put it back on. Put your NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000528 State of California - Health and Human Services Agency Department of Public Health SECT, ION "[424 NOTICE Page 3 of 4 CITATION NUMBER: SECTIONS VIOLATED 15-1022-0003485~S Date: 11117f2006 Time: CLASS AND. NATURE OF VIOLATIONS shoe on (Client A)..." The Psychologist said that this exchange went back and forth with SPT 1 repeating himself approximately five times. The Psychologist said that SPT 1 then turned to her and said words to the effect, "... He’s putting on a show for you... " The Ps~’chologist said that she then observed the situation for about five more seconds while she was still in the family room and she then proceeded to step outside the family room and around the doorway so she would be out of Client A’ s view. She said that she was still able to see SPT 1 and Client A through the reflection of a picture that was "hanging on the wall. She said SPT 1 again told Client A words to the effect "...Put your shoe back on..." The Psychologist said that SPT 1 then picked up the shoe and hit Client A across his arm two times with the bottom of the shoe sole. She said that she immediately stepped into the family room and Client A started screaming and becoming agitated. The Psychologist said that she told SPT 1 to leave Client A alone and he responded By saying words to the effect, "... That’s what he does..."’ The Psychologist said that she again told SPT 1 to just let him be and she proceeded to advise the unit supervisor of the incident that she had just observed. "(SPT 1) indicated that on or about 9/12t06, at approximately 10:00 hours, he was at the Corcoran Unit Nurse’s Station when he heard commotion down the hallway in the direction of the Family/Television Room. (SPT 1) said that as he was walking down the hallway, he observed (Client A) attempting to assault the Psychologist with his flailing hands. (SPT 1) said that he entered the room so he could intervene and redirect (Client A) to another activity. (SPT 1) said that he asked (Client A) to put his shoes back on. (SPT 1) said that (Client A) became resistive so he offered (Client A) his shoes and asked him to calm down. (SPT 1) said that (Client A) became agitated and he attempted to assault him with flailing his arms. (SPT) 1 said that at the time, he had (Client A’s) shoes in his hand and he attempted to block (Client A’s) flailing arms. (SPT) 1 said that after a brief moment of (Client A’s) aggression toward him, the Psychologist called for him to exit the room ..." On 10/5/06 the Psychologist was interviewed by the investigator regarding her reported allegation of abuse to the SDC Office of Protective Services: "My report to SDC is accurate ...The record should also reflect that before the staff member came to (Client A) and myself (Client A) slapped me on the shoulder. I ignored him, turned around and walked away. (Client A) remained in the room and sat back down. Then the staff approached me." NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000529 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS VIOLATED 15-1022-0003485-S Date: 11t17t2006 Time: CLASS AND NATURE OF VIOLATIONS "Regarding the actual contact, staff raised shoe behind head with right hand and came down with force on (Client A’s) left shoulder. There were two consecutive hits and I could. see these thru the reflection as well as hear the hits in the hallway" On 10/10/06, SPT 1 was interviewed by this Investigator regarding the incident: Client A and I walked off unit to meet site trainer. While walking, Client A was picking his face. I made a decision that Client A should not go to work because of his Self Injurious Behavior (SIB). 1 asked him to wait for me in the west day hall. I ran into the Psychologist who asked me what was going on. I talked with her. The next thing I saw was her running out of the room with Client A behind, her. I went into the room and asked Client A to stop, reminding him not to hit people. I requested him to come with me to the laundry. Client A then threw his shoes off. 1 picked up his shoes and requested him to put them on. He acted as if he was going to throw them again. I said to her that it looks like he is putting on a show for you. 1 turned back to Client A and he raised his hands. It appeared as he was ready to assault me. I had his shoes in my hand and I blocked the punches. The Psychologist was at the door. I did not look back at her because I needed to keep my eyes on Client A. The last I remember was her being in the doorway, t don’t recall her being in the room while I was dealing with Client A. Client A was sitting on the sofa and my back was to her. What the Psychologist saw was my a{ms moving to block Client A’s aggression, while I was holding his shoes. On 10tl 0/06 the Psychologist was informed of SPT 1 ’s description of the incident and re-interviewed regarding her allegation. The Psychologist stated that from where she observed SPT 1 and Client A, she had a very clear view of SPT l’s movements and she reiterated that she saw SPT 1 strike Client A twice on his shoulder with the client’s shoe. The facility failed to ensure that Client A was free from physical abuse with SPT 1 hitting the client on the shoulder, twice, with the Client’s shoe. This facility failure had a direct or immediate relationship to the health, safety, or security of Client A. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTE¥ CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000530 State of California - Health and Human Services Agency Department of Public Health ,SECTI0~ 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-1284-0003625~S Date: 01t10/2007 Time: Type of Visit : Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Tefephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) Incident/Complaint No.(s) ¯ CA00083935 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA Type of Ownership; 95814 State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000 Arnold Dr Eldridge, CA 9543t Intermediate Care FacilitytDeve]opmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B Capacity: 581 PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 1/24/07 6:00 a.rn. CITATION -- PATIENT RIGHTS 76525(a)(20) Clients’ Rights (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, .excessive medication, abuse or neglect. The facility failure to comply with the above regulation by failing to prevent Client I from biting vulnerable peers failed to ensure the peer clients’ rights to be free from harm including abuse, as follows: On 11/28/06, a review of Client l’s clinical record revealed an annual assessment dated 10tl 9/06 documented 22-year-old Client 1 had severe mental retardation and autism and was institutionalized at age 16 after beginning to bite family members. Client 1 was admitted to the facility on 7f19/05 for stabilization after sustaining a leg fracture in the community. The assessment indicated the clients on the unit were mostly nonverbal and Name of Evaluator: Linda Lucey HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000531 State of California - Health and Humar~ Services Agency ,SECTION "1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Deparlment of Public Health Page 2 of 3 15-1284-0003625-S Date: 01f10t2007 Timei CLASS AND NATURE OF VIOLATIONS relatively passive, while Client 1 is a quick learner and vulnerable to sensory over stimulation. Review of a semi-annual assessment dated 4/25t06 indicated the leg fracture was healed on 12t1105 and Client I had exhibited only minor hitting behaviors while recovering. Review of interdisciplinary notes documented on 116/06 Client 1 bit Client 2 on the arm after being re-directed by staff. On 1/14/06, Client 1 was re-directed to a group activity and without antecedents reached over and bit Client 2 on the abdomen. Notes of 3/5/06 indicated Client 1 bit Client 2 on the back after a staff re-direction. Notes of 4/28106 documented Client 1 bit Client 3 at the work site without provocation or antecedents. Notes of 6115f06 indicated Client 1 was in the family room and bit Client 4 without showing antecedents. On 6/20/06, Client 1 bit Client 5 while being re-directed by staff. Notes of a client protection meeting held on 6/23/06, after the sixth biting incident, indicated the .interdisciplinary team planned to create separate behavior plan just for biting. Review of a behavior plan dated 8/1/06 indicated the target behavior was aggression manifested by slapping, hitting, biting or pushing others. There was no separate behavior plan for biting. Review of the facility document entitled, "Family 2 Windows" (a cue sheet used by direct care staff) did not indicate Client l’s aggressive behaviors included biting others. Notes of 9/20/06 documented Client 1 bit Client 6 on the shoulder resulting in teeth marks and bruising. On 9t26/06 Client 1 came up from behind and bit Client 7 on the upper back. On 9t27/06, Client 1 bit Client 7 at the classroom site. Notes of a client protection meeting held on 9f28/06 documented the interdisciplinary team’s decision to revise the behavior plan. Notes of a client protection meeting held 10t5/06 after a total of 9 bites to peers, indicated the classroom teacher called psychologist to request revisionsto the behavior plan. The notes indicated the behavior plan would be revised. Notes of a client protection meeting held I0tl 1/06 indicated Client I bit Client 8 on 10t6t06. The notes indicated the psychologist was currently revising the behavior plan. Notes of a client protection meeting held on 11/22/06 documented the psychologist continued to work on re-developing the behavior plan, Notes of 11t27/06 documented Client 1 bit Client 9 on the shoulder. During interview on 11t28/06 at 4 p.m., after Client 1 had bitten vulnerable peers a total of 11 times, the unit supervisor stated the behavior plan revisions were not done as planned by the team on 6/30t06, 9/28t06, and I0/05/06 because the unit psychologist had left and psychologists from other units were covering while the unit’s position NOTE: IN ACCORDANCE WITH CALIFORNIA.HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000532 State of California - Health and Human Services Agency SECTtO’N 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Heatth Page 3 of 3 "15-1284-0003625-S Date: 01110/2007 Time: CLASS AND NATURE OF VIOLATIONS remained vacant. On 1217/06 a second review of the record revealed notes of a client protection meeting held 11/29/06 indicated the behavior plan had been revised. Review of the behavior plans indicated a revised plan dated 11t29f06. The plan stated.Client 1 should be directed to a quiet area when agitated. The plan indicated staff should offer choices of activities in the quiet area. Once Client 1 was engaged in an activ!ty staff should allow her some private time with frequent checks. If Client I exited the quiet area after being calm staff should provide close supervision for fifteen minutes. If Client 1 exited the quiet area while agitated, staff should redirect her back to the quiet area. Subsequent interdisciplinary notes of 12/4/06 indicated Client 1 was moving ,toward a peer and was redirected to her room. The notes documented Client 1 exited her room and bit Client 10. The notes did not indicate the revised preventive interventions in the behavior plan were implemented. The facility failed to prevent Client 1 from biting peers and inflicting harm over a period of 12 months. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000533 State of California - Health and Human Services Agency Department of Public Health SECTION 1424.. NOTICE Page 1 of 4. CITATION NUI~IBER: 15-0706-0003996-S Date: 06t05/2007 Time: Type of Visit ’ Complaint tnvestig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76315(b) IncidenttComplaint No.(s) ’ CA00109210 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP 1CFDD 15000 Arnold Dr EIdridge, CA 95431 Intermediale Care FacilitytDeve!opmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $700.00 Capacity: 581 DEADLINE FOR COMPLIANCE 6/19/07 6:00 a.m. CITATION .- PATIENT CARE 76315(b) Developmental Program Services-Individual Program (b) The individual program plan shall be implemented as written, The facility failed to implement the individual program plan as written. On 03/19/07 at 9:30 a.m., Staff A was interviewed. According to Staff A, on 03/14/2007 he had been assigned to provide direct supervision for Client 1. On that date, at about t0:30 a.m., he and Staff B and approximately six clients were in an activity/classroom located in the facility’s Oak Valley School. Staff A stated that he had accompanied Client ! while the client made a food selection from a vending area just outside the activity room. Staff A stated that normally Client 1 selects a pudding and that is what Staff A would have preferred for him to purchase. However, puddings weren’t available. Client 1 selected a package of cookies. Staff A stated that he and Client 1 returned to the activity room where Staff A broke up the cookies into a bowl. Client 1 began eating the cookie pieces according to Staff A. At this point Staff A told Staff B that he was going to accompany another client out of the room to make a food selection. Staff A asked Staff B to observe Client 1. According to Staff A, as he was leaving the room he heard Staff B calf out to him that Client 1 was choking. Staff A stated that he returned to Client 1 and determined that he probably needed the Heimlich maneuver (abdominal Name of Evaluator: George Ely Health Facilities Eval. Nurse Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000534 State of California - Health and Human Services Agency bepartmenl of Public Health. SECTION 1424 NOTICE Page 2 of 4 cI’rA~ION NUI~BER: SECTIONS VIOLATED 15-O706-0003996-$ Date: 06/05/2007 Time: CLASS AND NATURE OF VIOLATIONS thrust). StaffA stated he performed the Heimlich maneuver and food "popped out." On 03/19/07 at 10:40 a.m., Staff B was interviewed. According to Staff B she and Staff A and approximately nine clients were in an activity room in the Oak Valley School on 03t14/07. Staff B stated that she was "balancing the clients’ money." Staff B stated that Staff A had been taking the clients one at a time out of the activity room to purchase items..Staff B recalled that Staff A broke a cookie up into a bowl for Client 1. According to Staff B, Staff A told her he was going to accompany a client out of the room and asked her to watch Client 1 while the client was eating the cookie. Staff B stated that at this time she would have been supervising a total of eight clients. Staff B stated that Staff A was proceeding out of the room when she observed Client 1 to be choking. Staff B stated that she called out to Staff A to tell him Client 1 was choking. Staff B stated that Staff A returned to Client t and then performed the Heimlich maneuver on Client !. Staff B stated that she felt that the staffing in the activity room is not adequate in numbers on the one day per week that clients are escorted out of the room to make purchases; since one staff person is left alone to supervise all the remaining clients. On 03/19/07 at 10:10 a.m., Staff C was interviewed. According to Staff C she was on duty as a Supervisor on 03/14/07 in the vicinity of the Oak Valley School activity room containing StaffsA, B and their clients. Staff C recalled that she was told Client 1 had choked. Staff C responded to the activity room where the incident had occurred. She observed Client 1 and stated that he appeared to be fine. Staff C stated that she knows that Client 1 has a slight dysphagia and is at risk for choking if he eats whole foods. She stated that Client 1 ate a mechanically soft diet and that staff try to steer him away from certain food items when he makes purchases. Staff C stated that the cookies Client 1 had purchased probably should have been modified with milk or some other liquid. Staff C stated that she was not aware at first that a Heimlich maneuver had been done on Client 1. Once she was made aware that the maneuver had been performed, Staff C started making notifications to other staff to have Client 1 assessed. According to Staff C, the number of staff in the activity room where the incident occurred was normal on 03t14/07. On 03119/07 the following information was found in Client 1 ’s clinical record According to an IPP (Individual Program Plan) note dated 10/4/06, Client 1; "is at risk for aspiration secondary to dysphagia and receives an appropriate diet." According to a physician’s order dated 02/27/07 Client l’s diet was "Modified Ground NOTE; IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000535 State of California - Health and Haman Services Agency Department of Public Health SEC’rlON 1,424 NOTICE Page 3 of 4 CITA~ION NUI~BER: SECTIONS VIOLATED 15-0706-0003996-S Date: 06/05/2007 Time: CLASS AND NATURE OF VIOLATIONS Small portion ...check food to insure proper consistency. ---Avoid hard, sticky, crunchy andtor particle foods. ---Alternate liquids and solids." A physician’s note dated 03/15/07 indicated, "S - staff report choking incident 3/14 given dry broken cookies required Heimlich to clear airway. O ~ unable to examine client. A - choking (secondary to) dry crunchy food." IDN (interdisciplinary notes) dated 03/14/07 in Client l’s record stated, "Upon picking up a cookies from Oak Valley store for clients hold every Wednesday the client was feed a crushed version of the cookies. The client choked upon taking a small portion of it for about 7 second. The hamlet maneuver was applied and all the throat obstruction went out ..." Service/Health Care Objectives and Plans for Client 1 indicated the following: Plan P-3-5, updated 03/07107 * Step 5, "Diet = MODIFIED GROUND with SMALL PORTIONS ...Avoid any hard, sticky, crunchy, or particle foods." * Plan X-2, updated 10t31/06 Step 2, "Observe and report difficulties in chewing, swallowing, signs of choking to MD, HSS, OTR (SLP), and/or RD. Step 11, "Dining pace should be unhurried. Allow mouth to be clear of food. Observe for normal breathing after swallow. Step 12, a) Diet consistency: MMS. Check food to ensure proper consistency before serving. Avoid: hard, sticky or dry crumbly foods. Step 13, Feeding Interventions/Strategies. (Client 1) demonstrates tendency to overstuff. Close supervision due to risk of choking." According to a menu card for Oak Valley School, Client 1 was to receive a diet of "MGrd Small ...Avoid hard, sticky, crunchy foods. Check food for proper consis. Alternate liquids and solids. " According to a document titled Family il, Osborne, Client 1, "will 1) Put bite-sized portion of food inmouth. 2) Swallow first bite before putting next bite into mouth X3." On 04tl 1/07.Consulting Staff D was interviewed regarding Client l’s diet order. Staff D reviewed Client l’s diet order and ServicetHealth Care Objectives and Plans. Staff D reviewed the information describing the type and consistency of food (cookies) provided to Client 1 on 03It4/07. According to Consulting Staff D, providing Client 1 with NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAI=TEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000536 State 0f California - Health and Human Services Agency Department of Public Health SECTION ’1,424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS VIOLATED 15-0706-0003996-S Date: 06/05/2007 Time: CLASS AND NATURE OF VIOLATIONS crumbled cookies did not conform to the physician’s order or to the client’s care plan for eating and was probably an unsafe practice. On 04/12107 Staff E was interviewed regarding Client l’s diet order, dining care plans and the facility diet manual. The choking incident involving Client 1 was also discussed. According to Staff E, providing Client t with a crumbled cookie did not comply with the physician’s orders, ServicetHealthcare Objective and Plans and the facility diet manual. Staff E stated that exceptions to the diet manual can be made, but she felt that any exceptions should be addressed in the physician’s orders. Staff E provided copies from the facility diet manual describing a modified ground diet (Client l’s diet). According to the manual a modified ground diet includes, "Cakes, pies & cookies to be modified to mousse-like consistency." A diet of Ground Texture/Modified Ground includes, "Moistened soft cookies ..,Cakes, pies, and cookies to be modified to moist mouse-like consistency." The facility Nursing Procedure Manual contains Procedure R 707, Airway Obstruction, reviewed September 2006. The purpose of the procedure: "To prevent complications related to choking, and assure patent airway. Under STEPS, number 1 is, "Prevent choking episodes by: a. Providing proper diet consistency as ordered by physician." This facility’s failure to implement Client l’s plan of care regarding diet consistency and supervision while eating subjected Client 1 to a negative outcome involving the use of an urgent procedure (abdominal thrusts), not without potential serious risks for the client. The violation of this regulation had a direct or immediate relationship to the health, safety, or security of clients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000537 State of California - Health.and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 4 CITATION NUMBER: 15-1594-0003172-S Date: 06/13t2007 Time: Type of Visit ¯ Complaint Investig. YOU ARE HEREBY FOUND 11’4 VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facili~.y Name: Address: Telephone: Facility Type: Faci.lity ID: SECTIONS VIOLATED 76525(a)(14) 76525(a)(14) tncidenttComplaint No.(s) " CA00110359 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD Eldridge, CA 95431 15000 Arnold Dr Intermediate Care FacilitytDevelopmentally Disabled Capacity: 581 150000230 CLASS AND NATURE OF VIOLATIONS CLASS PENALTY ASSESSMENT $700.00 trebled to $2,100.00 DEADLINE FOR COMPLIANCE 6/22/07 6:00 a.m. B CITATION -- PATIENT RIGHTS 76525(a)(14) Clients Rights’ (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (14) To dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs. 76525(a)(20) Clients Rights’ (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section, Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. Name of Evaluator: Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE CAROL DEVITA I-IFEN Signature : Name : ~vatuator Signature Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000538 State of California - Health and Human Services Agency Department of Public Health SECTION t424 NO3"ICE Page 2 of 4, CITATION NUI~IBER; SECTIONS VIOLATED 15-1594-0003172-S Date: 06/13/2007 Time: CLASS AND NATURE OF VIOLATIONS The facility failed to comply with the above regulations by failing to ensure a client’s right to dignity and respect and by failing to ensure the right to be free from harm, including abuse, when staff, providing 1:1 supervision, was observed striking a client in the head and shoulder while being treated in a local emergency department. Physician’s Progress Notes, dated 3/22/07, revealed Client 1 was noted to have a 3-4 cm. raised mass over the left anterior lower rib cage, with no evidence of trauma. Interdisciplinary notes, dated 3/23/07 at 12:20 p.m., revealed that an x-ray revealed two left rib fractures and fluid within the pleural cavity (a fluid filled space that surrounds the lungs). The x-ray report (draft) of the left ribs, dated 3/23t07, was compared with films from 7t14/98 and revealed old fractures of the left 10th and 1 lth ribs, consistent with non healing fractures. Client 1 has a history of self injurious behaviors. The client was sent to an acute care hospital on 3/23/07 at t2:50 p.m. for a thoracentesis (insertion of an instrument into the pleural cavity to drain fluid) with removal of 1400 cc’s of blood tinged fluid. He returned to the home unit at 3:50 p.m. Later that evening at 9:30 p.m., Client 1 developed a temperature of 100.5 and was noted to have decreased breath sounds and crackles on the left side. He was transferred back to the acute care hospital with a 1:1 and licensed personnel at 10:20 p.m. He was found to have a re-accumulation of the left pleural fluid with possible pneumothorax (accumulation of air or gas in the pleural cavity). A chest tube was inserted with a removal of 400 ml. of fluid, and he was later admitted. Documentation from the emergency department nursing flow sheet, dated 3/23/07, included the following entries: 2300- Labs drawn. Patient with sitter at bedside. 2335 - Patient in the room hitting arm on bed rail. Bed rail padded. 0000- Patient sleeping. "Pt. (patient) with sitter behind closed curtain-pt, hitting rail with r. (right) arm-nurse (name inserted) peeked behind curtain and nurse observed sitter hit pt in r. shoulder very hard. @ 0050. Again I the nurse Observed (unable to read) 0051. I peeked behind the curtain and observed the sitter hit the pt. very hard in the LT (left) side of the pt’s head," During an interview with RN emergency room staff on 4/02/07 at 10 a.m., staff stated that two caregivers came in with the client and there were no behavior problems noted NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000539 State of California - Health and Human Services Agency Department of Public tdealth SECTION 1424 NOTICE Page 3 of 4 ’ CITATION NUI~IBER: SECTIONS VIOLATED 15-1594-0003172-S Date: 06t’13/2007 Time: CLASS AND NATURE OF VIOLATIONS at that time. The client wore a helmet I mask. When the shift changed, and the new 1:1 staff arrived, she noted that the client’s behaviors changed and he began to hit the rail. RN staff Stated that she witnessed facility staff (assigned as a 1:1) hit Client 1 on two occasions. The RN stated that she heard a "ruckus" coming from the client’s room, (room 2). The curtains were closed but she was able to lean back on her stool to visualize the client. She saw Staff A standing over the patient and observed his left hand go across the client’s right shoulder. In less than a minute’s time, she noted Staff A take his right arm and hit the client’s left side of his head while he was wearing his helmet. She stated that she then swung open the curtain. She stated that the 1:1 staff never turned around nor did he have any communication with her. Review of a signed declaration from RN staff, dated 5/26/07, revealed, "The sitter never turned around, I stood there waiting for him to turn around and look at me, he never did." She stated the patient was hit one time in the head, a " big swipe," more forceful than the hit to the shoulder. Additional documentation in the signed statement from the RN revealed .... hit Client 1 in the" left side of his helmet (on his head) wlgreat force." On 4/5/07 at 1 p.m., an interview was conducted with StaffA, the staff that provided 1 :I supervision. Staff A stated that at approximately 10:45 p.m. on 3/23/07, he relieved two staff from the p.m. shift to provide 1:1 supervision to the client at night. He stated that he was familiar with Client 1, as he was also the Client’s 1:1 on the home Unit one to two times per week on the night shift. He stated that the client normally has temper tantrums every night and bangs his hand. He was banging his hand on the bed rails once every couple of minutes. Staff A stated," He kept banging the rail. He was scared. I would grab him by the wrist to get him to stop. It happened 30 times on the bed rail." Staff A further stated that the client wore a helmet, facemask, jumpsuit, ~nd posey mitts for self protection. Staff A further stated that on eight, occasions, the client turned sideways, pushed on the bed rails, and would scream because he did not like to be moved. He stated that, " I would grab his ankle and shirt to rotate him." Staff A stated that he had trouble grabbing his shirt on two occasions. " I was afraid he would break something and did a fast rotation and grabbed the mask and right or left ankle to reposition him. He would scream, blood curdling, at one point." Staff A further stated that while banging his arm NOTE: IN ACCORDANCE WITH CALIFORNIA HEAL3rH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000540 State of California - Health and Human Services Agency Departrnenl of Public Health SECTION 1424 NOTICE Page 4 of 4 ClT.~,TION NUMBER: SECTIONS VIOLATED "15~1594-0003172-S Date: 06113t2007 Time: CLASS AND NATURE OF VIOLATIONS he "tried to grab me." He stated that one of his mitts had a hole in it and three fingers were exposed, He stated that the client reached near the side of his left upper chest area. Staff A stated, "At that point I went with a "shove" to his right shoulder to defend myself. Staff A further stated that throughout the whole thing he was "patting his head, back, and face mask," as that usually calmed him down, Staff A stated that it was done " heavy handed " and" man to man" and the client generally did not have a problem with it. He stated that he did this to the top of his arm, top of his head, leg, and to the front of the mask. He stated, "That is my style to calm him down." The facility failed to ensure that Client 1 was treated with dignity and respect and was kept free from the harm of abuse while ill and hospitalized in a possibly unfamiliar environment with unfamiliar staff. These actions may have.potentially caused anxiety and an increase in Client l’s behaviors. The violations above had a direct relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000541 State of California - Health and Human Services Agency Departmenl of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-0786-0004103-S Date: 08113/2007 Time: Type of Visit: Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facilif.y ID: SECTIONS VIOLATED 76525(a)(20) 76525(a)(14) Incident/Complaint No.(s) ¯ CA00119362 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 t 50000089 SACRAMENTO, CA 95814 Type of Ownership: Slate Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care Facility/Developmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $9oo.oo CLASS B Capacity: 581 DEADLINE FOR COMPLIANCE 8t20/07 6:00 a.m. CITATION -- ABUSEIFACILITY NOT SELF REPORTED 76525(a)(14) Client’s Rights (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (14) To dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs. 76525(a)(20) Client’s Rights (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. Based on interviews and record reviews the facility failed to comply with the above regulations by failing to ensure two clients right to dignity, privacy, respect and humane care in treatment and in care for personal needs for Client’s 2 and 3, and by failing to ensure residents were free from harm and abuse. 1. According to a written statement submitted 7t2/07 at 8:30 a.m., StaffA stated that he Name of Evaluator: Ann Fitzgerald HFEN Without admitting guilt, I hereby acknowledge receipt of thfs SECTION 1424 NOTICE Signature " Name ¯ Evaluator Signature Title ¯ NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000542 State of California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 2 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 15-0786-0004103-S Date: 08113/2007 Time: CLASS AND NATURE OF VIOLATIONS and Staff B went to check on Client 3 at 6:30a.m., on 7/2/07 and observed that Staff C was in the midst of changing Client 3. Staff C became angry and mad and yanked the pad from under the client. During an interview on 7/10/07 at 8:00 a.m., StaffA stated that he asked Staff C if Client 3 was wet. Staff C said "yes this shit is happening everyday" and she’s "tired of changing her." Staff C then yanked the pad from under Client 3 which was not wet and Staff A and B left the room. According to the written statement submitted by Staff B on 7/2/07,. staff B witnessed Staff C changing Client 3 and stating "[Client 3] is always wet and I’m tired of changing her and stripping her bed, this shit happens every morning". Staff C then moved the client’s legs and yanked the attends from under the client. During this time the client was stating:. "No, No" that she didn’t want to get up. Staff A stated he would change the client but Staff C started yelling again. Staff A closed the door. Duringan interview on 7/10/07 at 8:30 a.m., Staff B stated that she accompanied Staff A to Client 3’s room. Staff C was changing her and yelling: "she’s wet she’s always wet I’m tired of atways changing this group cause they’re always soaking wet." Staff A offered to change the client and Staff C said " I11 change her damn it." Then Staff C grabbed the attends from under the client and Client 3 yelled’ No, No I don’t want to get out of bed." Client 3 is a 55 year old with spastic quadriplegia and depression admitted to the.facility 9/29t89. The client functions within the severe range of developmental disability. Her self care and adaptive social abilities appear to fall. more at the profound range of disability. Transfers are totally dependent using a mechanical lift. Client 3 is able to assist only minimally with her ADL (activities of daily living) because of limits in fine and gross motor control. According to the client record there was no injury sustained by the client from the rough treatment. On 7/10/07 at 8:40 a.m. attempts were made to interview Client 3 however they were not successful. A psychologist note dated 7t3/07 indicated that during an interview on that date, Client 3 acknowledged knowing Staff C and when asked if Staff C had ever yelled at her she said "yes". When asked if Staff C ever hit her she stated "No". 2. On 7t10/07 at 8:45 a.m. during an interview Ctient 2 was asked if Staff C yelled at her. She said "yes". Client 2 was asked if she had been yelled at before and she said "Yes". NOTE: tN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000543 State of California - Health and Human Services Agency Department of Public Health SE~CT’ION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECT;ONS VIOLATED 15-O786-0004103-S Date: 08f13/2007 Time: CLASS AND NATURE OF VIOLATIONS Client appeared tearful. Asked if other staff yell at her the client said "No". Client 2 is described in her IPP (Individual Program Plan) as able to participate in decision making and very good at making her needs known with words and signs. A facility reported incident dated 7/12/07 indicated that Client 2 asked to speak to the psychologist. Per this interview Client 2 repeated Staff C’s name several times with a pained and sad expression on her face and teary eyes. She was asked "Did [Staff C] yell at you.’?" Client 2 said "Yes" and nodded her head. The psychologist then asked if Staff C ever hit her and she said "Yes". The psychologist asked where and Client 2 tapped the back of her right shoulder with her right hand, then carefully punched the side of her left shoulder with her right hand and looked straight at the psychologist with a frightened face. Client 2 was asked if she was sure and the client nodded "yes". According to a written statement by Staff B dated 7/2/07, Client 2 has frequently been seen crying and looking depressed after contact with Staff C. When asked what was wrong Client 2 would say the name of Staff C ". During an interviewon 7/10/07 at 8 a.m., Staff B stated that Client 2 would come out of her room with her.head in her hands and when asked what was wrong would state Staff O’s name. During an interview on 7110t07 at 9 a.m., Staff D stated, ’Tve seen [Staff C] yelling at [Client 2] with a lot of intimidation in her tone of voice and manner. I’ve seen Client 2 react in a fearful way. She would follow me and then point to Staff C." In summary, the facility failed to ensure two residents right, Clients 2 and 3. To dignity, privacy, respect and humane care in treatment and in care of personal needs, and by failing to ensure that residents were free from harm and abuse. This failure had a direct or immediate relationship to resident health, safety and security. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000544 State of California - Health and Human Services Agency Department of Pub;ic Health SECTION 1424 NOTICE Page 1 of 3 CfTATION NUMBER: 15-1022~0004239-S Date: 09t11/2007 Time: Type of Visit : Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID; SECTIONS VIOLATED 76315(a) (4) 76525(a)(20) Incident/Complaint No.(s) : CA00123954 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000 Arnold Dr Eldridge, CA 95431 Inlermediate Care Facility/Developmentally Disabled 50000230 CLASS AND NATURE OF VIOLATIONS CLASS B . Capacity: 581 PENALTY ASSESSMENT $700.00 trebled to $2,100,00 DEADLINE FOR COMPLIANCE 9/19/07 6:00 a,m. CITATION-- PR,C 76315(a)(4) Developmental Program Services-Individual Program (a) Each client shall have an individual program plan that: (4) Identifies the client’s developmental, social, behavioral, recreational and physical needs. 76525(a)(20) Clients’ Rights (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facifity shall establish and implement written policies and procedures to ensure that each client admitted is afforded the foflowing rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to identify Client A’s need for a behavior plan to address his repeated elopements from his unit of residence and failed to provide adequate supervision to maintain his right to be free from harm. Findings: On 8t17/07 the facility initiated an Incident Report (IR) regarding an absence without Name of Evatuator: Jose Figueroa HFEN Wilhout admitting guilt, I hereby a(~knowledge receipt of this SECTION I424 NOTICE Signature : Name: Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000545 State of California ~ Health and Humar~. Services Agency Department of Public Heall.h SECTION 1424 NOTICE Page 2 of 3 ’CITATION NUMBER: SECTIONS VIOLATED 15-1022-0004239-S Date: 09t11/2007 Time: CLASS AND NATURE OF VIOLATIONS leave (AwoL) of Client A, who has a history of seizures and whose level of supervision is documented as "constant", when outdoors or in unfenced areas: The Program Assistant reviewed the IR on 8/21/07, at 12:00 p.m. and provided the following information regarding the AWOL of Client A: "[Client A} eloped from Malone while his regularly scheduled group leader was on lunch break. [Psychiatric Technician 1] was assigned supervision of [(Client A’s] group at the time he walked away from Malone...This writer [Program Assistant] reviewed [Client A’s] record and found no plans for elopement. [Client A} has had at least 3 AWOL episodes this year. Spoke with Unit Supervisor [(US)], Psychologist and Individual Program Coordinator, directed them to develop Behavior Plans, and review at weekly Client Protection and Prevention meeting. Plan of Correction is to supervise [Client A} closely during transition times, staff lunch break times, when other clients-are .leaving residence, or any time when [Client A} is prone to take opportunistic advantage of elopement situations..." While Client A was AWOL, he was observed by Psychiatric Technician Assistant 1 (PTA 1) who was on his lunch hour. PTA 1 narrated the following report to PT 1: "[PTA.i] had walked from GAC [(General Acute Care)} on his lunch hour down Holt Street and crossed Arnold Drive to the Ceders Unit side when he saw [Client A} walking on the same side toward the bridge. He recognized him and wondered why he would be out alone because of his seizure risk so decided to observe him and see what he was going to do.. [Client A} continued to walk without stopping and before he reached the end of the sidewalk, [PTA i] ran up to him and told him that when he was ready to go back to Malone, he would go with him. Just about that time [a staff person from Sequoia] stopped by and [PTA 1] asked if she would call Malone and tell them where [Client A} is and [PTA 1] would try to walk him back...When they reached the James Unit side lawn area, [Client A} tried to kneel down on the grass and then slumped down to his left side with mild seizure activity for approximately 10 seconds. Then [Client A} tried to get up and [PTA 1] supported him as he was in crouched position. The seizing continued so [PTA 1] laid [Client A} on the right Side approximately 1 minute. [PTA 1] saw a staff member from James and asked him to call Malone and about the same time [DR. S} and [Acting Coordinator of Nursing Services, (ACNS 1)] were exiting James and came to assist. [PTA 1] stayed until Malone staff arrived and [ACNS 1] dismissed him." NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000546 State of California - Heatth and Human Services Agency Page 3 of 3 ¯ SECTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED ¯ Department of Public Health I5-1022-0004239-S Date: 09t11/2007 Time: CLASS AND NATURE OF VIOLATIONS A review of Client A’s clinical record on 8/28t070 confirmed that he had several elopements including 5t9/07 and 6/26t07 and there was no plan for Client A’s elopement behavior. On 8/28/07 at 9:30 a.m., the US was interviewed regarding the 8/17/07 AWOL of Client A: "Malone is an unlocked unit, The front door is unlocked and all but about five of our clients are allowed to come and go as they please. Of course they have to be home by curfew, but they usually follow this plan, only now an again do we have to locate them if they are late, to remind them to come home. We also have a small group that leaves the unit and goes out into the front yard by themselves without supervision. They sit out there and walk around but they don’t leave. When they travel away from the unit they are always supervised, but they are not an elopement risk just going out into the front yard. However, there are about five clients including [Client A] who have to be supervised whenever they are outside of the unit and [Client A] has managed to get out unobserved several times. It’s easy for him to do if the staff is busy, as the front door is always unlocked and as you can see the Nurses Station does not have a view of the front door". Based on the failure of the facility to identify Client A’s need for a behavior plan addressing his repeated AWOL behavior, and the subsequent failure of the facility to provide supervision and maintain his right to be free from harm, it was determined that the facility’s failures had a direct relationship to the health, safety and security of Client A. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000547 ~5tate ot L;aJ~torn~a - Health and Human Nervices Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUI~IBER: 15-0706-0004409-S Date: 10t30/2007 Time: Type of Visit ’ Complaint Investig, YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(14) Incident/Complaint No.(s) ’ CA00114870 State of CA Dept of Developmenta Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA Type of Ownership: 95814 State Agency SONOMA DEVELOPMENTAL CENTER DIP ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care Facility/Developmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B Capacity: 581 PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 11/8/07 6:00 a.m. CITATION -- PATIENT RIGHTS 76525(a)(14) CLIENT RIGHT’S (a) Each client has the .rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (14) To dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs. Based on interviews and record reviews, the facility failed to ensure that each client was treatedwith dignity, respect and humane care. On 5116107 the Department of Health Services received information from the facility that an allegation of a violation of clients’ rights involving five developmentally disabled, non-interviewabte individuals, had been made by Staff A against Staff B. On 5/12/07 Staff A completed an Incident/Unusual Occurrence Report regarding the alleged incident involving Staff B and five clients. On 5/15/07 Staff A completed an additional written statement. Staff A wrote that on 5112/07 she was in the room with Clients 1 - 5 and Staff B from 11:25 a.m. to 11:45 a.m. StaffA wrote that Staff B was the Name of Evaluator: George Ely Health Facilities Evat. Nurse Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000548 State of California - Health and Human Services Agency Department of Public Health SECTION t1424 NOTICE Page 2 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 15-0706-0004409-S Date: 10f30/2007 Time: CLASS AND NATURE OF VIOLATIONS "level of care in the room that day ..." StaffA wrote that during that entire time Staff B’s,"attitude was harsh and unprofessional." Staff A wrote that she heard Staff B make several comments to the clients in the room using an unprofessional.tone of voice. Staff A further wrote regarding the interactions between Staff B and the clients: (Client 1) was sitting in the chair with his legs crossed and sleeping and (Staff B) walked over shoved his leg aside and said, "wake up! You gonna sleep all day?! "To Client 2 Staff B said, "come on your done. Then took his plate, or ice cream away from him. (Client 3) was eating his food when Staff B walked up to him and asked him, "do you want to donate your spaghetti to (Client 4) Then he took it (Staff B) and scooped.it into (Client 4’s) plate. Mr.(Client 4) didn’t push his plate away or give any indication he didn ’ t want it. " Staff A concluded her written statement regarding Staff B: "(Staff B) at one point grumbled about ’people calling in sick, clients acting out’. But the whole time I was in the room the clients were passive and his attitude was very unnecessary. I was upset when I walked out of there. I thought that this man is in their home talking to them like this. I don ’ t think he should be with these residents, at least by himself. " On 6/21/07 at 11:00 a.m. StaffA was interviewed. According to StaffA, she had been assigned to work in the Butler Building, Sequoia residence, on 5t12/07 as a Food Service Worker. At about 11:25 a.m. she was present in a dining area on the residence with Clients 1, 2, 3, 4, 5 and Staff B. According to Staff A, Staff B was the PT (Psychiatric Technician) assigned to care for the clients. Staff A stated that she observed Staff B treat the clients in the room in a brusque and sarcastic manner. Staff A stated that she observed Staff B remove food from one client’ s plate (without the client’ s permission) and place the food onto another client’ s plate. Staff A stated that Client 1 appeared to be asleep. Staff A observed Staff B state to Client 1 words to the effect, what are you going to do, sleep all day? Staff B then proceeded to use a large sweeping motion with his arm and hand, physically forcing Client l’s legs to uncross. Staff A immediately reported her concerns about Staff B. Staff A stated that she would not want Staff B caring for her mother. During the interview, Staff A was asked about an alleged prior incident involving her and Staff B. Staff B had alleged that Staff A might be making false allegations against him due to an earlier incident in April 2007. Staff A denied that she was making false allegations about Staff B in the instant matter and stated that she wasnot present during the alleged April 2007 incident; but had heard about it after the fact. On 6/21/07 at 10:00 a.m.,Staff B was interviewed in the presence of a union NOTE: ~N ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000549 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-0706-000440.9-S Date: 10/3012007 Time: CLASS AND NATURE OF VIOLATIONS representative. Staff B agreed to talk about the alleged incident Of 5/12/07. Staff B stated that he had scraped food off of one client’s plate (with a clean spoon) onto another client’ s plate, after asking the first client’s permission to do so. Staff B stated that client 4 has a problem with falling asleep. According to Staff B, Client 4 was at the table with his legs crossed and head slumped. Staff B stated that he did physically use his hand to push on Client 4’s legs causing them to uncross. Staff B demonstrated this action by making a sweeping motion with his hand and arm. Staff B further indicated he was upset at the time because a co-worker had gone on lunch break without telling him. On 6/26/07 at 11:00 a.m. Staff D was interviewed. Staff D stated that she has known Staff B.for about 4 years and is his supervisor, Staff D stated that Staff B "doesn ’ t care what he says to people." Staff D stated regarding Staff B that, she "wrote him up" several years ago about how clients should be addressed. Staff D stated that she has warned Staff B regarding his conversations with other staff (during break time). Staff D indicated that it is not appropriate to take one client’s food, leftover or not, and give it to another client. Staff B’s verbal and physical interactions with Clients 1, 2, 3, and 4, resulted in a failure to treat the clients in a dignified and respectful manner. The violation was determined to cause or under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to the client. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000550 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 2 CITATION NUI~IBER: 15-1022-.0004532-S Date: 12/27/2007 Time: Type of Visit ¯ Complaint ]nvestig, YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APP LICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(14) IncidenttComplaint No.(s) ’ CA00130553 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 958"}4 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD Eldridge, CA 95431 15000 Arnold Dr Intermediate Care FacilitytDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $500.00 Capacity: 581 DEADLINE FOR COMPLIANCE 1/3/08 12:00 a.m. CLASS B CITATION-- PATIENT RIGHTS 76525 (a) (14) Patient Rights (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (14) To dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs. The facility failed to ensure that Client A’s right to dignity and respect were maintained when Psychiatric Technician Assistant t (PTA 1) encouraged Client A to use obscene language and gestures. Findings: The facility submitted an Incident Report (1R) to the California Department of Public Health on 10/29/07. The report stated that on 10/26/07 a female staff person reported to the Bemis Unit Supervisor an incident that occurred on Tuesday, October 23, 2007, in which she alleged that a male staff person was prompting Client A to make obscene gestures and statements. She also stated this was similar to another incident that had Name of Evaluator: Jose Figueroa HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name: Evafuator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000551 State ofCalifornia - Health and Human Services Agency Department of Public Health SECTION. 1424 NOTICE Page 2 of 2 CITATION NUMBER: SECTIONS VIOLATED 15-1022-0004532-S Date: 12127/2007 Time: CLASS AND NATURE OF VIOLATIONS taken place two or three weeks previously. The following statement was documented in the IR by Psychiatric Technician 1 (PT 1): "This writer walked up to family one doorway, asked (Client A) to come to get his medications. As (Client A) stood up and began to walk, staff member (PTA 1) grabbed (Client A’s) arm and stopped him. He told (Client A) to ’go like this’, and he held up his finger in an obscene gesture. I stated to (PTA 1) ’f just saw what you did.’ (Client A) came to med (medication) cart held up his finger in my face and said ’luck you.’ (Client A) took his medications and went back to family area. Approximately two to three weeks ago I was in the clinic when (Client A) came in to get his blood sugar checked before dinner. (Client A) repeated ’God damn you, you fucking bitch.’. I looked out the doorway and (PTA 1)was standing outside the door with both hands held up making obscene gestures, mouthing words while nodding his head. He appeared to be prompting (Client A)." On 10/29107 the Unit Supervisor (US) was interviewed regarding the incident. The US stated that PT 1 worked PMs and PTA 1 works AMs but does a lot of overtime on the PM shift. The US stated that PT1 and PTA 1 have worked together before and there has never been a reported altercation between them nor had there been any previous allegations by either of them against the other. The .US stated that Client A has used obscene language before but the staff had not observed him using obscene gestures before. The facility’s Office of Protective Services conducted an investigation of the allegation on 11/8/07. The investigation included interviews with PT 1, PTA 1 and PTA 2, a witness to the incident. PTA 1 denied the allegations and PT 1 repeated what she had documented in the IR. PTA 2’s interview i~cluded information that on October 23,2007, while Client A was sitting on a couch, he heard PT 1 call Client A over to get his medication. PTA 2 said that as Client A Walked past PTA 1, PTA 1 showed Client A the middle finger .hand gesture and said the words,’fuck you’to Client A. The facility failed to treat Client A with dignity and respect when PTA 1 encouraged and provoked Client A to make obscene gestures with his middle finger and use obscene language. These actions of PTA 1 caused or occurred under circumstance likely to cause significant humiliation, indignity, anxiety or other emotional trauma to Client A. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000552 State of California - Health and Human Services Agency Department of Public Health SECT, tON 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-1284-0004879-S Date: 04111/2008 Time: Type of Visi( ’ Complaint Investig, YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORN IA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(14) Incident/Complaint No.(s) ’ C~A00136835 State of CA Dep{ of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P tCFDD Eldridge, CA 95431 15000Arnold Dr Intermediate Care Facility/Developmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $900.00 trebled to $2,700.00 Capacity: 581 DEADLINE FOR COMPLIANCE 4/17/08 12:00 a.m. CITATION -~ PATIENT RIGHTS T22 DIV5 CH8 ART4-76525(a)(14) CLIENTS’ RIGHTS (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shail establish and implement written policies and procedures.to ensure that each client admitted is afforded the following rights: (14) To dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs. The facility failed to ensure Client 1 ’s right to dignity, privacy, respect and humane care. Client l’s conservator was overheard by facility staff speaking to Client 1 in a loud voice, physically escorting Client 1 into the hallway exposing the front of his body and physically forcing Client 1 into the shower room with Client 1 resisting the entire time. On 1f30/08, review of the Individual Program Plan (IPP) dated 6t14/07, indicated Client 1 is a very physically active 40 year old male who was admitted on 8t26/05 with diagnoses including mental retardation and autistic disorder. The plans indicated Client 1 has severe delays in expressive language ability and understands simple requests. Name of Evaluator: Linda Lucey HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000553 State of California - Health and Human Services Agency Department of Public Heallh SECT-ION 1424 NOTICE Page 2 of 3 CITATION NUIVlBER: SECTIONS VIOLATED 15-1284-0004879-S Date: 04/11/2008 Time: CLASS AND NATURE OF VIOLATIONS Review of an incident report dated 12131t07 at 10:30 a.m., Staff Member A reported an incident that occurred on 12/30/07 at 2:25 p.m. The report indicated Client 1 was in his room with his conservator with the door closed. The report stated that Staff Member A heard the conservator speaking in a loud voicestating, "Why are you doing this. You need to stop it right now. You’re making this worse. You can’t go into the community if you are acting like this." Documentation indicated the bedroom door opened and the conservator physically escorted Client 1 down the hall to the shower room area. At the door to the shower, Client 1 resisted entry by placing his hands and feet against the threshold of the door. The incident report indicated the conservator then pushed/shoved CIient 1 using her hands and then her back to force Client 1 into the shower room. The incident report stated physical escort is not a part of Client l’s IPP. Review of the interdisciplinary notes revealed a locument entitled "DOCUMENTATION OF HIGHLY RESTRICTIVE INTERVENTION (HRI)" signed by Staff Member A on 12t31/07 at 10:00 a.m. Documentation indicated Client 1 was dressed in a robe and was agitated and resistive. Client 1 had defecated in his room with his conservator present prior to the escort. Client l’s hands, robe, posterior and legs were smeared with fecal matter. During interview on 3/13/08 at 3:00 p.m., Staff Member B stated he was acting shift lead on 12/30/07. Staff Member B stated he arrived on the unit at about 2:30 p.m. and overheard the conservator directing Client 1 to the shower. Staff Member B stated Client 1 had urinated and defecated in his room and the conservator appeared angry and frustrated at Client l’s behavior. One 3/28/08, a review of a police report dated 2/29/08, indicated Staff Member A reported the incident to the facility police. The police report documented that Staff Member C told the investigating officer Client 1 came out of his bedroom wearing only a bathrobe, which was left open in the front. Staff Member C reported the conservator had a hand around Client l’s waist and was pulling Client 1 to the shower room. Client 1 appeared to be resisting. Staff Member C reported that when they arrived at the shower room, Client 1 refused to go through the doorway. Client 1 placed his hands on the sides of the door frame and locked his arms so he wouldn’t go in. Staff member C reported the conservator placed her shoulder against Client l’s back and pushed him into the shower room. The report indicated the moment he was pushed into the shower room, Client 1 showed signs of agitation and began rectal digging, making himself bleed. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000554 ,State o~ ua~ltornla ~ nealm an~ Human ~erv~ces Agency uepar[ment o; vurmc Nealm SECTION ’1424 NOTICE Page 3 of 3 CI’I:ATION NUI~BER: SECTIONS VIOLATED 15-1284-0004879-S Date: 04/11f2008 Time: CLASS AND NATURE OF VIOLATIONS Interdisciplinary notes signed on 12131/07 at 7:25 a.m., indicated that on the day before, on 12t30/07 at 2:25 p.m., "Conservator arrived ... (Client 1) became agitated and defecating (sic) in his room. Rectal digging, rectal bleeding, and obsessing on bathroom (sic). Conservator physically escorted (Client 1) to ... shower room .... (Client 1 ) refused to enter the shower room so he placed his hands on the door trim to stop. Conservator then placed her shoulder on (Client l’s) back and pushed him in ... Staff observed blood on the towel as (Client 1) was drying his perineal area." Review of interdisciplinary notes dated 12t30/07 at 10 p.m. indicated Client t, "...has needed constant re-direction to keep him from rectal digging + straining to defecate in his pants. Much spitting + continue (sic) to try to vomit...Conservator on the unit at (change) of shift. Prior to her arrival (Client 1) was calm + watching a move (with) peers. It took several hours to calm him." The facility failed to ensure Client l’s right to dignity, privacy, respect and humane care. Client l’s conservator was overheard speaking to Client 1 in a loud voice, physically forced Client 1 into the shower room with Client 1 resisting the entire time. This violation had a direct or immediate relationship to the health safety, or security of tong-term care facility patients or residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000555 State of California - Health and Human Services Agency Department of Public Health SEC’ff~N I424 NOTICE Page 1 of 3 CITATION NUNIBER: 15-2021-0004848-S Date: 04/07/2008 Time: Type of Visit : Complaint Investig.. YOU ARE HEREBY FOUND 1N VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76315(b) 76525(a)(14) Incident/Complaint No,(s) ’ CA00130310 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD Eldridge, CA 95431 15000 Arnold Dr Intermediate Care FacilitytDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $800.00 Capacity: 581 DEADLINE FOR COMPLIANCE 4/18/08 12:00 a,m. CITATION -- PATIENT RIGHTS T22 D]V5 CH8 ART3-76315(b) Developmental Program Services-Individual Program (b) The individual program plan shall be implemented as written. T22 DIV5 CH8 ART4-76525(a)(14) Clients’ Rights (a) Each client has the rights listed in (a) of this section whichshall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (14) To dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs The facility failed to comply with the above regulations by failing to: 1) implement Client l’s individual program plan as it is written; and 2) provide Client I with the right to dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs which led to Client 1 becoming.emotionally upset and due to this, became unsteady on her feet requiring staff assistance to help her maintain her balance while she was standing and staff assistance in order for her to walk to her bedroom. Name of Evaluator: Christina Mangum HFEN Without admitting guilt, t hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000556 State ot California - Health and Human Services Agency Deparf,ment ol Public Health SEC,Tli3N 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-2021-0004848-S Date: 04/07t2008 Time: CLASS AND NATURE OF VIOLATIONS On 11/1/07 at 3 p.m., review of Client l’s medical record revealed that Client 1 had diagnoses that included generalized anxiety disorder and profound mental retardation. Facility Incident Report dated 10/25/07 indicated that on. 10/24/07 at 10:30 p.m., Staff A approached Client 1, who had fallen asleep on the bench located by the nurses’ desk on the unit where Client 1 resides. StaffA removed Client l’s jacket;which she was wearing at the time, and took away her stuffed animal which she was holding in her arms. Staff A took the jacket and the stuffed animal into Client l’s room and told Client 1 that if she wanted them back, she needed to go to her room. Staff A overturned the benches to prevent Client 1 from sitting on them. Staff A indicated to the evening shift, "This is how you get Client 1 to go to bed." During this time, Client 1 was observing Staff A. Client 1 became unstable while standing and emotionally upset, requiring assistance from the evening shift. During an interview on 10/31/07 at 4 p.m., Staff C stated that Client 1 sleeps on the benches by the nurses’ desk in intervals during the night, as she feels safe when she is around staff. Client 1 will often wake up and return to her bedroom to sleep for the remainder of the night. Review of the facility document titled IPP (Individual Program Plan) Narrative, dated 3/3/07, indicated that Client 1 embodies considerable tension and anxiety, and Client l’s inability to sleep is a sign of her anxiety disorder. Review of facility document titled Individual Plan - Skill/Behavior Development Objectives and Plans dated 3/3/07, indicated that Client 1 has a target behavior RestlessnessfAnxiety, resulting in constant movement. Client I requires praise and interaction with the staff and holding soft objects; overstimulating such as anxiety-provoking situations and absence of staff supervision can contribute to her anxiety. Under the title of Prevention Strategies, it indicated that staff interaction should be in a calm and soothing voice and avoid confrontations with her. Review of the facility document titled Approaches and Strategies dated 3/9/07, indicated that if Client 1 appears anxious, staff is to provide a favorite toy o[ object for her to hold and that staff is to monitor the time Client 1 is awake during the night and record her sleep time. Listed under Training Steps, it indicated that if Client 1 requires physical prompting, she requires soft, gentle prompts, and if she becomes resistive, staff is to wait. NOTE: 1N ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY. CODE, FAILURE TO CORRECT VIOLATIONS 1S GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000557 State of California - Health and Human Services Agency Department of Public Health SEC,TION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-2021-0004848-S Date: 04/07f2008 Time: CLASS AND NATURE OF VIOLATIONS Review of the IPP dated 9/18/07, indicated that this is a six month review for Client 1 and that her anxiety level has not improved, evidenced by her being awake most nights. The facility failed to comply with the above regulations by failing to: 1) implement Client l’s individual program plan as it is written; and 2) provide Client 1 with the right to dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs which led to Client 1 becoming emotionally upset and due to this, became unsteady on her feet requiring staff assistance to help maintain her balance while she was standing and staff assistance in order for her to walk to her bedroom. These facility failures had a direct relationship to the health, safety, or security of patients. NOTE: 1N ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000558 State of California - Health and Human Services Agency Depar[ment of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-1022-0005350~S Date: 11/19/2008 Time: Type of Visit: Complaint Investig. YOU ARE HEREBY FOUND IIN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED Incident/Complaint No,(s) ¯ CA00151707 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP fCFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care FacilitytDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS Capacity: 581 PENALTY ASSESSMENT $1,000.00 trebled to $3,ooo.oo 76525(a)(20) CLASS B DEADLINE FOR COMPLIANCE 12/16108 12:00 a.m, CITATION -- PATIENT CARE T22 DIV5 CH8 ART4-76525(A)(20) CLIENTS’ RIGHTS (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility did not maintain visually impaired Client 1’s, right to be free from harm, when she was left unattended, resulting in her fail down a flight of stairs where she sustained a head injury requiring 16 sutures and 6 staples to close the wound, as follows: Findings: On 5t22t08 the facility initiated an Incident Report (IR) describing Client l’s fall: "Today May 22, 2008, a staff person who was in route to one of the classrooms at Oak Valley School observed (Client 1) walking unescorted down the halfway towards the Name of Evaluator: Jose Figueroa HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature Title ; NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000559 State of California - Health and Human Services Agency Department of" Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS 15-1022-0005350-S Date: 11/19t2008 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED stairway. Before staff could intervene, (Client 1) fell down the stairs. As a res’ult of her fall, (Client 1) sustained a jagged laceration to the right side of her forehead. Staff immediately initiated first aid to control the bleed from wound and called an emergency code. (Client 1) was stabilized by the Code Team and then was transported to the trauma center at Santa Rosa Memorial Hospital for further assessment and treatment. A report from Santa Rosa Memorial hospital indicated that (Client 1) had sustained a concussion in addition to the laceration on her forehead. (Client 1’) laceration was closed with 16 sutures and 6 staples..." Review of facility documentation contained the following information: "Client arrived at Oak Valley via Facility Transportation. Ambulatory individuals are escorted off the bus first and second those requiring wheelchair assistance are assisted off of the vehicle. Three staff are involved; one assists the ambulatory to the class and then stays with them as the remaining staff assists those in wheelchairs through the hall to the classroom. Once all clients are safely in the classroom and accounted for, staff huddle and designate zones. The first staff lunch is scheduled to begin at 0930 a.m. Reporledly this did no occur today. Psychiatric Technician Assistant 1 (PTA 1) escorted the ambulatory clients to the classroom and then left. [PTA 2] states she heard bus driver tell [PTA 1] that she would wait for her at the other end of court yard...[PTA 3] saw somebody walking in the hall but did not know it was [Client 1] until she got to the fire doors. There she screamed for other staff and started to run. No staff were able to reach her and she turned the corner into the stairwell and fell striking her head on the cement floor..." Further review of facility documentation revealed the following information: "Employee (PTA 1) was responsible to escort 5 visually impaired clients from the vehicle to the classroom and then to remain until the others arrived. Those individuals are (Clients 2, 3, 4) and (Client 1). When (Client 1) fell, (Client 2) was still in the hallway, the others were in the class. PTA 2 and PTA 3 wrote the following statements regarding the incident. PTA 2:"1 was the last person to get out in the bus. While in the process of walking down the hallway near class room f, I heard [PTA 3] at the double door, who is that down on the stairway, its [Client 1], and I said run [PTA 3], but [PTA 3] said ’She is down the stairs already’ When I came to the class room [PTA 1] is not here. She did not check out with another PTA and she did not check out with me." NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000560 State of California 4 Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-I022-0005350-S Date: 11t19t2008 Time: CLASS AND NATURE OF VIOLATIONS PTA 3:. "While I was pushing two clients in a wheelchair in the hallway from. that fire door, I saw a person walking toward the hallway near the stairs but I wasn’t sure it was our client because I didn’t see good and I keep walking. When I was nearer t saw it was our client near the top the stairs...it was [Client 1] and there she fell." PTA 1 was interviewed on 7/15/08, at 9:15 a.m., regarding the incident: "1 came from the unit with the bus. We unloaded the clients at entrance and then I walked with them past the double doors and into the class room. We had three staff on, [PTA 2], [PTA 3] and myself. [Client 1] was walking by herself, she is independent. She was behind us. All of the clients were taken to the classroom. [PTA 2] and [PTA 3] were pushing clients in wheelchairs. [PTA 2] told me to go with the bus going back to the unit. They were in the hallway. [PTA 2] told me to go ahead and go. I want back to bus with the driver to get more clients. [Client 1] was with my group going to class room. As 1 left to go to the bus I passed by [PTA 2] and [P-I-A3] in the hallway." A review of Sonoma Developmental Center Administrative Directive for Supervision of Clients indicates in 1.2 Assessment of Supervision Needs: "For all levels of supervision.., staff will not reduce their assigned client’s level of supervision until another employee has assumed the same level of responsibility .for the client." The facility failed to maintain Client 1 ’s rights by failing to ensure that staff supervises clients to ensure their right to be free from harm. This failure had a direct relationship to the health, safety, and security of Client 1. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR, REVOCATION OF YOUR LICENSE DPH POD 000561 State o! ual.orn~a - Health ancl Human ~erv~ces Agency uepartment o~ r-uonc Hea~tn SECTION ..! 424 NOTICE Page 1 of 2 CITATION NUI~IBER: 15-1284-0006100-S Date: 0413012009 Time: Type of Visit’Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNtA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED Incident/Complaint No.(s) " CA00169241 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP 1CFDD Eldridge, CA 95431 15000 Arnold Dr Intermediate Care FacilityfDev.elopmentally D sab ed Capacity: 581 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $1,000.00 trebled to $3,000.00 76525(a)(14) CLASS B DEADLINE FOR COMPLIANCE 5/11/09 12:00 a.mo CITATION-- PATIENT RIGHTS T22 DIV5 CH8 ART4- 76525(a)(14) (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (14) To dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs. Based on interview and record review the facility the facility failed to comply with the above regulation when Staff A failed to follow the behavior plans and used harsh tones and demeaning words when speaking to Client 1, as follows: Findings: During an interview on 12t15t08, the Unit Supervisor stated she was monitoring the halls on 10/23/08 at 8:50 a.m. when she overheard Staff A yelling with a harsh angry voice, ’Tm tired of you. I’m not going to help you." The Unit Supervisor stated Staff A, "Called [Client 1] a monkey" and threw a pair of her shorts down on a table. The Unit Supervisor Name of Evaluator: Without admitting guilt. I hereby acknowledge receipt of this SECTION 1424 NOTICE Linda Lucey HFEN Signature : Name : Evaluator Signature Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000562 Page 2 of 2 SECTION ,1.424 NOTICE CITATION NUMBER: ¯SECTIONS VIOLATED 15-t284-0006100-S Date: 04/30/2009 Time: CLASS AND NATURE OF VIOLATIONS stated she observed Client 1 was in a corner with her hands in a defensive position. The Unit Supervisor stated Client 1 was agitated after the incident exhibiting behaviors including being loud and striking out at other clients. Review of an annual assessment dated 4t3t08 documented Client 1 had diagnoses including Severe Mental Retardation, Autism, and Generalized Anxiety Disorder. Client 1 exhibited maladaptive behaviors including agitation, purposeful wetting, harm to self, and harm to others. Review of Client l’s behavior plan dated 4t3/08 indicated interventions included, "Always greet (Client 1) warmly when you see her ... Be aware of your tone of voice when working with [Client 1] ..." (and) "... If [Client 1] wets herself.., use the methods ... such as ... responding in a non-reactive manner, and instructing her to go to her room and change into clean clothes by herself." During interview on 12/16f08, Staff A could not describe Client l’s behavior plans. The facility failed to ensure Client l’s right to dignity, privacy and humane care when Staff A failed to follow the behavior plans, used harsh verbal tones, and called Client 1 a "monkey". Client 1 exhibited agitation after the incident. This facility failure caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000563 State of California - Health and Human Services Agency Department of Public Health SEC’I’ION 1424 NOTICE Page 1 of 4 CITATION NUMBI=R: 15-0786~0006070-S Date: 01/05/2010 Time: Type of Visit ’ Complaint Investig, YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALl FORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(7) IncidenttComplaint No.(s)’ CA00179705 State of CA Dept of Developmental Services 16009TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care Facility/Developmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $1,000.00 Capacity: 581 DEADLINE FOR COMPLIANCE 1/13/10 12:00 a.m. CLASS B CITATION .- PATIEN’I" CARE T22 DIV5 CH8 ART4 - 76525(a)(7) (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shaf] establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. Based on interviews, record reviews and facility document review, the facility failed to ensure Client l’s right to be free from abuse when StaffA engaged Client 1 in sexual activityl On 3/9/09 .review of the facility reported incident indicated that on 2t16109 at 3 p.m., Client 1 reported to staff that she saw Staff A’s genital .area when he exposed himself to her, in her room during the morning shift. The incident was immediately reported to the police. According to the Individual Program Plan (IPP) dated 12/4/08, Client 1 was admitted to the facility in April 2006. The client was described as verbaf and bright with a history of mild mental retardation. Client l’s communication skills were described as good, with Name of Evaluator: Ann Fitzgerald HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature TitLe : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTI=y CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000564 State of California - Heallh and Human Services Agency Department of Public Health ,.SECTIOf~ 1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS VIOLATED 15-0786-0006070-S Date: 01t0512010 Time: CLASS AND NATURE OF VlOLAT!ONS good memory skills in talking about present day and past events. An Interdisciplinary Note (IDN) dated 2/16t09 at 3:45 p.m., indicated that Client t came out of her room anxious and reported to staff that an a.m. staff showed her his genital area. Client 1 stated: "He asked me to suck on it, I did it and got a dollar". The IDN further indicated that the staff was not currently on the unit and the incident was immediately reported. At 5:30 p.m. the IDN indicated that the client told the nurse: "1 had sex today." The examination by the nurse did not reveal any signs of physical trauma. A section of the incident report written by the program director, Staff C, dated 2/17f09 referred to a conversation with Client l’s mother, after she had been informed of the incident. The mother, who had spoken to her daughter, stated tha;[ she knew her daughter very well and believed this incident happened. On 3/9/09 during an interview, licensed Staff B, who was in charge on the day of the alleged incident, stated that Staff A was assigned to Client l’s group that day. This group of clients was mostly all women who reside on the back hallway. The day of the alleged incident was a Monday holiday and the clients were on the residence. Staff B recalled that Client 1 and. StaffA came up to the nurses’ station at approximately noon on the day of the alleged incident to ask for change for a dollar. During an interview on 415/09 at 1:30 p.m., Staff D stated regarding Ctient 1 having money, that "as soon as she got any money she spent it." An entry written by the psychologist dated 2t17/09 indicated that Client 1 stated that she didn’t know that she was going to get a dollar for it." She stated: "He [Staff A] gave me a dollar later in the group room he said don’t tell anybody." Client 1 stated that she did not feel good about what happened that she should have gotten the money from her parents or the acting unit supervisor, Staff D. She indicated that she did not want to see this staff person again, because "he came in my room and that is how it happened," and that she would like her room locked and hoped that he doesn’t do it again.+VVhen the psychologist asked if there was anything she needed at this time, Client 1 responded: "1 want to know why he did it. Maybe it felt good to him". The psychologist described the client as anxious about the event and clearly unsafe about what had occurred and the possibility of recurrence. The psychologist assessed Client 1 as behaviorally stable with "appropriate reactions to her experience of the alleged incident". During an interview with the facility police on 2/26t09, Client 1 described the incident in response to questions posed. Client 1 stated that before breakfast StaffA entered her NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000565 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 4 CITATION NUMBER: SECTIONS VIOLATED 15-0786-0006070-S Date: 01/05/’2010 Time: CLASS AND NATURE OF VIOLATIONS room, that he came over to her bed, pulled down his pants and underwear right away and told her to suck it [his penis] like a sucker. She described his penis as up and hard. Client I stated that she had never done this before and denied ever hearing staff or family talk about someone engaging in this act. The investigator posed the question: If someof~e had walked by your window at the time of the incident what would they say. Client 1 stated: "they would say it happened because the shades were up". When asked if anything else happened Client 1 stated that he told her he would give her a dollar and that she hoped he doesn’t do it again. The facility police interview with Staff A on 3t24t09, indicated that at approximately 6:45 a.m., Staff A stated that he had been in the client’s room that morning to give her some clothes and she asked him if he could bring her some underwear. The second time he saw her was in the hallway at approximately 7:05 a.m., she was dressed and asked him for some shampoo. The next time he saw her was at breakfast in the dining room at about 7:30 a.m., then again at 8:10 a.m., in the activity room. He stated that before lunch she asked him if he had any money and he said no. Then after lunch she approached him with a dollar in her hand and asked him to take her to get a soda from the machine. When the investigator told Staff A that the client’s story had been detailed and consistent and she had no history of false allegations, the police report indicatedthat Staff A paused for 10-15 seconds then laughed and stated: "It’s your guys’ word against mine". Staff A had no explanation for the client’s allegation. Staff A denied the allegation but admitted that he failed to check on the female clients every 5 minutes as required for the past year, although he documented that he had done so. During an interview with the surveyor on 4t2/09 Staff A stated that he had been made aware of the allegation that for a dollar he had asked Client 1 to have sex with him. Staff A stated that he had been in Client t’s room that morning to drop off some clean clothing before breakfast and the client was in bed. "She asked me for underwear and I went to get that and dropped it off and left the room. Fifteen minutes later she asked for shampoo and she was dressed." He responded that it was not unusual for Client t to be fully dressed and then ask for her shampoo. Staff A stated that just before lunch Client 1 asked for a dollar and he told her no. Later she came after lunch and she had a dollar and asked if he could take her to the machine to get a soda but it wouldn’t work so they tried to find change..Regarding hearing of the allegation Staff A stated: "1 was totally shocked." Staff A stated that he was not aware that it was the unit practice to always have two staff present when working in a female client’s bedroom. During an interview on 4/5/09 Staff D stated that Client 1 was very capable of retrieving NOTE: 1N ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000566 State of Carifornia - Health and Human Services Agency Department of Public Hea~th SECqqON 1424 NOTICE Page 4 of 4 CITATION NUI~IBER: SECTIONS VIOLATED 15-0786-0006070-S Dale: 01t05/2010 Time: CLASS AND NATURE OF VIOLATIONS her own clothing. There was no reason for Staff A to bring clothing into her bedroom in the morning. Staff D added that she specifically had told Staff A that since he worked mostly with the female group, that there should always be two staff when working in a female client’s room. The poiice investigative report noted, and interview with Staff D a~d E indicated, that it would be unusual for Client 1 to ask for shampoo when she was fully dressed. She usually came into the hallway in her bathrobe and asked for her shampoo. In summary Client 1 was able to give a detailed description of this alleged incident, which was consistent in detail over time to various interviewers. According to the psychologist Client l’s reaction was appropriate to the alleged incident. The client expressed fear and anxiety and requested safeguards be put into place such as the automatic locking door and requested not to see this staff person again. The client’s mother felt the account of her daughter to be credible. Staff A had opportunity and, there were conflicting accounts of the client’s usual pattern in regards to her usual activities of daily living and StaffA stated that he was not aware of the unit practice to always have more than one staff present when working in a female client’s bedroom. StaffA admitted that he falsified documentation records reflecting that female clients whereabouts, were accounted for every.five minutes as per the unit practice. The facility failed to ensure that Client 1 was not abused. This failure had a direct or immediate relationship to Client l’s health, safety and security. NOTE: IN AOCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000567 State of California - Health and Human Services Agency Depadment of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15 1284-0007152-S Date: 05120/2010 Time: Type of Visit ’ Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address; License Number; Facility Name: Address: Telephone: Facility Type: Facility 1D: SECTIONS VIOLATED 76301(e) 76523(c)(1)(A) IncidentfComplaint No.(s) ¯ CA00223529 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD Eldridge, CA 95431 15000 Arnold Dr Intermediate Care FacilitytDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $1,000.00 Capacity: 581 DEADLINE FOR COMPLIANCE 6/3/10 12:00 a.m. CLASS B C~TAT~ON .. PATIENT CARE T22 DIV5 CH8 ART3-76301(e) Required Services (e) Ciient care provided, by all team members shall be safe and considerate as ordered or indicated by the needs of the client and in accordance with acceptable standards of practice. T22 DIV5 CH8 ART4-76523(c)(1)(A) Required Committees (c) Committee Organization and Structure shall be as follows: (1) Client Care Policy Committee (A) Written client care policies shall be established and followed ir~ the care of clients governing the following services: developmental programming, health support, dietary and pharmaceutical services and such social, therapy and diagnostic services as may be provided and administrative cfient records and housekeeping functions. The facility violated the above regulations when it failed to provide client care procedures that ensured safe client care. Facility procedures did not provide complete instructions for the safe use of instant hot packs and a client sustained second degree burns to the skin. A review of Physician Progress Notes (PPN)s dated 314110 documented an infected Name of Evaluator: Linda Lucey HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evalua[or Signature Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000568 State of California - Health and Human Services Agency Department of Public Health SECT{,ON t424 NOTICE Page 2 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 154284-0007152-S Date: 05/2012010 Time: CLASS AND NATURE OF VIOLATIONS sebaceous cyst on Client l’s left shoulder. Physician’s orders dated 3/4/10, 3/10/10, and 3/22/10 indicated on-going warm compresses every shift. PPNs dated 3/22/10 indicated second degree burns on Client l’s left mid-back with redness and blisters. A review of an incident report dated 3t21/10 indicated two red areas with 51isters on Client l’s mid-back. One area was 2 X 3 cm in size and the other 3 X 4 cm. The incident report indicated staff were using instant "Hot Compresses by.Rapid AI D". During an interview on 4/14/10, a licensed staff member stated he left Client 1 during treatment to attend an emergent event with another client. When he returned, he noticed the hot pack had slipped out of the towel it had been wrapped in. Observations of an activated "Hot Compresses by RAPID AID" wrapped in a towel and placed against the skin revealed the reading of a thermometer under the towel and against the skin rose to a high of 105 degrees Fahrenheit. Measurements of the temperature of the exterior of the pack without a towel wrapping revealed a high of 124 degrees. A review of the, "Hot Compresses by RAPID AID" package reflected information including, "... Shake bag ... wrap in soft cloth and apply ... Temperature of this compress may exceed I60 (degrees Fahrenheit) ... The unattended use of a hot compress by children, elderly or incapacitated persons is dangerous ..." During an interview on 4/14/10, the facility central ,supply Unit Supervisor stated the product identified as "Hot Compresses by RAPID AID" had been replaced with another product known as "INSTANT HEAT COMPRESS by SOL-R HEAT". A review of the information on the package of "INSTANT HEAT COMPRESS by SOL-R HEAT" indicated, "Temperature may reach up to 200 (degrees Fahrenheit) ... Burns may occur if skin temperature reaches above 107 (degrees) F. Always wrap in a dry or moist towel before application ... do not apply directly to skin ... Do not use for more than 15 minutes ... WARNING ... May cause serious burns ... The unattended use ... by children or incapacitated persons may be dangerous ..." A review of the facility document dated April 2009 entitled, "WARM AND COLD APPLICATION" indicated, "HEAT PACK (INSTANT)... Shake gently to mix chemicals ... apply pack.promptly to affectedtdesired area with washcloth or towel between pack and skin .,. Leave on ordered area per physician’s order. Usual duration is 15 to 30 minutes NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000569 Slate of California - Health and Human Services Agency Department of Public Health SEQ1,’ON 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS " VIOLATED 15-1284-0007152-S Date: 05t20/2010 Time: CLASS AND NATURE OF VIOLATIONS ... Check the clientttreatment area within 5 minutes ..." The procedure did not refer the reader to the manufacturer’s directions for use of the product, The procedure did not reflect a limit on duration of treatment. The procedure did not instruct the staff member to remain with the client for the duration of the treatment. The procedure did not warn staff of the possibility of excessive temperatures and burns to the skin, Therefore, the facility failed to establish procedures to ensure the safe use of instant hot packs and Client 1 sustained second degree burns to the skin. These facility failures had a direct .or mmediate relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS 1S GROUNDS FOP, SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000570 State of California - Health and Human Services Agency Department of Public Health SECTION 1.424 NOTICE Page 1 of 3 CITATION NUI~IBER: 15L159440007149-S Date: 0712312010 Time: Type of Visit: Complaint Invesligo YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76315(a)(5) 76525(a)(20) Incident/Complaint No.(s) : CA00218646 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P tCFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care FacilitylDevelopmentally Disabled Capacity: 581 150000230 PENALTY ASSESSMENT $1,000.00 CLASS AND NATURE OF VIOLATIONS CLASS B DEADLINE FOR COMPLIANCE 8/16/10 12:00 a.m. CITATION-- PATIENT CARE T22 DIV5 CH8 ART3 - 76315(a)(5) Developmental Program Services - Individual Program (a) Each client shall have an individual program plan that: (5) Includes established prioritized objectives, written in behavioral terms, that are measurable and time limited, for meeting the identified needs. T22 DIV5 CH8 ART4 - 76525(a)(20) Clients’ Rights (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded ’the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to comply with the above regulations by failing to ensure that program plans provided protective interventions for a repeated behavior for a client with identified risks of suicidal threatslgestures and self injurious behaviors. These failures resulted in self harm with the potential of harm to others. The IPP ( individual Program Plan), dated 12/29/09, indicated that Client 1 is at life Name of Evaluator; CAROL DEVITA HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000571 State of California - Health and Human Services Agency Department of Public Health SECTION.’1424 NOTICE Page 2 of 3 OlTAT1ON NUMBER: SECTIONS VIOLATED 15-1594-0007"149-S Date: 07t23/2010 Time: CLASS AND NATURE OF VIOLATIONS threatening risk of injury to herself resulting from her self-injurious behavior (i.e. swallowing objects, cutting wrists). Aggressive behaviors present a moderate to severe risk of injury to others. Additional documentation in the IPP indicated that Client 1 has repeatedly had to have 1:1 supervision for suicidalthreats. She has made several attempts to cut herself and has taken hazardous items to either swallow or cut herself. She has stolen scissors from the ~?ursing station and later used this to cut her wrists. Behavior Support Plans for target behaviors include: -Suicidal threats/gestures - Verbal threats to "kill self" by swallowing items. -Pica t SIB (self injurious behaviors) - As acting on suicidal threats, swallows .hazardous items, scratches herself, and has wrapped a radio cord around her neck. -Aggression - Hits, kicks, and bites. A denial of rights is in place for keeping and using personal possessions and for telephone use during times when Client 1 is experiencing suicidal ideation, A denial of rights report, dated 12/23/09, indicated that the client reportedly has threatened suicide, including covert storing of a broken CD and scissors purloined from her roommate. She has hidden items such as broken CD’ s and scissors in her room and on her person and used these items to cut herself. The facility Unusual Occurrence.Report indicated that came from her bedroom and reported to staff that she craft scissors because she was jealous that her peers linear scratches on the right side of her abdomen with inches. on 2/16110 at 6:35 p.m., Client 1 had scratched her abdomen with had a 1:1. Client 1 sustained 6-7 the longest scratch measuring 8 During .an interview with the US (Unit Supervisor) on 3/4110 at 11:50 a.m., the US stated on the day of the incident, Client 1 had been given pens, pencils, paper, and craft scissors to make cards. During an interview with the unit psychologist on 3/4/10 at 12 p.m., the psychologist stated that for provision of active treatment, Client 1 was interested in arts and crafts which also helped with her behaviors. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE 3"0 CORRECT VIOLATIONS tS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000572 State of California - Health and Human Services Agency Department of Public HeaIth SECTION,1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1594-0007149-S Dale: 07/23/2010 Time: CLASS AND NATURE OF VIOLATIONS In 12109, prior to the above incident,Client 1 had stolen a pair of scissors and later used it to cut her wrist. Client l’s behavior plan lacked specific interventions that addressed this repeated behavior involving the use of scissors. The CPP (Client Protection and Prevention) meeting minutes failed to reflect any preventive interventions to ensure the client’s safety related to the use of scissors. The IPC and Psychologist acknowledged that the accountability of the scissors and the supervision of the client while using scissors should be addressed in the plan and that a team meeting would be held to further address this. These failures had a direct or immediate relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000573 State of California - Health and Human Services Agency Department of Public Health 8. ECTIOI~ 1424 NOTICE Page 1 of 6 CITATION NUMBER: 15-0706-0006816-S Date: 10106/2010 Time: Type of Visit Complafnt Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility tD: SECTIONS VIOLATED 76525{a)(t6) 76345{c) Incident/Complaint No.(s) " CA00201352 State of CA Dept of Developmental Services 1600 9TH S~REET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD Eldridge, CA 95431 15000Arnold Dr Intermediate Care FacilitytDevelopmentally Disabled 150000230 CLASS AND NATURE OF ViOLATiONS Capacity: 581 PENALTY ASSESSMENT $25,000.00 DEADLINE FOR COMPLIANCE 10t20/10 12:00 a.m. CLASS AA CITATION-- PATIENT CARE Title 22, Section 76525 Client’s Rights, (a)(16) Each client has the rights Iisted...Each facility Shall establish and implement written policies and procedures to ensure that each client admitted is .afforded the following rights: (16) To prompt medical care and treatment. Title 22, Section 76345 Health Support Services - Nursing Services, (c) The attending physician shall be notified immediately of any signs of illness or marked change in condition. The facility violated the above regulations by not communicating a significant change in condition to the physician, and by not providing cardiopulmonary resuscitation (CPR) promptly. On 9/9/09 the facility notified the California Department of Public Health by written notice that on 9/8f09 at approximately 11:40 p.m., Client 1, age 51 years, died unexpectedly at Sonoma Developmental Center after vomiting a large amount. A subsequent autopsy finding, dated 11f19t09, indicated the cause of death: "Sudden cardiac event, due to partial small bowel obstruction due to strangulation of incarcerated midline epigastric hernia." According to Staff C (interviewed 2/12/10 at 2:20 p.m.) and Staff B (interviewed 12/8t09 Name of Evaluator: George Ely Health Facilities Eval. Nurse Without admitting guilt, I hereby acknowfedge receipt of this SECTION 1424 NOTICE Signature: Narne: Evatuator Signature Title : NOTE: IN ACCORDANCE WiTH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS iS GROUNDS i=OR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000574 State of California - Health and Human Services Agency Department of Public Health .SECTION 1424 NOTICE Page 2 of 6 CITATION NUI~IBER: SECTIONS VIOLATED 15-O706-0006816-S Date: 10t06/2010 Time: CLASS AND NATURE OF VIOLAT!ONS at 2:00 p.m.): Client 1 was developmentally disabled and ~onsidered to be non-verbal. According to Staff B and C, it was difficult to determine when/if Client 1 was in pain or discomfort. Since the client could not verbally state when he was in pain, determination was made through a subjective assessment of the client’s facial expressions and changes from baseline behavior and vital signs. Client 1 had episodes of dystonia (tightening of muscles) which also made it difficult to determine if he was in pain. Staff B, C and A (interviewed on 9/8/09 at 8:00 a.m.) indicated that Client I was independent in most activities of daily living, was physically active, ambulatory, in a generally good state of health, with no major acute clinical issues prior to the date of his death. Review of annual physician assessments and quarterly nursing assessments made no reference ’ to Client 1 having a history of abdominal hernia. According to interdisciplinary notes (IDNs), on 9t8/09 at about 2:00 a.m. Client1 had become ill (about 21 hours prior to his death) with vomiting, 480 cc’s (cubic centimeters), of light, brown-colored vomit. At that time, care staff showered the client and annotated, "found a bump on top of belly, slightly red."A Registered Nurse assessed Client 1 at about 3:00 a.m. and charted that, "staff noted hard raised area posterior umbilical area 5 cm (centimeters) x 5 cm (1.97 inches). Slightly discolored. Non-tender to palpation; no (increased) warmth." According to physician’s progress notes (PPN) dated 9/8/09 at 8:00 a.m., Client l’s physician, Staff A, examined the client. Staff A wrote that the abdominal examination indicated; "Small reducible umbilical hernia with no. surrounding erythema or tenderness to palpation. Staff A noted that ihe client had vomiting earlier in the morning and seemed to be improved and clinically stable. Staff A’s plan was to continue to observe clinically. and to provide diet as tolerated. No orders were written. According to IDNs, on 9/8/09 at 11:00 a.m. Client 1 was examined by Staff B. Staff B wrote in IDNs: the client "was reported to have a raised 5 x 5 cm area above the umbilicus -Abdomen was flat, soft and nontender with palpable 5 x 5 cm mass above central umbilicus. Was seen by M.D. earlier in AM and was submitting a consult for surgical clinic to assess for possible hernia." During an interview on 12t8/09 at about 2:00 p.m. Staff B stated that Client l’s umbilical hernia had not been diagnosed prior to 9t8/09. Staff B stated that he thought the physician was going to get a surgical consult and found out later that it had not been ordered. On 2/2/10 at 3:00 p.m. Staff G was interviewed. Staff G stated that on 9/8/09 at about 6:30 p.m. he observed Client 1 in the residence day room before the client was seen by NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000575 State of California ~ Health and Human Services Agency Page 3 of 6 rSEC~IoN 1424 NOTICE CITATION NUI~IBER: SECTIONS VIOLATED Department of Public Health 15-0706-0006816-S Date: 10106f2010 Time: CLASS AND NATURE OF VIOLATIONS Staff C. According to Staff G, Client 1 was normally a physically active person. The client would usually not sit for very long before getting up and walking around. At 6:30 ’ p.m. on 918/09 the client was lying on a couch in the day room and appeared to be lethargic and his eyes were closed, acco.rding to Staff G. On 9/8/09 at 6:30 p.m., according to IDNs, Client 1 was examined by Staff C. At this time, the client appeared to be hard to arouse, face flushed, temperature of 100.5 Fahrenheit (F) and in some discomfort. Staff C observed the abdominal lump and charted: "Bump above umbilicus. Client seen with 5 cm x 5 cm raised hard area, appears light red in color, seen by MD today no new orders no increased warmth, non-tender to palpation...Monitor for changes." When interviewed, on 2/2/10 Staff C reviewed her nurse’s notes written on 9t8/09 and stated that they were correct. Staff C stated that she did not feel that Client 1 was displaying a significant change in condition when she observed him at 6:30 p.m. Staff C did recall that she told another staff person to monitor the client’s temperature and to notify her if there was any change. ¯ On 9t8/09 at around 9:00 p.m. an IDN indicated that Client 1 was "burping a lot and sweating," heart rate was 92 per minute and temperature was 100.3 F. There was no indication that a physician was notified. During interview on 2/17/10 at about 11:00 a.m.i Staff A, Client I’S primary physician, reviewed the IDN entries for 9/8/09 at 6:30 p.m. and 9:00 p.m. (as noted above). Staff A stated that the symptoms as described in the IDNs were significant and that he would have expected a physician to be notified of these symptoms. Facility internal investigations, including an investigation by program management (per facility Incident/Unusual Occurrence Report, page 3, Level li review, dated 9/9/09 ), an independent investigation by the Department of Developmental Services Special Investigator (per interviews on 10/27/09 at 2:15 p.m., 11/1/09 at 11:00 a.m., 11/23/09 at 2:30 p.m. and 1/5t10 at 10:00 a.m.), the facility Nursing Mortality Review Committee report (dated 10t7/09), and the facility Organized Medical Staff, Level 2 Mortality Review report (dated 12/15/09), indicated that on 9t8t09 at approximately 11:15 p.m. when the client was discovered in bed with a large amount of vomit, he was unresponsive and full CPR was not initiated immediately. Facility policy number P 917, Medical Emergency Response, dated November 2007, section Client Medical Emergencies, states when EMS (emergency medical services) services are needed, the SDC (facility) staff shall: "2. Initiate Basic Life Support NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS 1S GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000576 State of California - Health and Human Services Agency Department of Public Health SECF]ON 1424 NOTICE Page 4 of 6 CITATION NUI~IBER: SECTIONS VIOLATED 15-0706-0006816-S Date: 10t0612010 Time: CLASS AND NATURE OF VIOLATIONS (BLS)/first aide as per the American Heart Association Guidelines." The facility provided a copy of the AHA (American Heart Association) Basic Life Support Guidelines. According to the guidelines: "The AHA’s basic life support guidelines are detailed by the chain of survival. The chain of survival is a protocol that helps first responders, emergency medical providers and certified civilian responders provide essential care to a victim of choking or cardiac or respiratory arrest. The goal of the chain of survival is to increase the victim’s chance for recovery through early action. The chain of survival as outlined for adults is first, early access followed by early CPR..." In the section titled, Early CPR, the guideline states: "If the victim is non-responsive, start cardiopulmonary resuscitation, or CPR. First, assess the patient’s breathing attempt a head tilt and chin lift only if no neck or spine injury is suspected...Next visually check for foreign objects that may be obstructing the airway. Remove any 6bjects with a finger sweep...Begin chest compressions and rescue breathing." Interviews with staff (D, E, F, and C) as noted below, who responded to the client’s bedside on 9/8/09 supported the various investigative findings that CPR was not initiated timely and in a correct manner per the facility policy and American Heart Association Guidelines. Staff D was interviewed on 2/4/10 at 3:00 p.m. Staff D stated that on 9t8/09 he came on duty for the night shift around 10:45 p.m. Staff D stated that he heard noise coming from another client’s room and while responding, stopped and checked Client 1. According to Staff D, Client 1 was lying in his bed, making gurgling sounds and moving his fingers in a pill-rolling motion. The client’s eyes were open, and Staff D noted a small amount of vomit on the bed. Staff D went to find Staff F and reported his findings to her. Staff D stated that it took about five minutes for him to locate Staff F. Staff D stated that Staff F told him to return to Client 1 and clean him up. Staff D stated that when he returned to Client l’s room, the client was lying on his back, not moving and not breathing. Staff D observed more vomit on the side of the client’s face and bed. Staff D stated that he did 15 chest compressions and the client was still not breathing. Staff D stated that he did not administer pulmonary resuscitation (assisted breathing) because he did not have a pocket mask. Staff D stated that he called for help and Staff F responded to the client’s bedside. Staff D stated that Staff F tapped the client on the shoulder and said his name, but didn’t do anything e]se. Staff D stated that the emergency cart was brought to the room, but the suction machine wasn’t plugged in. Staff D stated that he waited for guidance from Staff F, because, "she was the license" (licensed Psychiatric Technician). NOTE: IN ACCORDANCE WITH CALIFORNIA 14EALTH AND.SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000577 State of California - Health and Human Services Agency .SECT’IO~ 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public .Health Page 5 of 6 15-0706-0006816-S Date: 10t06/2010 Time: CLASS AND NATURE OF VIOLATIONS Staff E was interviewed on 2/3/10 at 8:00 a.m. Staff E stated that on 9/8/09 he came on duty at about 10:45 p.m. Staff E stated that shortly after he arrived on duty he heard Staff D call for help from Client l’s room. Staff E stated that he responded to the room and observed Staff D standing near the foot of Client l’s bed. Staff E stated that Client 1 was lying on his bed, partially on his right side. The client’s eyes were open, his color was pale, he was not moving and there was vomit present. Staff E stated that he went to get the emergency cart. Staff E stated that he took the emergency cart to Client l’s room, and Staff F took the cart and guided it into the room. Staff E stated that Staff D was now standing a little farther away from the foot of Client l’s bed. Staff E stated that he left to telephone the facility operator to activate the emergency response system. Staff E then went to the door of the residence and waited for the arrival of emergency response personnel. Staff F was interviewed on 2/4/10 at 10:00 a.m. Staff F stated that she had been the acting shift lead the night that Client 1 had died. Staff F stated that just after change of shift report, she heard Staff D call for help. Staff F stated that she responded to Client l’s room. Staff F stated that Client 1 was in bed, on his.back, eyes open and he wasn’t moving.. Staff F stated that the client’s skin color was "bluish-ashey." Staff F stated that she yelled the client’s name and shook him, but there was no response. Staff F stated that she assessed the clientfor a carotid pulse, but found none. Staff F stated that there was a large amount of vomit trailing out of the client’s mouth, across his face and onto the bed. Staff F was asked if she had attempted CPR on Client 1. Staff F stated that she "panicked, froze" and thought the client was dead. Staff F stated, "1 know I can’t make that call" (pronouncing death). Staff F stated that CPR was not initiated until the emergency response team arrived. Staff C (interviewed on 2/12tl 0 at 2:20 p.m.) stated that she was still on duty the night of 9t8/09 when she was notified by pager of an emergency situation on Client l’s residence. Staff C stated that she responded to Client l’s room and "nothing was happening." Client 1 was on his back in bed, with vomit all over him, the bed and the floor. According to Staff C, Staff D and Staff F were standing in the client’s room. Staff C stated that she immediately attempted to suction the client’s mouth and airway, but the suction machine was not plugged in. After plugging the machine in, Staff C stated that she suctioned the client’s mouth and did chest compressions while someone else got an AMBU bag and tried to ventilate the client. Staff C stated that CPR was not initiated as it should have been. The Facility Dispatch Office documentation (Fire Service Dispatch Report), dated NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000578 State of California - Health and Human Services Agency .SEC’i’IC~N 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health Page 6 of 6 15-0706-0006816-S Date: 1010612010 Time: CLASS AND NATURE OF VIOLATIONS 9t8t09 indicated that the code (emergency involving Client 1) wastelephoned in at 11:18 p.m. The emergency medical services personnel were on the scene at 11:30 p,m., CPR was started at 11:31 p.m. and the emergency procedures were halted by a responding physician (medical officer of the day) at 11:41 p.m. when Client 1 was pronounced deceased, according to the report. Facility staff failed to notify a physician regarding a significant change in Client ;l’s condition (deterioration) on 9/8/09 at 6:30 p.m. and again at about 9:00 p.m. Additionally facility staff failed to implement complete emergency resuscitative measures (CPR) promptly, as required by regulation, facility policy and American Heart Association Guidelines, when the client was found in bed, unresponsive and not breathing, at about 11:00 p.m. on 9f8/09. 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 and was a direct proximate cause of the death of the client. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000579 State of ~.aliforn[a - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 7 CITATION NUMBER: 15-1569-0001958-S Date: 11/12/2002 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76327(d) 76525(a)(20) 76327(a) 76525(a)(7) IncidenlfComplaint No.(s) " 150015030 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA Type of Ownership: 95814 State Agency SONOMA DEVELOPMENTAL CENTER DIP ICFDD 15000 Arnold Dr Eldridge, CA 95431 intermediate Care Faci]ityfDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $900.00 trebled to $2,700.00 Capacity: 581 DEADLINE FOR COMPLIANCE 11/14!02 12:00 a,m. CITATION -- PATIENT CARE 76327.Developmental Program Services--Restraints. (a) Restraints shall only be used as measures to protect the client from injury to self or others and only upon a physician’s or clinical psychologist’s written or telephone order. Telephone orders shall be received only by authorized licensed personnel, shall be recorded immediately in the client’s record and shall be signed by the prescriber within 48 hours. Restraint shall not be used as punishment, as a substitute for more effective programming or for the convenience of the staff. (d) There shall be no PRN orders for physical or treatment restraints. 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that Name of Evaluator: Cathy Ruebusch HFEN Without admitting guilt, 1 hereby ackr)owledge receipt of this SECTION 1424 NOTICE Signature : Name : Evalualor Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000580 State of ~alifornia - Health and Human Services Agency Departmenl of Public Health SECTION 1424 NOTICE Page 2 of 7 C~TATION NUI~IBER: SECTIONS VIOLATED 15-’156£-0001958-S Date: 11/1212002 Time: CLASS AND NATURE OF VIOLATIONS each client admitted is afforded the following rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. An unannounced visit was made to the facility on 07/10/02 at 3:47 p.m. to investigate an unusual occurrence report #150015030 regarding Client 1, During the investigation information was obtained that resulted in a citation pertaining to restraints and patient’s rights. The facility: 1) Failed to obtain physician or clinical psychologist orders for application of 4-point soft tie restraints on five occasions, 2) Used "PRN-as needed" orders for 4-point restraints, 3) Failed to ensure Client 1 was free of physical harm from the use of physical restraints, These violations of regulation resulted in Client 1 sustaining bruises to his inner arms and right inner leg while he was restrained in a wheelchair on April 8, 2002 at 12:15 a.m, Client 1 was a 29-year-old man admitted to the facility on 06122t88 with diagnoses that included anxiety disorder, severe mental retardation, infantile autism, and epilepsy. He had a documented history of physical aggression toward other clients and staff. On 04/09/02, Client 1 presented with "multiple bruises" to his "forearms" that did "not all appear accidental or self inflicted." The psychologist caring for Client I initiated NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000581 ¯State of ~;alifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 7 CITATION NUI~IBER: SECTIONS VIOLATED 15-1569-0001958-S Date: 1111212002 Time: CLASS AND NATURE OF VIOLATIONS the facility incident reporting system and described this finding. A second facility incident report for the s’ame incident was initiated by a staff registered nurse (RN) and staff senior psychiatric technician (SPT) and stated "wounds appear self inflicted according to behavior from previous week." The Nursing Coordinator recorded on both of these reports that a "CPP (Client Protection Plan) meeting" was to be held "to discuss the incident, behavior plan and strategies to prevent recurrence." Client l’s medical record revealed Interdisciplinary Notes (IDN) dated 04/08t02 at 6:00 a.m. that at "approx (approximately) 23;10 (11:10 p.m.)" oN 04/07/02, Client 1 began exhibiting "extreme aggression, property destruction, [and] assaults to staff." This note went on to describe, "at approx 0015 (12:15 a.m. on 04/08/02) [Client 1] was placed in 4 pt (point, involving both arms and both legs) restraint to wheelchair." The every 30-minute documentation recorded Client 1 as exhibiting "intense struggle" that was "surprisingly sustained" until his release at 5:30 a.m. This note recorded that Client 1 required reapplication of the 4 point soft tie restraints "approx 25 min (minutes)" later and that at 6:00 a.m. Client 1 was "in bedroom under 1:1 (one staff to one client) supervision." An IDN dated 04/09/02 at 7:15 a.m. stated, "2 bruises noted anterior L (left) forearm- one 9 cm x 5 cm and a 5 cm x 5cm bruise, one R (right) forearm bruise noted approx 5 cm x 5 cm. A slight swelling seen behind (proximal) to (L) 2nd finger knuckle. A 4 cm abrasion seen on anterior L shoulder. A (unable to read word) abrasion is found on L wrist. These wounds appear to be at least 12 hrs (hours) & poss. (possibly) 24 hrs old." Another IDN dated 04/09/02 at 1:50 p.m. recorded, "another bruise of same age as arm bruises noted on R inner leg (upper)." Interview with the psychologist caring for Client I on 07/17/02 at 2:55 p.m. revealed that he was concerned that the bruises on Client l’s arms and leg were secondary to the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000582 ,~tate of California - Health and Human Services Agency Department of Public Health SECTION "I424 NOTICE Page 4 of 7 CITATION NUMBER: SECTIONS VIOLATED 15-1569-0001958-S Date: 11t12/2002 Time: CLASS AND NATURE OF VIOLATIONS client being soft tied to a wheelchair "for an extended period of time." The psychologist related that he sat in a wheelchair and determined that the location of the bruises he observed on Client 1 were in locations that were adjacent to the arms of a wheelchair and that it "appear[ed] to me" that the bruises were secondary to the client flailing his limbs while restrained. He stated that the observed bruising could have been prevented if the wheelchair arms had been padded while the client was restrained to the chair. The psychologist also stated that the use of a wheelchair for 4-pbint restraint was "very unusual" but that Client 1 was difficult to restrain in a bed as he "destroyed the bed" when tied to it. The psychologist stated that a weighted bed had been created especially for Client 1 as a result of his destructive behavior and that "in the future" Client 1 was "only to be restrained in that bed" when requiring the use of 4-point soft tie restraints. Further review of Client l’s medical record revealed that the IDNs documented use of 4-point soft tie restraints for Client 1 on 04/05/02 at 8:20 p.m. to 10:00 p.m., on 04/06/02 at 10:00 a.m. to 11:45 a.m., on 04/06/02 at 5:15 p.m. to 6:15 p.m., on 04/08t02 at 12:15 a.m. to 5:30 a.m., on 04t08102 at 5:55 a.m. to an unknown time, and 04t10/02 at 2:00 a.m. to 2:30 a.m. Review of the physician’s orders for these dates revealed that physician or clinical psychologist orders were obtained for the use of the 4-point restraints on 04105/02 at 8:30 p.m. There were no other orders found indicating 4-point restraints could be used for Client 1 on these dates. Review of the physician’s progress notes (PPN) for these dates revealed no reference to the use, appropriateness of use, or examination of the client while in use of 4-point soft tie restraints for Client 1. Review of the facility’s policies and procedures on the use of restraints revealed that "Nursing Procedure NC 219 ’Physical Restraints’" stated under "Procedures: ICF Level of Care" "Behavioral Restraints: See SDC Policy 4521453." NOTE: IN ACCORDANCE WlTH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000583 .State’of’California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 5 of 7 CITATION NUI~1BER: SECTIONS VIOLATED 15-1569-0001958-S Date: 11/12/2002 Time: CLASS AND NATURE OF VIOLATIONS The facility policy and procedure labeled "Physical Restraint" and "452" and dated March 2002" stated under section, labeled "Intermediate Care Facility (ICE)" "Behavioral Restraints: When an individual is determined to need restraint for behavioral intervention (For example, intentional or unintentional self-abusive or self-injurious behavior.). 3.4.1 If the restraint is used as an ’Emergency’ (that is, where a need was not anticipated and there is no written, approved plan for the individual),. follow procedures in SDC Policy 453, Section 11.0, ’Emergency Restrictive Interventions.’ 3.4.2 For on-going ’Programmed’ use (that is, where there is a need for written,, approved plan for the individual), the individual’s team must obtain approvals according to SDC Policy 453, Section 8.0, ’Programmed Restrictive Interventions.’" The facility policy and proce~ture labeled "Behavioral Support & Intervention Services" and "453" and dated "March 2002" stated in Section 11.0 "Emergency Level 2 Restrictive Interventions" "Emergency Level 2 Restrictive interventions, as presented in Section 9.1 ..."Section 9.1 identified "Level 2 Review" as not including physical restraint. Physical restraint was listed under Section 9.2 as "Level 3 Review" as "Mechanical Behavioral Restraint." "Emergency Level 3 Restrictive Interventions" were under Section 10o0 and included the following statements, "only permissible under circumstances in which they are required to protect the individual or others from harm," "follows the principle of ’least restrictive effective alternative,’" "a licensed physician’s or licensed psychologist’s order is necessary for emergency mechanical restraint. The order shall include date, physical treatment profile number, type of restraint, and a 1.2-hour time limit for application," "telephone orders shall be.. (c) recorded immediately on the physician’s order form," "the on-campus ordering physician or psychologist shall go to the residence within one hour to assess the individual and the circumstances, and sign the order." NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000584 ,State’of’California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 6 of 7 CITATION NUI~IBER: SECTIONS VIOLATED 15-1569-0001958-S Date: 1"1/12/2002 Time: CLASS AND NATURE OF VIOLATIONS Further review of Policy 453 under Section 8.0 revealed that this section did not refer to "Programmed Restrictive Interventions" but referred to "Restrictive Interventions Prohibited." Section 9.0 "Behavior Plans Requiring Human Rights Committee Review and Approval" discussed the requirements of the use of behavioral restrictions including "mechanical behavioral restraint" as part of the Individual Program Plan. Under Section 1:~.4 "Mechanical Behavioral Restraint (soft ties, helmets, mitts, arm splints, etc.)" in Policy 453 the following was stated "13.4.1 Mechanical restraint shall only be applied to prevent injury to self or others," "13.4.5 In lCF, the physician or psychologist may preauthorize programmed use by signing the plan which makes use of the intervention," and "13.4.13 See the Management of Assaultive Behavior Manual for proper procedures." The "Management of Assaultive Behavior ManuaI" was reviewed and stated that "whenever possible [a client should be restrained] in own room, on own bed." There was no mention of the use of alternative sites for restraining a client including the use of a wheelchair. Interview with the Unit Supervisor on 09/03/02 at 10:00 a.m. revealed that the use of a wheelchair for four point restraints was not "usual" for the unit. The "only" rationale she could, give for using a wheelchair was for greater supervision of the restrained client "at the station" due to "short staffing." She stated that if a wheelchair was used for restraining, the safety features provided would be "lock the brakes" and "put the chair against the wall" to prevent the client from tipping the chair while in restraints. She did not recognize the need to pad the arms and legs of the chair to prevent injury to a flailing client until it was suggested by the interviewer. She did not know the reason for the lack of using Client 1 ’s bed for restraints. She stated the bed was the usual place NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000585 .:State’of’California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 7 of 7 CITATION NUI~1BER: SECTIONS VIOLATED 15-1569-0001958-S Date: 11112t2002 Time: CLASS AND NATURE OF VIOLATIONS to restrain a client because of the safety issues. She was not aware that physician’s orders were required for each restraint use. She agreed that "programmed restraints" was equivalent to an "as necessary" order for restraints. Therefore, the facility: 1) Failed to obtain physician or clinical psychologist orders for application of 4-point soft tie restraints on five occasions, 2) Used "PRN-as needed" orders for 4-point restraints, 3) Failed to ensure Client 1 was free of physical harm from the use of physical restraints, These facility violations had a direct relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000586 .State of,California - Health and Human Services Agency Departmen! of Public HeaIth SECTION 1424 NOTICE Page 1 of 5 CITATION NUlYlBER: 15-1569-0001961-S Date: 12/06/2002 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76301 (e) Incident/Complaint No,(s) : 150015041 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care Facility/Developmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 Capacity: 581 DEADLINE FOR COM PLIANCE 1/2/03 12:00 a.m. CITATION -- PATIENT CARE 76301. Required Services. (e) Client care provided by all team members shall be safe and considerate as ordered or indidated by the needs of the client and in accordance with acceptable standards of practice. An unannounced visit was made to the facility on 07/10/02 at 4:10 p.m. to investigate Unusual Occurrence report #150015041 regarding alleged client neglect/abuse. During the investigation information was obtained that resulted in a citation pertaining to lack of safe client care. The facility failed to ensure Client 1 ’s care was safe and according to the needs of Client 1 when the facility did not monitor and supervise the secondary dining room while Client 2, a client with a history of peer focused violent aggression, was present. Client 1 sustained a left eye injury with loss of visual acuity when Client 2 stabbed Client 1 with a butter knife. Name of Evaluator: Cathy Ruebusch HFEN Without admitting guilt, [ hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name: Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000587 ~State,of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1569-0001961-S Date: 12/06/2002 Time: CLASS AND NATURE OF VIOLATIONS Client 1 was a 42-year-old man admitted to the facility on 08/14t73 with diagnoses that included severe mental retardation and epilepsy. Client 2 was a 49-year-old man admitted to the facility on 02f05163 with diagnoses that included moderate mental retardation secondary to encephalitis. He had a documented history of emotional lability and impulsivity associated with frontal lobe damage of his brain. Healso had a documented history of physical aggression toward other clients and staff. On Saturday, May 4, 2002, at approximately 8:00 a.m., before breakfast, Client 2 assaulted Client 1 in the secondary dining room of the unit on which they lived. Client 2 struck Client 1 in the "left eye area" using a metal butter knife. According to the facility incident report, the "serious laceration to his (L) eye" that resulted in "bleeding" required surgical intervention at a local acute hospital and Client l’s vision in that eye was in question. The event was unwitnessed by staff, which "entered onto the scene moments after the injury occurred." An operative report received from the acute hospital dated 05t04/02 stated that Client 1 underwent an "examination under anesthesia" and "repair of globe laceration with reposition of ocular contents" to his left eye. The medical record revealed Client 1 returned to the facility on 05f07/02 and was hospitalized in the general acute care unit until 05/10/02 secondary to the need for continued eyedrop therapy and oral antibiotics. Client 1 required repeated eye examinations to determine healing and on 05t22/02 was returned to the acute hospital for further surgery. An operative note dated 05t22/02 stated that Client 1 underwent "three port trans pars plana vitrectomy, membranectomy, endolaser, gaslfluid exchange- left eye indirect laserright eye" to repair the "retinal (seeing nerve surface inside the eye ball) detachment, vitreous hemorrhage NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTE¥ CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000588 .State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1569-0001961-S Date: 12/06/2002 Time: CLASS AND NATURE OF VIOLATIONS (bleeding into the fluid cavity of the eye ball), epiretinal membrane (tissue formed from healing of the injury to the eye)" of his left eye. The operative report also stated that the lens in Client l’s left eye had to be removed during this surgery. Review of the Client 2’s medical record revealed an Individual Program Plan (IPP) dated 04/11t02 stating, "Behavioral: [Client 2] receives formal behavioral intervention to decrease aggression (hitting and kicking both peers and staff)." The tPP Narrative further stated, "Despite the noted improvement, [Client 2] continues to have significant problems with his anger." The IPP Narrative further stated, "[Client 2] has averaged 13 episodes of aggression.., per month." Review of the IDN revealed that an entry dated 02/14/02 at 4:30 p.m. recording a client protection plan meeting (CPP) stating Client 2 "has a history of saying things to his peers, and striking them when staff are not present... Staff are instructed to observe [Client 2] coming and going to and from the dining room, as this is the time [Client 2] is likely te agitate peers, and to intervene if necessary..." The facility’s "Crime Incident Report" dated 05/22/02 recorded an interview with Client 2 in which the client stated that a third client (Client 3) was present in the "kitchen" when the attack on Client 1 occurred. The report stated that according to Client 2, "[Client 3] had asked [Client 1] to leave the kitchen and he was not leaving. [Client 2] said that [Client 1] just wouldn’t leave the kitchen. [Client 2] said that he then grabbed the knife, got up out of his chair, walked over to [Client 1], and asked him to leave the kitchen. [Client 2] said that when he didn’t leave the kitchen, he hit him with the knife. [Client 2] said, ’1 hit him in eye.’ [Client 2] said that after he hit [Client 1] in his eye, he walked back to his chair and sat down." NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000589 ., State, of, California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1569-0001961-S Date: 12t06f2002 Time: CLASS AND NATURE OF: VIOLATIONS The Crime Incident Report also recorded an interview with Client 3 that stated "[Client 3] said, ’[Client 2] stabbed [Client 1] in the eye with a knife. I saw him do it.’ [Client 3] said, ’He wanted to. He got up from his chair, walked.over to [Client 1], and stabbed him in the eye.’ [Client 3] said, ’[Client 2] hit him with the knife and punched him."’ Interview with the Unit Supervisor on 09f03f02 at 10:30 a.m. revealed that it was routine for two "program staff’ members to assist with supervision with breakfast from Monday through Friday and that one of these persons was usually in the secondary dining room before breakfast, He also stated that it was routine that on Saturday and Sunday for no staff member to supervise the secondary dining room b~efore breakfast. He stated the reason for the change in staffing on the weekends was secondary to clients not needing to prepare for their workday on weekends and not needing to be focused by staff on completion of their breakfast. He also stated that the program staff, which assisted with breakfast during the week, did not work on weekends and were not available to assist. Interview with the Senior Psychiatric Technician (SPT) in charge.of the unit for the day shift on 08/06/02 at 11:00 a.m. revealed she was present on the morning of the incident (05t04t02). She stated that no staff members were stationed in the secondary dining room to supervise clients coming to breakfast. She stated that no staff members witnessed the incident. She stated a staff member responded when he entered the secondary dining room while bringing another client to breakfast. Therefore, the facility failed to ensure Client l’s care was safe and met his needs when it did not monitor and supervise the secondary dining room while Client 2, a client with a history of peer focused violent aggression, was present NOTE: IN ACCORDANCE W~TH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000590 .+State,of,California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 5 of 5 CITATION NUMBER: SECTIONS VIOLATED . I5-1569-000t 961-S Date: 12/06/2002 Time: CLASS AND NATURE OF VIOLATIONS resulting in the injury to Client l’s left eye with toss of visual acuity. This facility Violation had a direct relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000591 Slate.of California - Health and Human Services Agency Department of Public Heallh SECTION 1424 NOTICE Page 1 of 4 CITATION NUMBER: 15-1106-0001964-S Date: 01/22t2003 Time: Type of Visit ¯ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS IncidenttComplaint No.(s) ’ 150015042 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD Eldridge, CA 95431 15000Arnold Dr Intermediate Care FacilitytDevelopmentalty Disabled 150O00230 PENALTY ASSESSMENT $800.00 CLASS AND NATURE OF VIOLATIONS VIOLATED 76521(a) 76525(a)(20) 95814 CLASS B Capacity: 581 DEADLINE FOR COMPLIANCE 1/23/03 12:00 a.m. CITATION -- PATIENT RIGHTS 76521. Policies and Procedures. (a) Written administrative, management and personnel policies shall be implemented to govern the administration and management of the facility. 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall-not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to comply with the above regulations by failing to prevent several clients from mental and physical abuse and to follow their policy and procedure on abuse. Name of Evaluator: Christine Young Health Fac. Evaluator Nurse Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature ; Name ; Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000592 Stale,of ,California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 4 CITATION NUI~IBER: SECTIONS VIOLATED ~5-1106-000"1964-S Date: 01t2212003 Time: CLASS AND NATURE OF VIOLATIONS Clients L, R, M, J, D, C and A are blind with diagnoses of 3rofound and severe mental retardation. They are all nonverbal and could not be interviewed. Client L will verbalize by repeating what you have said but is unable to understand orrespond to questions, In a written statement to the facility dated 5/7t02, Staff N said she witnessed several incidences on 5t5/02 that she was concerned about. The following are the events witnessed: * staff J took Client E’s hand and used it to hit Client L in the head "a few times". * Staff J then "snapping" Client R’s face and hands a few times with a rubber glove. * Staff J hit Client R over the head with a wooden puzzle tray. When Client R "whined" Staff J put ice on Client R’s back as "punishment". * Staff J hit Client R in the head with a wooden tray to make him play with a puzzle. * Client M was asleep in a rocking chair when Staff J took softball and threw it at Client M’s stomach to wake him up. * Staff J called Client J "stupid" for wearing a hat on a hot day.. * While Staff N was trying to get Client M up to eat dinner, Staff J came up and said this is how f get him up and 3unched Client M in the stomach. * After showering Client C was given a gown by Staff J, which Client C did not like and did not want to wear. Staff J at this point slapped Client C across the face "causing her head to turn fast and her hair to fly in her face". Staff J stated she knew what Client C liked to wear. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000593 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 4 CITATION NUI~IBER: SECTIONS VIOLATED 15-1106-0001964-S Date: 01/22/2003 Time: CLASS AND NATURE OF VIOLATIONS * Client C went to the refrigerator and opened it, Staff J slammed the door on Client C so she would sit back down. Staff N stated that sometimes the door hit Client C on the back of her arm and shoulder and sometimes on her face and chest. * While Client D was sitting in the hallway in his wheelchair Staff J poured ice water on his back. Staff J then told Staff N in Tagalog "it feels good to kill him". Staff N stated, in an interview on 10/31/02, that she had not stopped the incident from happening at the time because she was afraid Staff J would lie about What happened. She stated she was also afraid of Staff J and Staff M retaliating if she told. She said Staff M saw what happened. In the facility’s investigation (no date) Staff M was interviewed as a witness to the incident. She stated she had seen nothing of what Staff N had seen. She said she was in the room most all the time of the incident and saw no abuse by Staff J. She stated she was doing a 1:1 with a client and was not paying much attention to Staff J or Staff N. She said it would be difficult for Staff J to grab Client E’s hands as he was much larger than Staff J and would resist her. She did notice Staff J playing ball with some clients. Staff M stated Staff N appeared to be more interested in the movie playing than in the clients she was responsible for. Staff B stated in an interview with the special investigator on 6/17t02 he felt Staff N was a reliable employee and had no doubt she was telling the truth in this matter, The investigator interviewed several other staff, however none witnessed the incident. Two staff person noted a bruise on Client C’S left eye on 5/6102 at approximately 8:30 a.m., which was the day after the alleged incident. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000594 State of,California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS VIOLATED 15~1106-0001964-S Date: 01/22/2003 Time: CLASS AND NATURE OF VIOLATIONS Staff S told the special investigator on 6125/02 that she felt the allegations where true especially given the details given. She said Client C has self-injurious behavior but does not hit herself on the face, will usually hit herself on her legs or hit or pinch others. The Unit Supervisor also stated that Staff M would "cover" for Staff J. She further stated Staff J had "issues" with several staff at times and it would not surprise her that she could have issues with clients. The facility policy on abuse states any staff witnessing, having knowledge of, or suspecting that abuse, mistreatment, or neglect of a client has occurred. 1) Sees to any urgent client needs. 2) Immediately reports to his/her supervisor or another channel such as the program director, program assistar~t, facility police, supervisors, etc. The facility failed to prevent the physical and verbal assault of several clients by Staff J. The facility further failed to follow their policy and procedure on abuse in that Staff N-witnessed several clients being assaulted over an extended period of time and did nothing to stop it during the time it was happening, report to anyone until 2 days after the incident, or see to the needs of the clients after it happened. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to the clients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEAI.:TH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000595 State of. California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 2 CITATION NUMBER: 15-1155-0001£72-S Date: 04t18t2003 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE State of CA Dept of Developmental Services Licensee Name: Address: 1600 9TH STREET, RM 340 150000089 License Number: Facility Name; 15000 Arnold Dr Type of Ownership: State Agency Eldridge, CA 95431 Intermediate Care Facility/Developmentally Disabled 150000230 Facility Type: Facility ID: 76525(a)(7) SACRAMENTO, CA 95814 SONQMA DEVELOPMENTAL CENTER D/P ICFDD Address: Telephone: SECTIONS VIOLATED Incident/Complaint No.(s) ¯ 150015187 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $800.00 Capacity: 581 DEADLINE FOR COMPLIANCE 4/23/03 12:00 a.m. CITATION -. PATIENT RIGHTS 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. The facility failed to follow the above regulation by failing to ensure that clients are not subjected to physical and verbal abuse of any kind as follows: Client A is a 49-year-old male. He is blind. He has diagnoses that include severe mental retardation and obsessive-compulsive disorder. A unit staff person interviewed on 4/9/03 stated that Client A is continent with occasion accidents. Name of Evaluator: DONNA BUSCOVICH HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name: Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000596 State of California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 2 of 2 CITATION NUMBER: SECTIONS VIOLATED 15-1155-000"1972-S Date: 04/1812003 Time: CLASS AND NATURE OF VIOLATIONS Client B is a 46-year-old male with diagnoses that includes severe mental retardation, bi-polar, autism and he is legally blind. An [PP dated 11/02 documented that he has limited communication. The plan also documents that he has a behavior of tearing his clothes. According to an event reported to Licensing and Certification by the facility, a pre-licensed psychiatric technician (PLPT) reported that on 9/10t02, she witnessed a psychiatric technician (PT) physically grab Client B by the back of the neck, causing a loud slapping noise then "thrusting" him to his feet, escorting him from the room with his hand remaining on Client B’s neck. This occurred in response to the client ripping the seat of his pants. She also stated that the PT verbally admonished Client A for wetting hispants and made him sit in his soiled condition. The PLPT stated that the PT told Client A, "You pissed your pants. You just sit there". The PLPT documented in her report that prior to Client A being incontinent, he tried to leave the family roomtwice but was refused. The PLPT also doc.umented that she told the PT that she would brush the client’s teeth and she was told to let them be and "if we brush them once or twice a week that’s good enough". The facility’s investigation unit substantiated the claim of client abuse. The PT used excessive force on Client B which was physically abusive and he treated Client A and B in an undignified, belittling manner. This facility failure caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or Other emotional trauma to patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTHAND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATIQN OF YOUR LICENSE DPH POD 000597 State of Catifornia - Nealth and Human Services Agency Departmen{ of Public Health SECTION 1424 NOTICE Page 1 of 4 CITATION NUMBER: 15-1155-0001976-S Date; 04/23/2003 Time: Type of Visit ¯ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE State of CA Dept of Developmental Services Licensee Name: Address: 1600 9TH STREET, RM 340 150000089 License Number: Facility Name: 15000 Arnold Dr Type of Ownership: State Agency Eldridge, CA 95431 Intermediate Care FacilitytDevelopmenta]ly Disabled Facility Type: Facility ID: 76525(a)(7) SACRAMENTO, CA 95814 SONOMA DEVELOPMENTAL CENTER D/P ICFDD Address: Telephone: SECTIONS VIOLATED Incident/Complaint No.(s) ¯ 150015190, 150015158, 150015135 Capacity: 581 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $900.00 DEADLINE FOR COMPLIANCE 4/29/03 12:00 a.m. CITATION -- PATIENT RIGHTS 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this sectionwhich shall not be denied or withheld except as provided in (c) of.this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. The facility failed to follow the above regulation by failing to ensure that clients are not subjected to physical abuse as follows: Client .B’s record documents him to have diagnoses that include moderate mental retardation and schi~oaffective disorder. Client A is a 48-year-old male. A 30-Day post Admission Psychological Evaluation documents that he had been Name of Evaluator: DONNA BUSCOVICH HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name ; Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000598 State of California - Health and Human Services.Agency Departmenl of Public Health SECTION 1424 NOTICE Page 2 of 4 CITATIONNUMBER: SECTIONS VIOLATED ¯ 15-1155-000t976-S Date: 04123/2003 Time: CLASS AND NATURE OF VIOLATIONS discharged from the developmental center in 3t95 and his readmit to the center was prompted by repeated assaults, with several assaults focused on one particular peer. Client A was hospitalized in late May after assaulting with a fork. Just before that, he had broken a chair and attempted to assault staff with one of the pieces. The group home came to the conclusion that they couldn’t adequately protect Client A’s peers at this time. The evaluation documents a longstanding issue for Client A of his need to be in an "enforcer" role for clients that he perceives as not behaving appropriately. In the area of cognifitv functi0r~ing, he was noted to have records indicating an IQ score.of 50 which was described as Moderate Mental Retardation. A review of the medical record for Client A and Client B revealed numerous incidents of assaults by Client A on other clients since admission. Examples include: Qn 7/16/02, Client A hit a peer. Client A was moved to a new room. On 7t17/02, Client B hit Client A in the arm. Client A retaliated and hit Client B in the face 3 times. On 7/25/02, a peer was attempting to enter Client A’s bedroom. Client A had both hands around a peer’s neck, choking him. Staff intervened, and the peer fell to the floor. On 8t3f02, Client B was found arguing with Client A. Client B was found to have two scratches on the right side of his face and one scratch to his nostril. Shortly after he complained of shoulder pain. An x-ray was taken and he was found to a fractured right scapula. On 8t16/02, Client A punched a peer for no apparent reason. The peer sustained discoloration and swelling on his left NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000599 State, of,California - Health and Human Services Agency SECTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health Page 3 of 4 15~1155-0001976-S Date: 04/23/2003 Time: CLASS AND NATURE OF VIOLATIONS eye. On 9/16/02, for no apparent reason, Client A pushed a peer to the ground and began kicking him on and around the stomach and back. Client A refused and was noncompliant to stop aggression and the peer was pulled to safety instead. On 9/21/02, Client A pushed and hit a peer. Later in the day he pushed another peer. On 10/3/02, Client A hit a peer. On 10/10/02, Client A was in a van with Client B, when be began hitting and kicking him for no apparent reason. On 10/23/02, while coming back on his paper route, Client A started to hit Client B. On 10/25t02, Client A was seen fighting in front to the nurses station with Client B. On 1 I/3/02, Staff observed yelling in Group hallway. Client B and A were fighting in front of Chris’ room. Client B’s mouth was noted to be bleeding. On t 1/13/02~ Client A was in the hallway when for no apparent reason, he began punching a peer. On 12/11/02, Client A hit a peer. On 12/31/02, Client A was observed hitting Client B unprovoked. Client B was asking him to stop and Client A would not. Client B then hit Client A. An IDN in Client A’s record documented "while walking toward family room this staff observed chair hitting Client B. On 2t19/03, client A begame aggressive towards Client B. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SA]::TEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000600 State of, California - Health and Human Services Agency Department of Public Health SECTION "~424 NOTICE Page 4 of 4 CITATION NUI~1BER: SECTIONS VIOLATED 15~1155-0001976-S Date: 04/23/2003 Time: CLASS AND NATURE OF VIOLATIONS On 3/18/03, clients were heard screaming in the main hallway, Staff observed Client A holding Client B by the collar of his shirt attempting to punch him. When a unit staff member was asked on 3/23/03, about the observation after reading Client A’s medical record that he had frequent altercations with Client B, the staff member stated that Client A is an enforcer and if clients do something wrong, he wants to fight them. Another staff member stated that Client A is the aggressor. The facility failed to develop an effective plan to protect clients from being assaulted by Client A, A plan has not been implemented to protect Client B from repeated assaults though.medical record review revealed he is being targeted by Client A. These facility failures had a direct relationship to the health, safety, or security of clients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000601 State of California ~ Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-1022-0002018-S Date: 06/13/2003 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALl FORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(14) 76525(a)(20) Inciden~Complaint No.(s) ’ 150018983 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA Type of Ownership: 95814 State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care FacilitylDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $600.00 Capacity: 581 DEADLINE FOR COMPLIANCE 8/27/03 12:00 a.m. CITATION -- PATIENT RIGHTS 76525. Clients’ Rights. (a) Each client has the rights listed iu (a) ofthis section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (14) To dignity, privacy, respect and humane care, including privacy in trea{ment and in care for personal needs. (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to ensure that clients are free from any physical abuse and treated with dignity, respect and human care as follows: Client A is a 62-year-old male with a diagnosis that includes profound mental retardation and a history of Name of Evaluator: Jose Figueroa HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000602 State of California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1022-0002018-S Date: 06t’13t2003 "Fime: CLASS AND NATURE OF VIOLATIONS socially unacceptable, hyperkinetic behavior treated with clonidine. In addition the Independent Program Plan (IPP) in the Client A’s clinical record documents that the Client A does not always respond to staff directions and when he is anxious his problem behavior increases. A Sonoma Developmental Center (SDC) Incident Report dated 5t31t03, states that on 5t30t03, while Client A was attending an Off-Site Program on the Parmelee unit at SDC, he was punched in the stomach. Based on statements by two witnesses, Staff person 2 and Staff Person 3, at approximately 1305 p.m Client A was punched twice in the stomach by Staff Person 1 who had been assigned that day to provide direct care to Client A. At 1345 p.m. Client A was examined by the Health Service Specialist RN, who documented in the Interdisciplinary Team notes "...there is a red mark on his abdomen, left upper quadrant adjacent to umbilicus and is 4.25 inches by 2 inches in size. it is very red and may develop increased ecchymosis with time. (almost looks like a contusion) advised unit staff to apply a cold pack to the area and to call the unit MD to examine (client)." Client A was examined by the MD on 5/30/03 at 1440 p.m with subsequent orders for vital signs every 4 hours times 24 hours; then every shift for 48 hours and to report any emesis, decrease of blood pressure, and/or any increase in pulse to the RNf MD immediately. During an interview with the Area Coordinator, Client A’s behavior was described as very active and challenging at times so that the staff had been instructed to provide relief to any co-workers who demonstrated frustration with the client A’s behavior. The Area Coordinator stated that Staff Person 1 had worked with Client A several times before and aware of the unit policy. On the day of the incident, he had been offered relief by Staff Person 2, but refused NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000603 State ,of California - Health and Human Services Agency Depadment of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUI~tBER: SECTIONS VIOLATED 15-1022-0002018-S Date: 06/13/2003 Time: CLASS AND NATURE OF VIOLATIONS it. Staff Person 2 stated during an interview that Client A is a difficult client to work with, as he is very active. "Staff Person 1 looked like he had had enough and I asked him if he would like me. to relieve him with Client A, he said no." Staff Person 2 described how she was looking after other clients in a day room which leads out to a patio and she heard Client A screaming from the bathroom: "1 went to the bathroom. The door of the bathroom was open, it is always kept open to allow clients access to go in and use the toilet. There are privacy curtains around the toilets. I could see both Client A and Staff person 1 standing in the bathroom. Staff person 1 was trying to pull a t-shirt over client A’s head, it was on his shoulders and he was trying to pull it down, but Client A pulled it up again. I called to Client A to come over to me. I stepped into the bathroom and when Client A was close to me I tried to pull the tshirt dewn. Staff Person 1 pulled Client A sideways to me and punched him in the stomach. I told him to Stop and he punched Client A again. Staff Person 3, who was also a witness to the incident, was walking past.the bathroom and stated during an interview, "1 saw Staff Person 1 and Client A standing facing the door that was open. Staff Person 1 had Client A’s shirt pulled up and hit him in the stomach once with a closed fist. A coworker (Staff Person 2) who observed this incident removed Client A who was holding his side. I reported this to the Senior Psychiatric Tech, what t had seen." The facility did not ensure that Client A was free from abuse or treated with dignity, respect and given humane care when punched in the stomach by Staff 1. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000604 State of G~alifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 5 CITATION NUf~E]ER: 15-1284-0002017-S Date: 07/0912003 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR IncidentfComplaint No,(s) ¯ 150015055 APPLICABLE Licensee Name: Address: License Number:. Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76315(b} 76525(a}(7} 76521 (c)(10)(A) State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD Eldridge, CA 95431 15000 Arnold Dr Intermediate Care FacilitytDevelopmentatly Disabled Capacity: 581 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $800.00 CLASS B DEADLINE FOR COMPLIANCE 7/25/03 12:00 a.m. CITATION -- PATIENT CARE 76525. Clients’ Rights, (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (7) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329. 76315. Developmental Program Services--Individual Program Plan. (b) The individual program plan shall be implemented as written. 76521. Policies and Procedures. (c) Each facility shall establish the following policies and procedures: Name of Evaluator: Linda Lucey HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION I424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000605 State of Galibrnia - Health and Human Services Agency Department of Public Health SECTION ’1424 NOTICE Page 2 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0002017-S Date: 07/09/2003 Time: CLASS AND NATURE OF VIOLATIONS (10) A procedure by which allegations of client abuse are immediately reported. Such procedures shall assure that there shall be evidence that: (A) All alleged violations are thoroughly investigated. The facility violated the above regulations when it failed to ensure the behavior plans were implemented as written, when it failed to assure an allegation of abuse was thoroughly investigated, and when it failed to ensure each client the right to be free from abuse. Client 1 is a 27-year-old female admitted 9121101 with of mild mental retardation, depressive disorder, cerebral palsy, and right-sided hemiparesis that affects her arm more than her leg. An annual assessment dated 10/16/01 revealed Client 1 has graduated from high school and can read and write. She has strong receptive and expressive communication skills. She exhibits appropriate complex conversational skills. A behavior plan for stealing dated 3/05/02 included the interventions, "If (Client 1) is found with an item that does not belong to her, do not accuse her of stealing. Say something to the effect of "You know that does not belong to you so please return it (or give it to me). Do this with a very matter of fact, unemotional, tone of voice and stand at least four feet away. Wait approx 20 seconds and then repeat if she had not complied. If she has not complied after two requests tell her you will return in 5 minutes to get the item and walk away. Return in 5 minutes and repeat the request. If she still refuses tell her you expect her to give you the item by the end of the shift and walk away." On 4/16/03, Employee B stated she came in to work at 6:30 AM on the day of the incident and was picking up trash from the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000606 State qf California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0002017-S Date: 07t09t2003 Time: CLASS AND NATURE OF VIOLATIONS clients’ rooms. At that time, she saw that Client 1 had a sugar bowl in her bedroom. Later while Employee B was cleaning the nurses’ station, she saw Client 1 had the sugar bowl in her pocket. Employee B stated Staff Member A was the only staff member present. Staff Member A asked Client 1 about the sugar bowl and took it away from her. Employee B stated she observed Client 1 get upset and try to hit Staff Member A. Then Staff Member A hit Client 1 on her back and on her shoulder and took Client 1 to her room. On the.way to the room, Staff Member A hit Ctient 1 on the back of the head with an open hand. They went into the room and Employee B heard noise and commotion. About five minutes after Staff Member A came out, Employee B went into the room. Employee B stated Client 1 was on the floor and the linen from the bed was on the floor. A preliminary police report dated 5/29/02 indicated additional information that Employee B went into Client l’s room and found Client l’s bed pushed up against the wall, which was unusual. The incident took place on 5t17, 5/18, or 5119t02. An investigative summary reportdated 7t26/02 indicated Staff Member A denied hitting Client 1 but the investigator substantiated the allegation since Employee B had no reason to fabricate the allegation against Staff Member A. On 12/31/02, Client 1 said, "(Staff Member A) really did hit me in the back of the head really hard." and, "(He) hit me in (the) arm and then on (my) head." Client 1 stated that once in the bedroom, Staff Member A pushed her hard on the bed so she was face down. Client 1 said, "He was on top of me (with) his arms on my arms and his feet on my feet." and, "1 was banging my stuff because I was so mad he abused me." Client 1 stated she was upset and crying and screaming in the bedroom, but no one could hear her. Client 1 stated she was crying for help and Staff Member A said, "Shut the fuck up (Client 1). Client 1 stated she started screaming, "Let go of me." and Staff Member A left the room. Client 1 said NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS tS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000607 State af GalSfornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 5 CITATION NU~/IBER’ SECTIONS VIOLATED 15-1284-0002017-S Date: 07109/2003 Time: CLASS AND NATURE OF VIOLATIONS the incident made her feel, "Like I wanted to sock him back.., like I wanted to slap him across the face." Client 1 said, "... I still think about it." Client 1 stated she is scared of Staff Member A who is working on another unit. Client 1 said, "He is just plain mean." Client 1 stated no one ever spoke to her about the incident before the 12/31f02 interview. During a second interview on 4/16/03, with Unit Supervisor D present, Client 1 stated she was, "not going to make up stories". Client 1 said, "1 was being escorted... something I did was wrong... (my) arm was behind my back... (there was) something (at the) back of (my) head." Client 1 said, "... it’s like this. He hit me... because I was head-butting him..." On 4t21/03, Psychologist E stated there is no reason to doubt what Client 1 described in her interviews especially since Client 1 verbally stated her understanding of the importance of telling the truth. On 3t07/03, Staff Member A recalled an incident with Client 1 and a’sugar bowl. Staff Member A’s union representative was present and stated Staff Member A was cleared and the case was dropped. Staff Member A produced documents that indicated the facility issued a Notice of Adverse Action for Dismissal effective November 30, 2002, but on 12/02/02, an informal hearing took place and the facility Commander of Protective Services concluded that, "the allegation could not be substantiated to warrant dismissal." Staff Member A stated he was currently was working with clients. Staff Member A’s training records documented training in management of assaultive behavior on 4f29199, 6t28/00, 7f06/01, and 12/20t01. The faciiity document entitled, "Management of Assaultive Behavior" indicated the following, "First, never try to handle an individual in crisis by yourself if at all possible. This is the time to get NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000608 State ef California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 5 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0002017-S Date: 07t09/2003 Time: CLASS AND NATURE OF VIOLATIONS assistance,.. Counter assault is not permitted... When we feel threatened...Our judgment may not be at its best.., remember to call for help.., evasion is the best response... (Make) no attempt to hold or control the attacker... (if) you are going to get hit.., move away quickly at the first opportunity... There are no one person escorts, if a client needs to be transported from one place to another, then there needs to be two staff to escort them." The facility failed to ensure Client l’s right to be free from mental and physical abuse when Staff Member A failed to follow the behavior plan and used inappropriate techniques. to manage Client l’s assaultive behavior. The facility failed to thoroughly investigate the allegation of abuse when Client 1 was not questioned about the incident at the time of the allegation. The above violations either jointly, separately, or in any combination had a direct or immediate relation to patient health, safety, or security. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000609 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 2 CITATION NUMBER: 15-1106-0002021-S Date: 10/07/2003 Time: Type of Visit : YOU ARE HEREBY FOUND 1N VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS Incident/Complaint No.(s) ’ No complaints found State of CA Dept of Developmental Services 16009TH STREET, RM 340 150000089 SACRAMENTO, CA Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD 15000 Arnold Dr Efdridfle, CA 95431 Intermed)ate Care FacilitylDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $600.00 VIOLATED 76525(a)(!4) 95814 CLASS B Capacity: 581 DEADLINE FOR COMPLIANCE 10/13/03 12;00 a.m, CITATION -- PATIENT RIGHTS 76525. Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (14) To dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs. The facility failed to comply with the above regulation by failing to ensure, that Client B was assured dignity, respect and humane care as follows: Client B is a 50-year-old male with a diagnosis that includes moderate mental retardation. Client B is verbal. On 5/29/03 at approximately 6:15 a.m, Staff C was in the nursing station and heard Client B yelling from a group Name of Evaluator; Christine Young Health Fac. Evaluator Nurse Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Eva[uator Signature Title: NOTE: 1N ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000610 State of California ~ Health and Human Services Agency Department of Public Health ¯£ECI"ION 1424 NOTICE Page 2 of 2 CITATION NUMBER: SECTIONS VIOLATED 15-1106-000202!-S Date: 10/07/2003 Time: CLASS AND NATURE OF VIOLATIONS hallway. When Staff C began walking to the area to see what the problem was he heard StaffA "yelling " at Client B say "what the hell is wrong with you? What are you yelling for" and to "shut up, get back to your room". Staff C stated Staff A’s "tone" was abusive and definitely "nontherapeutic". He stated he felt it did not promote the "well being" of clients. The incident report noted Client B continued his normal routine and appeared "okay". Client B was observed the next 24 hours and did not appear distressed. Interdisciplinary notes dated 5/29/03 at 4 p.m. note Client B was spoken to and appeared to be "okay". The notes for 5/29f03 at 7 p.m. note Client B was in a cooking class and was "very despondent and cries incessantly at times. Client unable to communicate source of emotional distress. Client unable to respond to redirection. Client eventually calmed down & later returned to unit." A complete body check was done on Client B and no marks or bruising was found on him. Staff C stated in an interview on 8/26/03 that he felt Client B knew what had happened. The facilities failure caused humiliation, indignity and anxiety to Client B. NOTE; IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000611 Sta~.e ef California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 5 CITATION NUI~BER: 15-1634-0002023-S Date: 11t25/2003 Time: Type of Visit " YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility SECTIONS VIOLATED 4502(b) Incident/Complaint No.(s) - 150017630, 150017626 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care Facility/Developmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $600.00 Capacity: 581 DEADLINE FOR COMPLIANCE 11/25/03 12:00 a.m. CITATION -- PATIENT RIGHTS The facility failed to meet these requirements as follows: 1. The facility failed to ensure the rights of Client 1 to be treated with dignity and respect and as an individual by failing to protect him from being squirted on the back of the neck with a water bottle by PTA 1 (psych tech assistant). 2, In addition, the facility failed to ensure the rights of Client 2 to be treated with dignity and respect and as an individual when PTA 1 sat on the 3" arm rest above her head while she was lying on the sofa, in an effort to joke and _tease with the TA (Teaching assistant) who was present in the classroom. PTA 1 stated that he did not consider it disrespectful or an affront to the dignity of the Client to place his body adjacent to the face and head of the client because she was blind and could not see him. 1, Review of the clinical record of Client 1 revealed a 38 year-old male who was admitted to the facility in 1990. He is described as having a life-long history of episodes of Name of Evaluator: Treya Auge HFEN Without admitting guilt, hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name: Evaluator Signature Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000612 State ~2f California ~ Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1634-0002023-S Date: 1112512003 Time: CLASS AND NATURE OF VIOLATIONS aggressive and agitated behaviors. Current diagnosis included Severe Mental Retardation and intermittent explosive disorder. He is blind and has bilateral moderate to severe hearing loss. His current Individual Program Plan (IPP), dated 12/03t02, des&ribed him, as "generally quite sociable and he likes to be with and interact with staff." He bites his hand when upset or in pain." The teaching assistant (TA) who reported the incident was interviewed on 7/02/03 from 3:15 to 3:40 p.m. During the interview, she stated that while in the classroom, the group of clients and staff were sitting and waiting for a staff member to play his guitar. She stated that Psychiatric Technician Assistant 1 (PTA) was sitting behind Client 1. She observed PTA 1 squirt Client 1 on the back of the neck with a squirt bottle of water. She said that suddenly Client 1 jumped up from his chair and became agitated and began biting on his thumb. When asked what the bottles were used for, she stated that the bottles are used for many things.They are sometimesusedduring grooming to moisten a Client’s hair and sometimes during very hot weather to mist the clients skin to keep them cool. When asked if the bottles are ever used as "squirt guns" she stated definitely not. She stated that another staff noticed Client l’s sudden change of behavior and later asked her about it. She said that she took the squirt bottle from PTA 1 and threw it in a storage barrel for bags. While she was working with other clients, PTA 1 retrieved the bottle and again squirted Client 1 from behind. Again, Client 1 jumped up, biting his thumb and became agitated. She stated that she then put the bottle on the teacher’s desk and Client 1 sat down. When the teacher asked again what the problem was, she stated that she told him "the problem was now on his desk." She stated that after the class, the teacher asked what had caused the client to become upset and she told him about the behavior of PTA I. She stated that the teacher said that PTA 1 shouldn’t be doing that, and she of course agreed. She NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000613 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1634-0002023-S Date: 1112512003 Time: CLASS AND NATURE OF VIOLATIONS stated that she believed that PTA 1 .was teasing the client, trying to "get a rise" out of him. She stated "Client 1 had been really upset, that she has worked with him for a long time and aside from his agitation and biting of his own thumb, she could tell by his facial expression and the look in his eyes, that he was really distressed." She stated that because of the sensory deficits of Client 1, his blindness and loss of hearing, it is part of his care plan that he needs to know what is happening and what is going to happen next. "To surprise and tease him in this or any manner was really cruel." She stated: "Client 1 has had such a difficult life, for someone to try to increase his suffering by teasing him, especially in class which he usually enjoys, is just so terrible". The teacher who was present in the classroom on the day of the incident was interviewed on 7/I6/03 in the a.m. He stated that he had been a teacher for SCOE (Sonoma County Office of Education) for approximately 24 years. He stated that hehad observed the behavioral upset of Client 1 on the day of the incident and had told the TA that PTA 1 should not be doing that. He stated that he told her she should report the behavior and that the Unit Supervisor should be informed. The SP’[" (Supervising Psych Tech) of the Oak Valley School was interviewed on 7t16/03 in the am. When asked about the behavior of squirting a client with water bottle to joke or tease with himther she stated with intensity: "that behavior is inappropriate, abusive and I will make certain that all of the bottles are removed today." She also stated that the bottles had been used in very hot weather in the past to mist and cool client’s but were no longer used and were supposed to have been removed previously. PTA 1 was interviewed on 7/’I6/03. His supervisor had scheduled the interview for 12:00 noon after his return from lunch. He was 20 minutes late. He stated that on the day of NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000614 State of California - Health and Human Services Agency Departmenl of Public Health SECTION 1424 NOTICE Page 4 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1634-0002023-S Date: 1112512003 Time: CLASS AND NATURE OF VIOLATIONS the incident, he did not recall planning or consciously wanting to torment Client I. The water bottle was sitting on the table near him and Client 1 was sitting with his back to him. PYA 1 just picked up the bottle and sprayed Client 1 on the back of the neck. He stated that the client jumped up and became agitated and began biting his thumb. He stated that he did perceive that Client 1 was very upset, but he just did it anyway. He expressed that he didn’t think the Client would really mind. He stated that he was aware that Client "1 was blind and had hearing toss and was care planned to always to be told what was happening or going to happen, but he thought it would be funny to squirt him and that he just wanted to "play with the Client." He stated that he did not recall spraying the client more than once. When asked how he would feel if someone did that to him, he stated that he wouldn’t like it at all. 2. Review of the clinical record of Client 2 revealed a 49year -old female was born prematurely. As a result of this, she was currently diagnosed as having mental retardation, autism, blindness secondary to rentrolental fibroplasias, and a seizure disorder. She has resided at the facility since she was 13 years of age. Her current IPP, dated 10t08/02, stated: "she can be tactually defensive if startled. She does best when approached gradually and given sufficient time to adjust to someone entering her personal space." The reporting TA was interviewed on 7/02/03 from 3:15 to 3:40 p.m. During the interview she stated that she entered the room and observed PTA 1 in the process of lowering himself to a sitting position, just above the head of Client 1. She stated that when he saw her observing him, he stood up: She stated that she believed that the PTA was using his behavior with the Client to provoke her (the TA). PTA 1 was interviewed on 7/16/03 from 12:20 p.m. untit 1:40 p.m. During the interview he stated that he did not intend NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000615 Sta!e of Cafifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 5 of 5 CITATION NUI~IBER: SECTIONS VIOLATED 15-1634-0002023-S Date: ’11/2512003 Time: CLASS AND NATURE OF VIOLATIONS to sit on the head of Client 1, but was just acting like that to tease/joke with the TA. He stated that he stood up when she saw him, and then sat down on the arm of the sofa, which he demonstrated to be between 2-3 inches wide. He stated that he knew he was not supposed to be sitting there in that manner, and didn’t know why he did it other than to tease/provoke the TA. When asked how Client 2 responded to him sitting down with his buttocks so close to her head and face, he stated "she was covered with a blanket and that anyway, she was blind and not able to see where his body was." When asked if he would find it offensive to have someone sit down that close to his head and face, he stated yes. When asked if he had considered that due .to the narrow surface that he was sitting on he could have lost his balance and fallen onto the face and head of Client 2, he stated, no. The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to Client 1. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000616 State of...caiifornia - Health and Human Services Agency Depadment of Public Health "SECTION 14,24 NOTICE Page ! of 3 CITATION NUI~IBER: 15-1284-0007781-S Date: 04t08/2011 Time: Type of Visit : Complaint Invest!g, YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR Incident/Complaint No.(s) ¯ CA00238251 APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76301(e) State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD Eldridge, CA 95431 15000Arnold Dr Intermediate Care Facility/Developmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000,00 Capacity: 581 DEADLINE FOR COMPLIANCE 4/22/11 12:00 a.m. CITATION-- PATIENT CARE T22 DtV5 CH8 ART 3-76301 (e) Required Services (e) Client care provided by all team members shall be safe and considerate as ordered or indicated by the needs of the client and in accordance with acceptable standards of practice, The facility violated the above regulation whenstaff members failed to ensure client care was safe as indicated by the needs of the client. A medically fragile client with elopement and alcohol seeking behaviors was not seen for over an hour before staff noticed he was missing. Meanwhile the client left the unit after dark, climbed a fence, broke into an office area, and ingested toxic substances. A review of the Individual Program Plan (]PP) dated t2/15/09 indicated CLient 1 had Profound Mental Retardation and Autism. The IPP documented Client 1 had behavioral issues including elopement and alcohol ingestion. The IPP indicated Client 1 had a history of alcohol overdose and coma. The IPP indicated Client 1 could be very cunning in his attempts at procuring alcohol and his persistent interest in aJcohol was a serious risk. During elopement, the risk of accidental injury was present due to poor safety awareness. The IPP indicated staff were to have visual and/or verbal contact with Client 1 no less than every 15 minutes. Name of EvaIuator: Linda Lucey HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000617 State of California - Health and Human Services Agency Page 2 of 3 SECTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health 15-1284-0007781-S Date: 04/08/2011 Time: CLASS AND NATURE OF VIOLATIONS A review of Client l’s clinical record reflected an Annual Medical Summary dated 11ti7/10 documented Client 1 had been on chemotherapy since multiple tumors were resected from the intestines 101.15/09. The summary docu.mented Client I had sudden left-sided weakness on 6114110 and was sent to an acute care hospital where an acute cerebrovascular accident (CVA) was successfully treated with emergent thrombolytic therapy. Client 1 had been maintained on anticoagulant therapy since the CVA. A review of a nursing monthly dated 8/7110 indicated a diagnosis of carotid artery dissection. The clinicaf record was flagged with "Anticoagulation Precautions" including, "Protect from injury." A review of a Behavior Support Plan (BSP) dated 8/10/10 documented Client 1 was at risk for ingestion of life-threatening amounts of alcohol, which heightened the risk of injury during an elopement. "The primary sources of alcohol had been hand sanitizer and alcoholic beverages. The BSP indicated Client 1 required supervision checks every fifteen minutes at all hours of the day. A review of an incident report dated 8/2t10 documented staff noticed Client 1 was missing at 11 p.m. when night shift did rounds. The report documented Client 1 was last seen at 9:45 p.m., over an hour before he was noted missing. Client 1 was located 10 minutes fater as he was trying to climb back over the fence into th~ courtyard. Client l’s mouth and clothing were covered in ground coffee and he had the distinct smell of Purell hand sanitizer on his breath. He was walking unsteadily which was unusual for him. Client 1 vomited up ground coffee. A review of a Physician’s Progress Note (PPN) of 8/3/10 documented Client 1 was encouraged to drink water and vomited copious amounts of coffee grounds until he vomited clear fluid. PPN’s documented about one hundred Pall Mall cigarette butts and a coffee filter full of used coffee grounds was found in Client 1 ’s boot. On 12/3/10, observations of an office area adjoining a day program revealed cigarette butts in a trash can in the area outside the back door. During concurrent interview an employee of the area stated Client 1 had opened an unlocked window and entered the area. Client 1 had found the coffee maker and at least one bottle of hand sanitizer belonging to the employees. The incident report of 8/2t’10, documented Staff L, the evening shift lead, had left work early without approval or knowledge of management. This left only three staff on the unit to supervise clients. During the time of Client l’s elopement, two peer clients were NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000618 State ot Calitornia - Health and Human Serv;ces Agency Department ot HUbflC Health ~SEC~ION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0007781-S Date: 04t08t2011 Time: CLASS AND NATURE OF VIOLATIONS engaged in behavioral episodes which required staff intervention. This left only one staff onthe floor to supervise the rest of the clients. During an interview on 10/28/10, the Unit Supervisor stated accountability logs showed the last client supervision checks for the evening were not done. Therefore, the facility failed to ensure staff checked on Client l’s safety every fifteen minutes as planned. Client I was a medically fragile client with poor safety awareness and a life-threatening alcohol seeking behavior, who eloped from the unit after dark, climbed a fence, broke into an office area, and ingested toxic substances without staff noticing his absence for over an hour. These facility failures had a direct or immediate relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS ~8 GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000619 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-t022-0002960-S Date: 0312212006 Time: Type of Visit ¯ Complaint Investig, YOU ARE HEREBY FOUND tN VIOLATION OF APPLICABLE Incidenl/Complaint No.(s) ’ CA00070959 CALIFORN IA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name; Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 72311(a)(2) State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP SNF Eldridge, CA 95431 15000 Arnold Dr (707) 938-6000 Skilled Nursing Facility Capacity: 427 150000229 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT DEADLINE FOR $700.00 COMPLIANCE 4/4/06 6:00 a,m. CITATION -- PATIENT CARE 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 follow the above regulation when it failed to follow the Individual Program Plan (IPP) as written requiring Client A to be in a wheel chair when she was taken off of her home unit, which resulted in her falling and sustaining a fractured right patella. Findings: On 1/24/06, Client A was on an outing with staff. Staff was walking with the client and heading back to the van when Client A stumbled and fell. No injuries were noted and Client A was able to continue to walk to the van and to her home unit. No signs of pain or discomfort were noted. The following morning,on 1t25/06,Client A was unable to bear weight. The physician saw her and an x-ray was Name of Evaluator: Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Jose Figueroa HFEN Signature : Name : Evaluator Signature : Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000620 State ,of Ca;ifornia - Health and Human Services Agency Department of Publig Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMRER: SECTIONS 15-1022-0002960-S Date: 03/22/2006 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED ordered, The x-ray confirmed a fracture of the right patella. The facility initiated an Incident Report (IR) on the fall and on 1t25t06 the Unit Supervisor recorded the following information in the IR: incident took place while Client A was on an outing. After bowling and dinner Client A was being escorted to the van when she tripped over her own feet, then tripped over a 6 inch berm and was then lowered to the ground by Recreation Therapist 1 (RT 1). Client A is blind so there is a possibility that had she been with staff who are familiar with her plans, this incident might have been avoided. There are two plans in Client A’s clinical record addressing her ambulation. The plan for Gtaucoma states she is at high risk for falls and requires supervision from staff to intervene in potential accidents related to movement on the Nelson B unit. The plan for Osteoporosis states the client walks with a sighted guide on hand held assistance as needed at all distances in the Nelson building. Client A is to use a standard adult wheelchair with foot rest,calf panel,and front fastening seat belt for distances outside of the Nelson building. A review of Client A’s clinical record on 2/1106, revealed that her Service/Health Care Objectives and Plans for Transfer and Walking Ability initiated 5/2/05 included the following: Walking: -Client walks with sighted guide or hand held assistance, as needed for all distances in the Nelson building. -May use platform v~alker with supervision or limited assistance, as needed, when fatigued or weak. Wheelchair: -Client uses a standard adult wheelchair with foot rest,calf panel,and front fastening seat belt for distance outside of the Nelson building. On 211/06,at 11:45AM,Psychiatric Technician 1 (PT 1) on Nelson B was interviewed regarding Client A’s fall on 1/24/06. PT 1 stated, "Client A knows her way around the unit. She is able to go to the bathroom by herself." PT 1 stated that, however; Client A should not be let off of the unit without her wheelchair and RT 2 took her off Nelson B without being told that Client A needed to be in her wheelchair. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000621 State pf California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1022~0002960-S Date: 03/22/2006 Time: CLASS AND NATURE OF VIOLATIONS Recreation Therapist (RT 2) was assigned to Nelson B and was with Client A during the outing when Client A fell. RT 2 was interviewed at 11:55 AM on 2tlt06. RT 2 stated that although she had previously reviewed Client A’s health care objectives for ambulation she did not remember that she was supposed to be in a wheelchair when she left Nelson B. In addition, RT 2 stated, the shift lead on the PM shift had signed Client A’s field trip form and did not say anything to he.r about Client A’s needing to be in a wheelchair. The facility’s failure to implement the individual program plan as written had a direct relationship to the health, safety, and security of Client A, and resulted in her fall and subsequent fractured patella. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000622 State of California - Health and Human Services Agency Department of Public Health SE,CTION 1424 NOTICE Page 1 of 4 CITATION NUMBER: 15-1155-0002030-S Date: 03/08/2004 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE Incident/Complaint No.(s) ¯ 150019512 CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS State of CA Dept of Developmental Services Licensee Name: Address: I600 9TH STREET, RM 340 150000089 License Number: State Agency Eldridge, CA 95431 15000 Arnold Dr (707) 938-6000 Skilled Nursing Facility Address: ~elephone: Facility Type: Facility ID: 72523(a) 72313(a)(5)(B) Type of Ownership: SONOMA DEVELOPMENTAL CENTER DIP SNF Facility Name: SECTIONS VIOLATED SACRAMENTO, CA 95814 Capacity: 427 150000229 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT DEADLINE FOR $900,00 COMPLIANCE 3f11104 12:00 a.m. CITATION -- PATIENT CARE 72313, Nursing Service-Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (5) All medications and treatments shall be administered only by licensed medical or licensed nursing personnel with the following exceptions: (B) Unlicensed persons may, under the direct supervision of licensed nursing or licensed medical personnel, during training or after completion of training and demonstrated evidence of competence, administer the following: 1. Medicinal shampoos and baths. 2. Laxative suppositories and laxative enemas. 3. Non legend topical ointments, creams, lotions and solutions when applied to intact skin surfaces. Unlicensed persons shall not administer any medication associated with treatment of eyes, ears, nose, mouth, or genitourinary tract. Name of Evaluator: DONNA BUSCOVICH HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature ¯ - Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000623 State of California - Health and Human Services Agency Depadment of Public Health SE,CTt, ON 1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS VIOLATED 15-1155-0002030-S Date: 03/08/2004 Time: CLASS AND NATURE OF VIOLATIONS 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 facility failed to follow the above regulations by failing to ensure: 1) That all treatments were administered by licensed staff only, with the exception that unlicensed staff may administer lotions and solutions to intact skin surfaces after training and evidence of competence. 2) That written patient care policies and procedures were implemented to ensure that patient related goals are achieved as follows: Resident A’s medical record documented she is 43 years old and has diagnoses that include spastic quadriplegia. Her Minimum Data Set dated 1/8/04 documents that she is severely impaired with cognitive skills fo~" daily decision-making, rarely or never understands or is understood. She is not ambulatory and needs total assistance with activities of daily living and is incontinent. Her Physicians’ Progress Notes dated 1/16/04 documented that she had a condition that was diagnosed as being either a sebaceous cyst or folliculitis on her left groin. Warm compresses were ordered to be applied daily to the area to assist in healing. An Interdisciplinary note (IDN) dated 1t21t04 at 10:00 p.m., documented that after receiving her compress, redness was noted in Resident A’s groin and pubic area. The Health Services Specialist (HSS) and physician were notified. The HSS documented in the IDNs that she was called to the unit to examine Resident A’s groin area. She found the area to be bright red with erythema (a form of macula (a small spot or colored area) showing diffused redness over the skin). The NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000624 State of California - Health and Human Services Agency Department of Public Health SE,CTION 1424 NOTICE Page 3 of 4 C~TATION NUMBER: SECTIONS VIOLATED 15-1155-0002030-S Date: 03f08/2004 Time: CLASS AND NATURE OF VIOLATIONS note documented that the erythema extended up to and across the lower abdomen just below the naval. The impression was that the patient received first and second degree burns secondary to the compress that was applied. A physician note dated 1/21/’04 at 10:10 p.m., documented that unit staff noted redness with blistering to her pubic and groin area after a warm compress was applied. The physician also observed blistering. The physician determined Resident A received first and second degree burns. Resident A’s physician ordered Morphine and Ibuprofen for pain on 1 t22t04. Unit staff were interviewed on 1/23/04. Registered Nurse 1, who was on duty at the time that the burns occurred, stated that she gave a damp washcloth to PTA 1 to perform the warm compress treatment Psychiatric Technician Aide (PTA) 1 stated that she was told to provide a warm compress to Resident A’s groin area, She stated that she placed a damp washcloth in the microwave for one minute and tested the temperature on her inner arm so that she knew that is was.OK and placed it over the groin area of Resident A. She was then called away to assist another resident. She returned in 15- 20 minutes and noted that Resident A’s groin area was red. She notified the nurse. The PTA was asked if she had ever received instruction on the application of a warm compress and she stated she had not. She stated that she had applied a warm compress to Resident A previously by the same method, but had not left it on as long as she had when Resident A was burned. An IDN dated 1t22/04 at 12:30 p.m. documented that she showed signs of pain by restlessness, grinding teeth, red face and increase in heart rate. On 1t23t04 at 4:30 p.m., Resident A’s temperature was noted to be 100.7 and a physician order was received to transfer her to the facility’s acute care unit, A Physician Progress Note (PPN) dated 1t24/04 documented that Resident A was admitted to the acute care unit due to burns in the left groin and thigh areas, which resulted in NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000625 State ef California - Health and Human Services Agency Department of Public Health SE,CTtlON 1424 NOTICE Page 4 of 4 CITATION NUI~IBER: SECTIONS VIOLATED 15-1155-0002030-S Date: 03/08/2004 Time: CLASS AND NATURE OF VIOLATIONS cellulitis. The physician described the burns as second and third degree over her thigh, groin and the area below her navel. She was provided Intravenous antibiotics and fluids and returned to her unit on 1/29/04, Her unit physician documented that the areas were healing well but 2 areas could be third degree burns, A surgery consult to address her burns was ordered. A nursing procedure titled Hot and Cold Application requires that only a registered nurse, licensed vocational nurse, or a psychiatric technician are to apply a warm compress. A PTA is only allowed to apply a cold pack to intact skin. The procedure specifically states that a microwave can be used to heat the warm compress solution and the temperature cannot exceed 105 degrees. The procedure documents that a thermometer may be used to test the temperature of the solution. In bold, capital letters, the procedure documents, "Never heat compress directly in microwave". Resident A received thermal burns related to an improperly applied compress. An aide applied the compress though it was against regulation and not allowed by facility nursing proce~dures. Resident A sustained second and third degree burns and pain and required admission to the acute care hospital for treatment. Therefore, the facility failed to ensure that all treatments are administered by licensed staff only, with the exception that unlicensed staff may administer lotions and solutions to intact skin surfaces after training and evidence of competence and that written patient care policies and procedures are implemented to ensure that patient related goals are achieved. These facility failures had a direct relationship to the health, safety, or security of residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000626 ¯ State of California - Health and Human Services Agency Department of Public Health Page 1 of 2 SECTION 1424 NOTICE CITATION NUMBER: 15-1284-0003089-S Date: 05/18/2006 Time: Type of Visit : Complaint lnvestig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE IncidenliComplaint No.(s) ¯ CA00060748 CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 72527(a)(11) 72311(a)(2) State of CA Dept of Developmental Services 1600 9TH .STREET, RM 340 150000089 SACRAMENTO, CA Type of Ownership: 95814 State Agency SONOMA.DEVELOPM’ENTAL CENTER D/P SNF Eldridge; CA 95431 15000 Arnold Dr (707) 938-6000 Skilled Nursing Facility Capacity: 427 150000229 PENALTY ASSESSMENT $800.00 CLASS AND NATURE OF VIOLATIONS CLASS B DEADLINE FOR COMPLIANCE 5;25/06 6:00 a.m. CITATION-- PATIENT RIGHTS 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. 72527(a)(11) 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: (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. The facility failed to ensure a resident’s right to be treated with dignity and respect in the care of personal needs and to implement the care plan when one staff threw a resident Name of Evaluator: Without admitting guilt, t hereby acknowledge receipt of this SECTION 1424 NOTICE Linda Lucey HFEN Signature : Name : Evaluater Signature " Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000627 Stat’e of Cafifornia - Health and Human Services Agency Departmenl of Public Health SECTION 1424 NOTICE Page 2 of 2 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0003089-S Date: 05118/2006 Time: CLASS AND NATURE OF VIOLATIONS in bed from a distance of two to three feet. During interview on 2/1/06 at 5:30 a.m., Staff B stated StaffA was upset on the evening of 9t7/05. Staff B stated Staff A was "flipping out" in Resident 2’s room, kicking property and verbalizing profanities. Resident 2 was lying on a bathing trolley. Staff B offered to assist Staff A with transfer of Resident 2 to her bed. Staff A refused assistance and before Staff B could intervene, Staff A picked up Resident 2 and threw her in bed from a distance of two to three feet away. Staff B stated Staff A threw Resident 2, "like a sack of potatoes." Resident 2 landed on the mattress and bounced from the force of the impact. Record review on 11t02105 at approximately 3 p.m., indicated Resident 2 has profound mental retardation and severe spastic quadriptegia. Resident 2’s care plan included special alerts describing advanced degenerative spinal disease, severe osteoporosis and a history of fractures. A care plan indicated in bold, "ALERT fracture risk Cervical Degenerative Disease Precautions ... Do not use any external pressure to bend or turn head in any way. At risk of FRACTURE ...Totally dependent-Lift Style: Manual lift, minimum of 2 persons." During interview on 1t4t06 at approximately 4 p.m., Staff J stated she was at the nurses’ station on the evening of 9/7/05 when she heard a loud and startling "bed" noise coming from Resident 2’s room. Immediately after, Staff B rushed out of the room to speak with Staff C. On 11/15/05 at approximately 3:30 p.m., Staff C stated she was in charge on the evening of 9/7/05. Staff C stated she was at the nurses’ station about 10 p.m. and" ... ~ heard a big noise like something fell. (Staff B) came to me ... (and) said ...(Staff A) ... threw (Cli.ent 2) into bed." These violations lead Resident 2 not being treated with dignity and respect during care needs and did not have the care plan implemented as written. These facility failures had a direct or immediate relationship to the health, safety, and security of long-term health care facility patients or residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAI=TEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000628 State’bf California - Health and Human Services Agency Department of Public Health SECTION t424 NOTICE Page 1 of 2 CITATION NUI~IBER: 15-1284-0003560-S Date: 12t12/2006 Time: Type of Visit : Complaint Investig. Incident/Complaint No.(s) ¯ CA00079423 YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: ~:acility Type: Facility ID: SECTIONS VIOLATED 72315(b) State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP SNF Eldridge, CA 95431 15000 Arnold Dr (707) 938-6000 Skilled Nursing Facility Capacity: 427 150000229 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $300.00 DEADLINE FOR COMPLIANCE 12/19106 6:00 a.m. CLASS B CITATION -- PATIENT CARE 72315(b) Nursing Service--Patient Care (b) Each patient shall be treatedas individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. The facility failed to ensure each resident was treated with dignity and respect and not subjected to verbal abuse of any kind when a staff member used harsh verbal tones and words when speaking about a resident in the presence of the resident. On 6/8/06 a review of an incident report dated 4t23/06 documented Volunteer Advocate B reported Staff Member A spoke in an agitated tone about Resident 1 in the presence of Resident 1 stating Resident 1 is a nuisance and deliberately makes work for them (staff). On 8/15/06, review of an annual assessment dated 10/5105 indicated Resident 1 is at a pre-speech level developmentally, but is very communicative with facial expressions and vocalizations, She acknowledges people with direct eye contact and smiles. She will reach out with her arms to indicate happiness, she will cry, frown, crinkle her eyes, and push undesired object away to.indicate discomfort or unhappiness. The assessment indicated staff report facial expressions are very readable. Name of Evaluator: Wil.hout admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Linda Lucey HFEN Signature: Name : Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000629 Stateof California- Health and Human Services Agency Department of Public Heallh SECTION 1424 NOTICE Page 2 of 2 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0003560-S Date: 12/12/2006 Time: CLASS AND NATURE OF VIOLATIONS During interview on 8/23/06 at 12:30 p.m., Volunteer Advocate B stated Staff Member A came into the room and in front of Resident’l stated Resident 1 was a "difficult" resident, was a "nuisance", and was, "... doing things on purpose to make us work more". Advocate B stated Staff Member A used a harsh tone of voice, was abrupt, and seemed angry. Advocate B stated Resident 1 seemed to pick up on the agitation and verbal tone of Staff Member A. Resident 1 reached out to Advocate B, held tightly to Advocate B’s hands, and cried during the incident. Therefore, the facility failed to ensure each resident was treated with dignity and respect and not subjected to verbal abuse of any kind. These facility failures had a direct or immediate relationship to the health, Safety, or security of ]ong-term health care facility residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000630 Stale of California - Health and Human Services Agency Department of Public Heallh SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-1022-0003693-S Date: 02f20/2007 Time: Type of Visit ¯ Complaint tnvestig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE }ncident/Complaint No.(s) ’ CA00098845 CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: . Facility ID: SECTIONS Slate of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: Stale Agency SONOMA DEVELOPMENTAL CENTER D/P SNF EIdridge, CA 95431 15000 Arnold Dr (707) 938-6000 Skilled Nursing Facility Capacity: 427 150000229 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $700.00 VIOLATED 72527(a)(9) 72527(a){11) CLASS B DEADLINE FOR COMPLIANCE 2/27/07 6:00 a.m. CITATION -- PATIENT RIGHTS 72527(a)(9) Patients’ Rights 72527(a)(11) 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. (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. The facility failed to maintain Resident A’s right to be free from mental and physical abuse and failed to treat clients with dignity and respect when Psychiatric Technician (PT 1) slapped Resident A on the buttocks and yelled at her during routine bedside ca re. On 11/15/06, PT 1 and Registered Nurse 1 (RN 1) were cleaning Resident A when PT 1 became frustrated and slapped Resident A on the buttocks with an open hand and Name of Evaluator: Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Jose Figueroa HFEN Signature : Name: Evaluator Signature : Title : NOTE: tN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000631 State of California - Health and Human Services Agency Department of Public Health SECTI~)N 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1022-0003693-S Date: 02f20/2007 Time: CLASS AND NATURE OF VIOLATIONS made statements at how difficult it was to clean Resident A, RN 1 said she would finish cleaning Resident A but PT 1 insisted On completing the task. PT 1 then grabbed the Resident A’s legs and changed the Attends (name brand for adult diapers). RN 1 assessed the resident and found no signs of physical injury and filed an Incident Report (IR). On 11/15/06 at 0550 (5:50AM), RN 1 initiated an IR stating the following: "Around 0550 AM 1 tt15/06 as we were doing our rounds... (PT 1) called me to assist her in changing/cleaning (Resident A) who was covered with feces on her bottom and thighs. She asked me to hold the client’s hands to prevent her from scratching or touching her bottom. (PT 1) was very frustrated and irritated then smacked the client hard on her (left) bottom then yelled ’you are fucking difficul!!’ I offered to help clean the client but she would not let me. ’Just hold her hands and let me do it’ then she roughly rolledlpulled her legs (Resident A) and bottom towards the client’s head just like rolling a hay bail as she was putting.., the client’s Attends on which was very unsafe to do. ! did a quick assessment on (Resident A) just to make sure she was all right before we left her room and proceeded to special the rest of the clients. I did not notice any visible mark on her left. bottom where (PT 1) hit her with .her open (right) hand at that time. (Resident A’s) breathing was normal and she did not appear to be in pain..." On 1 t/29/06 at 3:05 PM, RN 1 was interviewed a second time via telephone and repeated what she had reported in the signed statement on the IR. RN 1 also stated that she was not a regular employee of the facility but worked for a nurse registry that contracted with the facility and she had not worked directly with PT 1 prior to this incident. PT 1 was interviewed on 1/3t07 via telephone and responded to the allegation that she had physically and verbally abused Resident A. She stated that they were doing last rounds. She went over to Resident A and noticed she had a bowel movement. She stated that Resident A moves around a lot. When the Attends are taken off the Resident goes right for her vagina. Resident A has frequent vaginal infections, PT 1 said she could not care for Resident A alone and called RN 1 to help her. PT 1 asked RN 1 to hold the resident’s hands and told RN 1 that she would do the rest, RN 1 came over and held Resident A’s hands. RN 1 let go of one hand to help me and when she let go Resident A reached down and got feces on her hand. PT 1 stated that she then cleaned Resident A’s hands and told RN 1 to hold the resident’s NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000632 State of California - Health and Human Services Agency Department of Public Health SE~TION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1022-0003693-S Date: 02/20/2007 Time: CLASS AND NATURE OF VIOLATIONS hands and not let go. Resident A had feces all over her back. Resident A was rolled over to clean her back. PT 1 then told RN 1 that Resident A was very difficult to clean, PT 1 stated that she was talking to both RN I and Resident A because Resident A is always difficult to clean up due to her moving around and her hands getting into her feces. PT 1 told RN 1 that you can never let go of Resident A’s hands, Then we left the room and finished rounds. RN 1 never said anything to me and PT 1 stated she had never worked with RN I before. PT 1 had no idea why RN 1 made the allegation except that PT 1 told her not to let go of Resident A’s hands, Resident A’s right to be free from mental and physically abuse and to be treated with dignity and respect was not maintained when PT 1 slapped Resident A on the buttocks and yelled at her during routine bedside care. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents, NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000633 Stale of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-11!6-0003148-F Date: 08/13/2007 Time: Type of Visit : Complaint Investig. YOU ARE HERESY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name; Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED Incident/Complaint No.(s) ¯ CA00064672 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP SNF Eldridge, CA 95431 15000 Arnold Dr (707) 938-6000 Skilled Nursing Facility Capacity: 427 150000229 PENALTY ASSESSMENT $90,000.00 CLASS AND NATURE OF VIOLATIONS DEADLINE FOR COMPLIANCE 8/27/07 6:00 a.m. CLASS AA CITATION -- PATIENT RIGHTS F224 F224 §483.13(c) STAFF TREATMENT OF RESIDENTS The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. (Use F224 for deficiencies concerning mistreatment, neglect or misappropriation of resident property.) The facility failed to comply with the above regulation by failing to ensure that Client 1 received appropriate services to prevent the swallowing of three lemon glycerin swabs. This failure lead to Client I sustaining a puncture wound between his esophagus and aorta, resulting in his death. Review of Interdisciplinary Notes (IDNs) dated 10/22/05, Staff A stated the following: At 9:15 (a.m.): "When I got inside Rm (room) 121, I saw [Client 1] vomiting c (with) blood, I called the clinic person right away, as soon as I saw a lot of blood .... "Staff B stated in the IDNs, at 9:15 (a.m.)," We saw he throw-up the glycerin swab as well. "At 10:45 a.m.: Staff C stated, "Staff observed an emesis from [Client 1 ] containing frank (obvious, clearly evident) blood ... appeared [Client 1] threw up a toothette swab & (and) swab end was covered c (with) clotted blood." Client 1 was transferred to a local General Acute Name of Evaluator: Gregory Hannan HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name: Evaluator Signature Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000634 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1116-0003148-F Date: 08/13/2007 Time: CLASS AND NATURE OF VIOLATIONS Care Hospital (GACH) at 9:35 arm., on 10/22t2005. At 0315 (3:15 a.m.) on 10/23/2005, Sonoma Developmental Center was notified that Client 1 expired at 0230 (2:30 a.m.) Review of Client l’s record stated that he was 25 years old with diagnoses which included cerebral palsy (condition affecting control of the motor system due to lesions in various parts of the brain), quadriparesis (partial paralysis of both arms and both legs), epilepsy, dysphagia (difficulty in swallowing), profound mental retardation, history of esophagitis (inflammation of the esophagus), GERD (gastric esophageal reflux disease - backward flow of stomach digestive juices into the esophagus), and a history of pneumonia due to aspiration (inhalation of food particles andtor liquid into the lungs). Review of Client l’s most recent full Minimum Data Set (MDS), dated 06/01/2005, stated that he was totally dependent on staff for all Activities of Daily Living, was confined to a special wheelchair, had highly impaired vision, and a limitation in the use of both arms with a partial loss of voluntary movement. Review of Client l’s Resident Assessmen1 Protocols (RAPs), dated 06/08/2005 contained in his Individual Program Plan (IPP), stated that he had a Jejunostomy feeding tube (a tube in. the upper portion of the small intestine to deliver food and medications) due his chewing problems, dysphagia, and hand dexterity problems. The RAPs further stated that "oral hygiene is provided daily by staff .... [Client 1] has an order to use a moistened toothette to gently clean the backside of the top front teeth and gums every AM and PM when teeth are brushed .... Staff discussed the reason for the use of the toothettes, ’it is due to relation to his thumb to mouth activity’, that this was soothing intervention and would provide moisture if dry and irritated area was present." Physicians Orders dated 10/15/200,5 show an order which reads, " Use moistened toothette to gently clean the backside of the top front teeth + the gums behind top front teeth, every AM & PM,’when teeth are brushed daily". Review of Client 1 ’ s Medication and Treatment Record for SEPIOCT (September/October) 2005, a period of 31 days, revealed that the client receive oral care twice daily with a moistened toothette, as noted by staff initials. Interview with Staff F revealed that the equipment required to give oral care would have been set on the client’s "side table and not on the bed." The Autopsy findings, dated 10/25/2005, stated the following: "1. Massive gastrointestinal hemorrhage (MGH): A. Acute traumatic aorto (main artery leaving the heart)-esophageal fistula (wound between the aorta and the esophagus) with granulation tissue (formation in wounds of small, rounded fleshy masses) between descending NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000635 Stale of California - Health and Human Services Agency Department of Public Health SI~CTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1116-0003148-F Date: 08/13/2007 Time: CLASS AND NATURE OF VIOLATIONS thoracic aorta and esophagus. B. Two plastic-handled cotton swabs in upper stomach .... Cause of Death: Acute Massive Upper Gastrointestinal Hemorrhage. " Under Comments, in the Autopsy findings, the following was noted: "This 25 year old man with cerebral palsy, quadriplegia with limb contractures, severe mental retardation...died as a result of a Massive Gastrointestinal Hemorrhage due to a traumatic aorto-esophageal fistula (an opening between the aorta and the esophagus) occurring hours prior to his death and initiated days prior as the result of esophageal injury from a plastic-handled cotton-tipped swab. The decedent’s conditions of quadriplegia with body and limb deformity related to cerebral palsy rendered him, in my opinion, very unlikely to have introduced the swabs to himself." Duiing an interview with Staff D, on 05/24t2006 at 11 a.m., it was stated that: " [Client 1} had no fine motor skiJls of his hands, could not grasp anything and had only spastic hand to mouth movements. " During an interview with Direct Care Staff E, on 05/24/2006 at 11:30 a.m., it was stated that: " tClient 1] would pick at his teeth with his right thumb, he could swallow his oral secretions, but nothing was given by mouth. "When Staff E was asked if Client 1 could push anything into his mouth, Staff E further stated that: " If a toothette had been left in [Client l’s] mouth, it would have been possible for him to push it further in," The facility failed to ensure that Client 1 received care to prevent the swallowing of lemon glycerine swabs when he was totally dependent upon staff for all aspects of daily care. Based on record review and staff interview, this client was not capable of placing the swabs into his mouth due to the lack of fine motor skills. This lack of care led to the client suffering a puncture wound of the esophagus through to the aorta, resulting in the client bleeding to death internally. This facility failure presents either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom, and was a direct proximate cause of death to the patient or resident of the long-term health facility. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000636 State of California - Health and Human Services Agency Deparlment of Public Health SECTION 1424 NOTICE Page 1 of 2 CITATION NUN1BER: 15-1594-0004381 -S Date: 10130/2007 Time: Type of Visit : Complaint Investig, YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 72523(a) Incident/Complaint No,(s) ¯ CA00128735 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA Type of Ownership: 95814 State Agency SONOMA DEVELOPMENTAL CENTER DIP SNF Eldridge, CA 95431 15000 Arnold Dr (707) 938-6000 Skilled Nursing Facility 150000229 Capacity: 427 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $600.00 DEADLINE FOR COMPLIANCE 11/12t07 6:00 a,m. CITATION-- PATIENT CARE 72523(a) PATIENT RIGHTS (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to comply with the above regulation by failing to ensure the procedure for "Warm and Cold Application " was implemented when staff warmed a compress in the microwave oven, resulting in a first degree burn to the client’ s feft axilla area. The Individual Program Plan, (fPP), dated 7t17t07, revealed that Client I is a non verbal individual and is totally dependent on staff for all activities of daily living. Physician Progress Notes, (PPN’s), dated 9t27t07, revealed that Client 1 had a 1.5 cm. nodule at the left mid axilla with some purulent drainage. Warm compresses were ordered every shift for 7 days. PPN’s dated 10f4t07 revealed that Client 1 continued to have a pustule in the left axilla. Warm compresses were increased to every 4 hours for 5 days. PPN’s, dated 10t06/07, revealed that warm compresses to the left axilla were warmed in the microwave and burned the client’ s skin, resulting in a first degree burn. The left Name of Evaluator: CAROL DEVITA HFEN Without admitting guilt. I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evatuator Signature ¯ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000637 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 2 C~TATION NUMBER: SECTIONS VIOLATED 15-1594-0004381-S Date: 10/30/2007 Time: CLASS AND NATURE OF VIOLATIONS axilla showed some erythema on the inner arm and chest wall. Facility documentation revealed that the burn measured 5 cm x 2.5 cm., at the upper axilla, and 5.5 cm. x 3 cm. at the lower axilla. The Nursing Procedure for "Warm and Cold Applications" includes the following: Warm Application - If microwave is used, heat solution then saturate compress. Never heat compress directly in microwave. Check area for increased redness within 1 to 2 minutes after initial application. Skin may be sensitive to heat. During an interview with Psychiatric Technician staff on 10/11/07 at 3:15 p.m., staff stated that she used a wash cloth wrapped with gauze for the compress. She stated that she used water to wet the cloth and then heated the wash cloth for 30 seconds in the microwave, She stated that the cloth felt warm but did not feel too hot. She further stated that she did not return to check the client ’ s skin after the compress was applied. The facility is in violation of the above regulation by failing to ensure Nursing Protocols were implemented for the correct procedure for application of warm compresses and for rechecking of the skin after the initial application of heat. The above violation had a direct relationship to the health, safety, or security of the Resident. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000638 State oflCalifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-0786-0004422-S Date: 04/01/2008 Time: Type of Visit ’ Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 72311(a)(1 )(A) Incident/Complaint No.(s) : CA00130169 Sta~te of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP SNF 15000 Arnold Dr Eldrid~e, CA 95431 (707) 938-6000 Skilled Nursing Facility 150000229 Capacity: 427 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 4/15/08 12:00 a,m. CITATION -- PATIENT CARE T22 DIV5 CH3 ART3-72311 (a)(1)(A) Nursing Service--General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient’s needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. Based on interview and record review, the facility failed to assess Resident l’s behavior of putting non-eatable items in her mouth by failing to assess on-going staff observations, and documentation of this behavior. This failure resulted in the resident choking on an exam glove necessitating emergency intervention. On 10/30/07 review of the facility reported incident indicated that on 10/23/07 at 1 p.m. staff observed Resident 1 choking. Staff summoned assistance and a vinyl glove was removed from the resident’s mouth. The resident recovered immediately. Review of the resident record on 10/31/07 revealed that Resident I was a 54 year old with a history that included seizure disorder, dysphagia (difficulty swallowing), gastro-esophageal reflux disease (regurgitation of stomach contents) and profound Name of Evaluator: Ann Fitzgerald HFEN Without admitting guilt I hereby acknowledge receipt of this SECTION 1424 NOT}CE Signature ’ Name ¯ Evaluator Signature : Title ’ NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT. VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000639 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-0786-0004422-S Date: 04101/2008 Time: CLASS AND NATURE OF VIOLATIONS mental retardation. The resident was described as totally dependent on staff for assistance with activities of daily living, required total assistance with meals by staff, and was able to ambulate about the immediate area with the use of a wheel chair. Resident 1 was non-verbal and not interviewable. There was no evidence in the record prior to this incident that the resident had been assessed for putting non-eatable items in her mouth. According to an IDN (Interdisciplinary Note) dated 10/23/07 "Client was observed frothing from both sides of her mouth, skin turning red slightly bluish. Staff assisted client to floor for comfort and removed her helmet. Code called emergency cart obtained. During examination finger swiped her mouth and removed vinyl exam glove. As soon as the glove removed client started to recover...." Review of IDN’s reflected the following incidents: 10t2t07 1 p.m.: "Client observed in active chewing - upon inspection staff removed small plastic (blue) pieces from her mouth." 10f5f07 2 p.m.: "Client observed chewing X2 between meals upon first inspection removed string and later in class while out on patio removed leafs (sic) will continue to monitor and notify M.D. and refer to CPP (Client Protection and Prevention)," 10t6t07 11 a.m.: "removed blue plastic from her mouth. Appears to have possibly torn some plastic from her adult briefs. Will continue to monitor." A CPP meeting dated 10/9/07 indicated a discussion of the incident that occurred 10t6t07 and read: "doesn’t appear to swallow items and allows staff to remove items. This happens in both the classroom and on the unit. Staff will be reminded to keep environment as clean as possible." During an interview on 10t31/07 at noon, Staff A stated she had observed and removed things from the resident’s mouth such as cotton, string, piece of attends, and paper towel. Staff stated that the behavior occurred about once a month. During interviews on 11tl/07 between 10 and I0:30 a.m., Staff B, C and D stated they had observed Resident 1 put non-eatable things in her mouth like paper, string, piece of attends and threads "maybe from a washcloth", which had to be removed. The facility failed to show evidence of an assessment of this resident’s behavior to put non-eatable items in her mouth although the behavior had been observed by many staff and documented prior to this incident of choking that occurred on 10t23/07. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000640 State of California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-0786-0004422-S Date: 04/01/2008 Time: CLASS AND NATURE OF VIOLATIONS This failure had a direct or immediate relationship to resident health, safety and security, NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000641 State bf California - Health and Human Services Agency Departmenl of Public Health SECTION 1424 NOTICE Page I of 2 CITATION NUMBER: 15-1022-0004909~S Date: 04116/2008 Time: Type of Visit Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED Incident/Complaint No.(s) ’ CA00138963 Slate of CA Dept of Developmental Services ¯ 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP SNF Eldridge, CA 95431 15000 Arnold Dr (707) 938-6000 Skilled Nursing Facility Capacity: 427 150000229 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $700.00 72527(a)(9) CLASS B 72527(a)(11) T22 DIV5 CH3 ART5 - 72527(a)(9)(11)- PATIENTS! RIGHTS DEADLINE FOR COMPLIANCE 4/28t08 12:00 a.m. CITATION -- PATIENT 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. (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. The facility failed to maintain Client 2’s right to be treated with consideration, respect and dignity and failed to ensure that Client 2 was not abused when Psychiatric Technician Assistant B (PTA B) told Client 2 that she was "smelly", and was observed placing a sheet over the face of Client 2 and then pushing her face backward in a rough manner. Findings: Name of Evaluator: ’vMthout admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Jose Figueroa HFEN Signature : Name: Evaluator Signature ’ Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS tS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000642 Slate’of California - H&alth and Human Serv;ces Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 2 CITATION NUMBER: SECTIONS 15-1022-0004909-S Date: 04t16/2008 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED On 1125/08, the facility initiated an Incident Report (IR) documenting a statement by Psychiatric Technician AssiStant C (PTA C) that on 1122/08, at 10:20 a.m., the following incident occurred. "(PTA B) asked assistance from me to transfer (Client 2) from bed to chair. (Client 2) was leaning forward in the chair. (PTA B) said (Client 2) was smelly, put a bed sheet covering (Client 2’s) face and roughly pushed (Client 2’s) face back. This happened on 1 t22/08." On 1/31/08, at 1:30 p.m. PTA C was interviewed regarding her allegation of physical abuse by PTA B..PTA C stated that her signed statement in the lR was correct. "1 observed her cover (Client 2’s) face with asheet and push (Client 2’s) face back." PTA C stated that recently she had heard PTA B complain a lot about her job, and that she seemed to be upset about something. PTA B was interviewed on the telephone on 2/14/08 at 10:15 a.m. regarding her alleged abuse of a different client (Client 1) which had occurred approximately 15 minutes after her alleged abuse of Client 2. In addressing her alleged abuse of Client 2, PTA B reiterated that she walked from the unit to Central Supply for gowns and masks and back to the unit. She then took her lunch at 10:30 a.m. and was therefore not on the unit at the time of either incident and the abuse could not have occurred. A review of the information provided by PTA B to explain why she was not on the unit at the time of the incidents could not be validated. The records at Central Supply did not substantiate that PTA B or any other Nelson A staff picked up gowns or masks on 1/22t08, as she claimed for the reason for not being on the unit during the time of the incidents. In addition, two Nelson A staff, including PTA C declared in a signed statement that she was on the unit during the time of the incidents and had been observed mistreating clients, including Client 2. The placing of a sheet over Client 2’s face and then pushing her face back resulted in a failure to protect Client 2% right to be treated with respect and dignity and to be free from abuse. These failures had a direct or immediate relationship to the health, safety or security of Client 2 and to the long-term health care facility clients. NOTE: IN ACCORDANCE WiTH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000643 Stale of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-1022-0004906-S Date: 04/16/2008 Time: Type of Visit ¯ Complaint I nvestig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 72527(a)(9) 72527(a)(11) Incident/Complaint No.(s) : CA00138959 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP SNF Eldridge, CA 95431 15000 Arnold Dr (707) 938-6000 Skilled Nursing Facility 150000229 Capacity: 427 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $700.00 DEADLINE FOR COMPLIANCE 4t28/08 12:00 a.m. CITATION -- PATIENT RIGHTS T22 DIV5 CH3 ART5-72527(a)(9)(11)- 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 representati.ve 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. (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. The facility failed to maintain Client ~l’s right to be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs and to be free from physical abuse when a Psychiatric Technician Assistant B (PTA B) was observed holding Client 1 at the waist and with her other hand pulling the client by the hair to transfer her. Findings: Name of Evaluator: Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Jose Figueroa HFEN Signature : Name: Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS tS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000644 State of, California - Health and Human Services Agency Deparlment of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1022-0004906-S Date: 04/16/2008 Time: CLASS AND NATURE OF VIOLATIONS On 1125/08 the facility initiated an Incident Report (IR). The IR documented the following signed statement from Psychiatric Technician A (PT A): "On 1/22/08, (PTA B) was trying to transfer (Client 1) from (sic) bed to chair. (PTA B) (sic) holding Client’s waist and on (sic) her other hand grabbed client’s hair, pulled (sic) it to transfer her." The approximate time of the incident is documented as 1/22/08 at 10:30 a,m. On 1/31/08, at 1:05 p.m. PT A was interviewed regarding the statement of observation she documented in the IR. PT A stated that she saw PTA B transferring (Client 1) out of her bed into a chair and she was doing it without assistance and she had not asked anyone to help her. PT A stated that what she reported in the IR was what she observed, "PTA B pulled Client l’s hair while trying to transfer her," On 2/14/08 PTA B was interviewed by telephone regarding the allegation of PT A. PTA B stated that she was on break a 10:30 when the incident was supposed to have occurred. "1 went to Central Supply to get gowns and masks for another client. PTA B stated that she walked from the unit to Central Supply and back to the unit and took her lunch at 10:30 a.m.. PTA B stated that the. person who reported her was .on bleak from 9:30 through 10:30 a.m., "So how could she see me at that time. I did work with (Client 1) earlier, but the incident did not occur. I was not on the unit." On 4/8/08, at 10:00 a,m., The Supervisor of Central Supply was interviewed regarding the system of documentation utilized by Central Supply to log request for Issues from Stock. The Supervisor of Central Supply stated that all request for Issues from Stock were hand written when received and then as soon as possible entered into the computer with the Item Number/Description, the name of the Unit receiving the item and the date it was requested. The Supervisor of Central Supply stated that all request orders were filled immediately on request unless they were not a standard stock item. The latest that Issues from Stock were entered in the computer was on the day following the request. A review of the computer log for Issues from Stock indicated that no request for gow,ns or masks were made by Nelson A on 1t22t08 or 1/23/08. On t/31/08, at 1:30 p.m., during an interview with PTA C regarding the investigation of an allegation of abuse of another client by PTA B, PTA C stated that PTA B was on the unit working with her at approximately 10:20 a.m. on 1/22/08. NOTE; IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION QF YOUR LICENSE DPH POD 000645 Stat,e of California - Health and Human Services Agency Depadmen! of Public Health SECTION t424 NOTICE Page 3 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 15-1022-0004906-S Dale: 04f16/2008 Time: CLASS AND NATURE OF VIOLATIONS The pulling of Client l’s" hair by PTA B, while Client i was being transferred from her bed to a wheelchair was a failure to protect Client I from physical abuse and a failure to treat Client 1 with consideration, dignity and respect in care of the client’s personal needs. These facility failures had a direct or immediate relationship to the health, safety, or security of Client 1 and tong-term health care facility clients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000646 Slate.. of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-1594-0005037-S Date: 05t27/2008 Time: Type of Visit ¯ Complaint[ Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 723t3(a)(2) IncidenttComplaint No.(s) : CA00140385 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P SNF Eldridge, CA 95431 15000 Arnold Dr (707) 938-6000 Skilled Nursing Facility Capacity: 427 150000229 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT DEADLINE FOR $8oo.oo COMPLIANCE 6/6/08 12:00 a.m. CLASS B CITATION -- MEDICATION 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 comply with the above regulation by.failing to ensure medications were administered, as prescribed. The Individual Program Plan, dated 3115t07, indicated that Client 1 requires assistance in all activities of daily living, has severely impaired decision making ability, and has limited self help skills. An interview with Supervisory Staff A on 2/25t08 at 1 t :15 am., indicated that Client 1 had a recent urinacy tract infection and continued to display signs and symptoms of discomfort. On 2/08t08, an order was requested for Pyridium, a medication that exerts anesthetic action on the urinary tract mucosa. Staff A stated that Psychiatric Technician, Staff B, contacted the physician by telephone and an order was received for Pyridium, 200 rag. tid (three times daily) for 2 days. Staff A stated that because Staff B worked part time and was unfamiliar with the computer Name of Evaluator: Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE CAROL DEVITA HFEN Signature : Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAI=TEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000647 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1594-0005037-S Date: 05t27/2008 Time: CLASS AND NATURE OF VIOLATIONS ordering system, she (Staff B) requested assistance from Staff A to input the order into the computer. An interview with Staff B on 3/18/08 at 11:15 a.m., confirmed that she received a telephone order from the physician for the above medication. Facility documentation indicated that the physician indicated that she could not remember the generic name but that it began with "phenazo..." Facility "Client Protection and Prevention" documentation indicated that when the order was entered via the PES (Prescription Entry System) everything looked correct until the order was accepted, The printer had printed out "quetiapine fumarate," a name that Staff A and Staff B "were unfamiliar with." Further documentation indicated that staff assumed that the computer translated from the brand name to the generic and took quetiapine fumarate to be the generic version of Pyridium. Further facility documentation stated, "Our mistake was not to verify that what was printed was the same reed that was ordered before transcribing and giving to the client." When the order printed out from the PES computer, it read "Quetiapine Fumarate 200.000 mg tablet, SIG. (directions) TID 3 TIMES DAILY WITH MEALS, ROUTE PO,( by mouth). Start 2/08t08 11:22 end 2/10/08 11:21. UTI (urinary tract infection)." Staff A stated that the order for Quetiapine was transcribed onto the Medication Administ~:ation Record. FaciLity documentation revealed that the medication was prepared by the pharmacy. The medication was approved for .pickup by unit staff and was administered to the client at 12:30 p.m. At 3 p.m., as staff enteied Client l’s room, Client 1 was found in seizure activity with severe cyanosis,lasting approximately 30 seconds. She had respiratory depression, hypoxia and became unconscious. Emergency response was initiated and she was transferred to the General Acute Care Hospital,where she remained until 2/11/08. Facility documentation revealed that Client 1 was on a Phenytoin (anti-seizure medication) taper and that her last seizure was on 12115/00. The facility failed to comply with the above regulation by failing to ensure medications were administered, as prescribed. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000648 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUNIBER: SECTIONS VIOLATED 15-1594-0005037-S Date: 05/27/2008 Time: CLASS AND NATURE OF VIOLATIONS The above violation had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000649 State ~f California - Health and Human Services Agency Depadment of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-1284-0006679-S Date: 11t17/2009 Time: Type of Visit : Complaint Investicj. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Incident!Complaint No.(s) " CA00200891 FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED State of CA Dept of DeveLopmental Services 1600 9TH STREET, RM 340 150000089 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP SNF Eldridge, CA 95431 15000 Arnold Dr (707) 938-6000 Skilled Nursing Facility Capacity: 427 150000229 CLASS AND NATURE OF VIOLATIONS CLASS B F314 SACRAMENTO, CA 95814 PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 12/1/09 12:00 a.m. CITATION-- PATIENT CARE T42 CFR 483.25 (c) PRESSURE SORES Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The facility violated the above regulation when staff faiied to assess the safety of using a heel protector over the knees and failed to establish a care plan for correct application of the protector and assessment of the skin under the protector resulting in Resident 1 ’s development of avoidable full-thickness pressure sores behind both knees. An annual assessment dated 1/13/09 indicated Resident 1 had profound mental retardation, severe spastic quadriplegia with flexion contractures, and muscle wasting of the extremities. The assessment indicated Resident 1 was at moderate risk for pressure ulcers. A review of an incident report dated 8t16/09 indicated during a scheduled bath, staff observed open lesions behind both knees of Resident 1, The notes indicated Resident 1 had been wearing heel protectors on both knees to protect the front of the knees from Name of Evaluator: Linda Lucey HFEN Without admitting guilt, i hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name: Evaluator Signature ¯ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000650 State ~f California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0006679-S Date: 11f17/2009 Time: CLASS AND NATURE OF VIOLATIONS abrasions. The report indicated the right wound was 2.0 cm X 1.0 cm and unstageable since the wound bed was covered with necrotic tissue. The left wound was 1.5 cm X 0.9 cm, Stage II10 approximately 3 mm deep with white slough. The report indicated the wounds had been there for a while before being noticed. The report indicated, "These pressure sores were caused by continuous use of the (heel protectors) During an interview on 9/21/09, the Unit supervisor (US) stated staff never took the heel protectors off the knees except during bathing. The US stated the protectors were soiled with blood and pus when staff found the problem during the bath scheduled for Sunday evening on 8t16109. ["The Heelbo Heel and Elbow Protector... is a sock made of a flexible stretch weave with an air-cushioned contour foam pad. "Description from Hollister Incorporated). Observations at the facility central supply on 10/1/09 revealed the protector was available in four sizes. The manufacturer’s directions for use indicated, "Make sure that the skin is free from any open wounds. Select appropriate size for heel or elbow ...The part of the sock with the HEELBO name should be positioned toward the top (proximal side) of the limb... If it appears too tight or too loose, choose the next appropriate size ... ".] A review of the manufacturer’s directions did not indicate the ,Heelbo" protector was designed for use on parts of the body other than the heels or elbows. A review of physician progress notes, (PPNs) of 8/7/09 at 8:45 a.m. documented staff had covered both the right and left knees with heel protectors the previous evening 8t6t09 at 10 p.m. Review of physician orders reflected an order dated 8/7/09 at 8:45 a. m. included, "Keep Right + Left knees covered with (Heelbo) continuously when in bed, + when out of bed + up in wlc (wheelchair), through night shift on 8t16/09". A review of the health care plans did not reflect a care plan for use of "Heelbos". There was no evidence of an assessment of the safety of using heel protectors on a resident’s knees. There were no written interventions addressing the correct size of the protector, the correct application, or the frequency of observation of circulation and skin under the protector. During an interview on 9t21/09, the US stated the nurses changed the dressings on the front of the right knee by rolling the heel protector down to access the area. The US stated the heel protectors were on both knees continuously for at least four days since the previous scheduled bath. During an interview on 10/8109, the licensed nurse caring for Resident 1 the evening of 8/13t09 when the previous bath was scheduled stated she NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000651 State ~f California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0006679-S Date: 11/17/2009 Time: CLASS AND NATURE OF VIOLATIONS could not remember bathing Resident 1 or removing the protectors from his knees. A review of the Activities of Daily Living (ADL) sheets did not indicate documentation that Resident 1 received a full bath with full skin observation between 8/6109 when the heel protectors were first applied and 8ti6/09 when the full thickness lesions were discovered. Therefore, facility staff applied heel protectors to Resident l’s knees without assessing the safety of using a heel protector on the knees, without developing a care plan to ensure safe application and use of the protector, and without measures to ensure periodic observation of the skin under the protector resulting in development of avoidable pressure sores behind Resident l’s knees. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term care facility residents. NOTE: IN ACCORDANCE WiTH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000652 State of’ California - Health and Human Services Agency Department of Public Health SECTIO’I~ 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-1284-00068,17-S Date: 01106/2010 Time: Type of Visit ¯ Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 72311(a)(2) Incident/Complaint No.(s) : CA00206988 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 958"14 Type of Ownership: Stale Agency SONOMA DEVELOPMENTAL CEN:TER D/P SNF Eldridge, CA 95431 15000 Arnold Dr (707) 938-6000 Skilled Nursing Facility Capacity: 427 150000229 PENALTY ASSESSMENT $1,000.00 CLASS AND NATURE OF VIOLATIONS CLASS B DEADLINE FOR COMPLIANCE 1115110 12:00 a.m. CITATION-- PATIENT CARE T22 DIV5 CH3 ART3- 723t 1 (a)(2) (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 violated the above regulation when a staff member failed to follow plans designed to ensure a fragile resident’s safety. The resident fell to the floor sustaining a head injury and hip fracture. A review of Resident 1 ’s clinical record reflected a medical history dated 10/12/09 documented a diagnosis of osteoporosis and history of multiple fractures. Full assessment protocols dated 7/14/09 documented a diagnosis of avascular necrosis (AVN or lack of blood supply to the bone causing weakening) of the left hip and indicated Resident 1 was at high risk for fractures, falls, and injuries. The document indicated Resident 1 required assistance of two staff members for all transfers, positioning, and dressing. A review of a care plan for quadriplegia dated 7t21/09 indicated Resident 1 was up in a customized wheelchair daily as tolerated up to six hours for activities, meals, and vehicular transport. Notes under "Mobility" indicated, "She attempts to weight shift with Name of Evaluator: Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Linda Lucey HFEN Signature : Name : Evaluator Signature " Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000653 State of California - Health and Human Services Agency Department of Public Health SEC’rloN 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0006817-S Date: 01t06/2010 Time: CLASS AND NATURE OF VIOLATIONS side rolling utilizing the bedrails. CAUTION: (Resident I) will suddenly log roll without safety rails. At risk for falling ..." Under "Repositioning" the plan indicated, "2-person assist" and "2-person dependent .., Note that (Resident 1) can make sudden unannounced log rolling movements." A review of an incident report dated 10/11/09 documented Resident 1 roiled out of bed and fell to the floor while a single staff member attempted to put the sling for a transfer lift in place under her. The report documented the side rail was in the "down" position and Resident 1 suddenly pulled herself over and rolled onto the floor. The report documented the staff person was working alone while all transfer and positioning plans clearly state assistance of two persons is required. During an interview on 12tl/09, the psychiatric technician who was attending Resident 1 during the accident said, "1 wanted to get the sling under her. It was my mistake not having two people ..." A review of physician’s progress notes (PPNS) of 10/11109 at 10:50 a.m. indicated Resident 1 sustained a large hematoma over the left eye and was transferred to the emergeocy, room of an outside acute care hospital. An admission history and physical of 10/12/09 indicated Resident 1 developed bilateral aspiration pneumonia and was admitted back to the facility’s acute care unit for continuation of treatment with intravenous antibiotics. PPNs of 10/16/09 indicated Resident 1 was returned to her home unit on that date. A review of interdisciplinary notes (IDNs) of 10/18/09 indicated Resident 1 was grimacing and grabbing ather head and left hip. IDNs of 10/20t09 documented swelling of the left hip and thigh. An X-ray report of 10/20/09 documented a comminuted intertrochanteric fracture. PPNs of 10t20t09 indicated the physician suspected the cause of the fracture was the fall on 10tllt09. An orthopedic note of 11/12/09 indicated the hip was broken into four paRKs and the family did not chose surgery for-Resident 1 due to the risks associated with anesthesia. An incident report dated 10/20/09 documented the lack of blood supply to the left hip may impede healing and cause pain. The orthopedist ordered complete bed rest for Resident 1 with turning only side to side with complete support from shoulders to feet. Therefore, the facility failed to ensure staff followed plans designed to protect Resident 1 from falls, fractures, and injuries. A staff member did not follow the care plans and left the side rail down while attempting to reposition Resident 1 without assistance from a NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000654 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS 15-1284-0006817-S Date: 01t06!2010 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED second staff member, Resident 1 fell out of bed sustaining facial bruising and a hip fracture, These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000655 State of California - Health and Human Services Agency Department of Public Health 8ECTI6N 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-1594-0006691-S Date: 02f02/2010 Time: Type of Visit : Co~nplaint Investig, YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE incident/Complaint No,(s) ’ CA00196715 CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility [D: SECTIONS VIOLATED 72313(a)(2) 72523(a) State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 . 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P SNF Eldridge, CA 95431 15000 Arnold Dr (707) 938-6000 Skilled Nursing Facility Capacity: 427 150000229 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 2/12/10 12:00 a.m, CITATION-- PATIENT CARE T22 DIV5 CH3 ART- 3- NURSING SERVICE-ADMINISTRATION OF MEDICATION -72313(a)(2) (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. T22 DIV5 CH3 ART-5 -PATIENT CARE POLICIES & PROCEDURES - 72523(a) (a) Written patient tare policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to comply with the above regulations by failing to ensure that medications were administered, as prescribed, and by failing to ensure that the policy for Medication and Treatment Administration (M601) was implemented, These failures resulted in a client receiving an incorrect dose of Morphine Sulfate and an admission to the general acute care hospital. Client 1 has diagnoses including terminal esophageal cancer and has been receiving comfort care since 3t25/09. The Unusual Occurrence Report indicated that on 7/t9/09 at 9:30 a,m., Client 1 was Name of Evaluator: CAROL DEVITA HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000656 State of California - Health and Human Services Agency " SE~T~)N 1424 NOTICE CITATION NUMBER: SECTIONS Departrnenl of Public Health P~ge 2 of 3 15-1594-0006691-S Date: 02t02/2010 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED given 200 mg. of Morphine Sulfate, via gastric tube, instead of 40 mg. Morphine Sulfate is a potent narcotic used for pain control. Documentation contained in the Unusual Occurrence Report indicated that the physician’s order read, "Morphine Sulfate 20 mg / 5 ml give 10 mls" (40 rag). Additional facility documentation indicated that a new bottle of Morphine, received from the pharmacy, was a different strength than the previous Morphine that the unit had been using. The new bottle was smaller and concentrated. The strength of the new bottle was 20 rag./ml, (clear in color) was 5 times the strength of the old bottle 20 rag. / 5 ml. (greenish blue in color). On 8/3/09 at 10:40 a.m., the stock bottle of Morphine was observed by the surveyor. The following warning was noted on both the bottle of Morphine and the box it was contained in: MS Concentrate (immediate release) concentrated oral solution 20mg/ml Highly concentrated. Check dose carefully. The policy for "Medication and Treatment Administration - (M 601-reviewed in April 2009) included the following: Purpose: To ensure completion of physician’s orders by providing the 5 rights: 1. 2. 3. 4. 5. Right Right Right Right Right client medication time dose route. Medications and treatments shall be administered as prescribed.., Morphine and Insulin require 2 licensed staff to check dosage and sign the MTR (Medication / Treatment Record) and / or accountability sheet when administered, Facility documentation indicated that, "It is clear that both the person setting up the medication and the person co-signing did not follow written policy on Medication and Treatment Administration Procedures, Policy 601, in that they did not have the right dose. During an interview with PT StaffA on 10/19t09 at 2:50 p.m., StaffA stated that when he NOTE: IN ACCORDANCE WITH CALIFORNIA HEAL’I’H AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000657 St.ate of California - Health and Human Services Agency ’ SE~;TI[3N ’1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Depadmenl of Public Health Page 3 of 3 15-1594-0006691-S Date: 02t02/2010 Time: CLASS AND NATURE OF VIOLATIONS got to work, he was the a.m. shift lead and medication person. StaffA stated that there was, "A lot going on" in the unit that morning. Staff A stated that it was time for the client’s medication and there was a brand new bottle of Morphine. Staff A stated that three months prior, a 100ml bottle of Morphine had been used and the client received medication at least once per shift. When he noticed only a 30 mf bottle, instead of a 100ml. bottle, he stated that he called the HSS (Health Services Specialist) and reported that, "There is only enough for 3 doses." He stated that the ACNS was also contacted to go to the pharmacy, check the order, and get additional solution. Staff A stated that the dose had not been noticed. Staff A stated, at that point, the patient needed his medication and he got the dose cosigned by a 2nd licensed person. Staff A’~stated that he did not hold the bottle against the MAR but just focused on the 30 ml. size bottle and not having enough medication to last for the weekend. These facility failures had a direct or immediate relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000658 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 6 CITATION NUMBER: 15-1592-0007257-S Date: 02/02/20!1 Time: Type of Visit ¯ Complaint Investi~J. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility 1D: SECTIONS VIOLATED 72523(a) Incident/Complaint No.(s) ¯ CA00203136 State of CA Dept of Developmental Services 1600 9TH STREET,.RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP SNF Eldridge, CA 95431 15000 Arnold Dr (707) 938-6000 Skilled Nursing Facility Capacity: 427 150000229 PENALTY ASSESSMENT $1,000.00 CLASS AND NATURE OF VIOLATIONS " CLASS. B DEADLINE FOR COMPLIANCE 2/9!11 12:00 a.m. CITATION -- PATIENT CARE 72523(a) 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 facility did not comply with the above regulation by failing to implement their established policies and procedures for a resident (Resident 1), who had a recent history of weight loss and decreased oral intake, then developed sudden onset of recurrent seizures associated with hypothermia and hypoxia, followed by hypotension and upper airway obstruction, The facility failure to recognize a marked adverse change in Resident l’s health status that resulted in his transfer to an acute care hospital (Hospital 2) where he was admitted in critical condition. Findings: On 2122/!0 review of the facility I ncidenceJUnusual Occurrence report (IR) dated 9116t09 at 10:20 a.m., indicated on 9/9/09 Resident 1 was transferred to Hospital 2 for evaluation and treatment of hypoxia (inadequate oxygen), hypothermia (a condition that occurs when the body gets cold and loses heat faster than the body can make it. A normal rectal body temperature ranges from 97.5F to 99.6F and for most people is 98.6), and seizure episodes. Resident I was admitted to the Intensive Care Unit (ICU) with impending signs of respiratory failure, acidosis, hypotension, and septic shock. Name of Evaluator: Adrian Long Health Fac. Evaluator Nurse Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signalure : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS tS GROUNDS FOR ,SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000659 State of California - Health and Human Services Agency .SECTIO~I 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health Page 2 of 6 15-1592-.0007257-S Date: 02/02/2011 Time: CLASS AND NATURE OF VIOLATIONS Resident 1 was intubated (insertion of a breathing tube) and remained on a ventilator (a mechanical device used to provide assisted respiration). The resident’s overall prognosis was considered poor. On 2122/10 review of Resident l’s clinical record reflected Interdisciplinary (IDT) Notes dated 918/09 at 5:08 p.m. that indicated Resident 1 was observed slumped in a chair and appeared lethargic while Staff A attempted to take his vital signs. Review of the Unit 24 Hour Report dated 918t09 at 5:08 p.m., indicated that immediately following, Resident 1 had a seizure lasting 45 seconds and the Seizure Protocol was followed. The entry further indicated "Hypothermic, Health Services Specialist and Medical Officer of the Day (HSS/MOD) called, Protocol followed." Resident l’s documented vital signs reflected temperature: 91.5, pulse rate: 55, respiratory rate: 16, oxygen saturation: 95, blood pressure: 102t68, pain: 0/10. At 5:15 p.m. (7 minutes later) the 24 Hour Report reflected documentation that indicated the HSS called and said she did. not need to come "client only hypothermic." At 5:30 p.m. (15 minutes later), Resi~Jent l’s documented..temperature was 91.6. A Physician Order was verbally received at 5:35 p.m. which indicated: "Put on a K-Pad until Temp reaches 96.0 (degrees)." There is no documented evidence that indicated the physician nor HSS came to the unit to assess Resident 1 at this time. At 9:45 p.m., Resident 1 had another seizure lasting 75 seconds and the HSS and. physician were notified. Resident l’s temperature was 92.6 (approximately one degree higher in a span of 4-plus hours). At 10:15 p.m., Resident 1 had another seizure and bruises were observed on his upper chest. The HSS was notified and the physician was notified by the HSS. There was a verbal order from the physician to hold medications. Review of the interdisciplinary Notes at 10:45 p.m. reflected an entry by the HSS that described Resident l’s multiple extremity bruising. The HSS note indicated the physician was notified and that Resident 1 was experiencing no pain or discomfort. There was no documented evidence by the HSS of the resident’s vital signs, including body temperature. The HSS limited her assessment to the skin discoloration. There was no documented evidence that the resident’s additional physical systems (heart, lungs, breath sounds, etc.) had been assessed after his significant change of condition NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000660 State of California - Health and Human Services Agency ,SECTION 1424 NOTICE CITATION NUI~BER: SECTIONS Department of Public Health Page 3 of 6 . 15-1592-0007257-S Date: 02f02/201t Time: CLASS AND NATURE OF VIOLATIONS VIOLATED On 9/8/09. An entry at 11:45 p.m. indicated "Code called (Resident 1) (decreased) Temp andBP 02 sat 83%." Review of the Physician Progress Notes dated 9/9/09at 12:10 a.m. indicated the physician was called to the unit for an emergency oxygen saturation below 90%. The note further indicated the physician had been called earlier in the evening for hypothermia and the resident was placed on "warming measures." Resident l’s temperature was now 92.2 (down .4 degrees in approximately 2 It2 hours). The physician documented that Resident l’s airway was clear, breath sounds with bilateral respiratory rate, and the resident’s skin was warm to the touch with "several small bruises." The physician’s plan was to monitor Resident on the unit, obtain a blood sugar (which indicated 75tlow), supplemental oxygen as needed and laboratory blood work to be obtained in the morning. At 1:20 a.m. the physician documented the resident had two more seizures and would be transferred to Hospital 2 for evaluation. At 2:00 a.m. (9/9t09) (Resident 1) was transported to Hospital 2 via ambulance with Staff A. This entailed a time period of approximately 9 hours from the first indication of the resident’s compromised health status, with no improvement in his condition. Review of the Emergency Room (ER) Report dated 9t9t09, indicated that Resident 1 was examined on admission to the ER and required bedside attendance and critical care attendance for over an hour and a half. His initial vital signs were low with a blood pressure of 60 to 80 palpable (perceivable by touch), a pulse of 60, and 02 saturation of 85% and his temperature was 92~. His respiratory rate was 16, and he had evidence of airway obstruction. Chest had decreased breath sounds on the right side. Resident 1 was neurologically obtunded. Review of Hospital 2’s Discharge Summary dated 9/16/09, indicated Resident 1 presented to the Emergency Room (ER) with institutionally-acquired pneumonia and respiratory failure. On admission he was minimally responsive and also had evidence of Disseminated Intravascular Coagulation (DIC). This condition is a rare, life-threatening condition that prevents blood from clotting normally. It can cause excessive clotting (thrombosis) or bleeding (hemorrhage) throughout the body and lead to shock, organ failure, and death. DIC can be triggered by a health problem that sets the clotting cascade in motion, which includes infection and hypothermia. Despite aggressive measures to resuscitate Resident 1, he continued to have problems with NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000661 State of California - Health and Human Services Agency Page 4 of 6 .SECTIO~ "1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Heallh 15-1592-0007257-S Date: 02t02/2011 Time: CLASS AND NATURE OF VIOLATIONS hypotension. Resident 1 was newly diagnosed with critical aortic stenosis and significant heart failure as well. Resident 1 had most of his DIC condition cleared with treatment of his sepsis and antibiotics. However, pneumonia continued. Aggressive measures for Resident 1 was discussed with the health care team, and it was agreed by all this was unreasonable. Resident 1 was converted to comfort care, extubated, and pronounced dead on 9t16/09 at 10:t5 a.m. Review of the facility procedure titled "Hypothermia and Hyperthermia Care" reviewed March 2009, indicated the purpose of the unit is to reduce or elevate the body temperature and to provide comfort and relaxation for the resident. "Maintenance of body temperature is a balance between heat production (by metabolism), conservation and heat loss." The procedure reflected a note which indicated: "Physician and HSS should be notified of any sudden or acute changes in a client’s temperature. Licensed nursing staff will implement a health care plan, which addresses hydration needs." There was no documented evidence of a health care plan which addressed Resident l’s use of the Thermal pump, nor hydration needs. The procedure further indicated to monitor the individual’s vital signs every 30 minutes during heating, then every 1 to 2 hours for 8 hours. If, after the first hour, the client’s temperature has not increased staff are to notify the HSS/ACNS and check the Thermal pump as the procedure indicated. There was no documented evidence that reflected the vital signs were monitored as instructed in the policy. There was no documented evidence the HSS was notified of Resident 1 ’s temperature after an hour, nor if the thermal unit had been checked. During interview on 4/16/10 at 1:00 p.m., StaffA stated she called Staff C at 5:15 p.m. and Staff C stated she did not need to come to the unit to assess Resident 1 as "he was just hypothermic" and we were to follow the Seizure and Hypothermia Protocol. Staff A stated later in the evening Staff C came to the unit to deliver a thermometer and stated "we (unit staff) were doing exactly what we were told to do." Staff A stated the physician did not come to assess Resident 1 until the Code was called. Staff A stated the she stayed overtime that night and accompanied Resident 1 upon transport to Hospital 2, "because I was not comfortable with how he was doing." During interview on 4/21t10 at 2:50 p.m., Staff B stated she and Staff A were both NOTE: 1N ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000662 State of California - Health and Human Services Agency .sEcTIoN 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health Page 5 of 6 15-1592-0007257-S Date: 02/02!2011 Time: CLASS AND NATURE OF VIOLATIONS "scared" about Resident l’s condition and StaffA had called Staff C "a number of times." Staff B stated despite ongoing warming measures (warm blankets and the heating pad): Resident l’s temperature "came up only a little bit." During interview on 4t30/10 at 3:20 p.m., Staff C stated she had a very busy shift and that resident’s with respiratory problems who require deep suctioning take priority. Staff C stated she told Resident l’s unit staffto follow the Hypothermia protocol and to take the resident’s temperature "every hour per protocol." Staff C stated when she first made rounds on 9/8/09 (approximately 3:20 p.m.) Resident 1 "was fine." Staff C stated when she spoke with unit staff on the telephone regarding the resident’s condition, she was told he was "alert, awake, and his respiratory rate was fine." When inquiry was made as to a physical assessment of Resident 1, Staff C stated she only assessed his bruising (10:40 p.m.), and she notified the physician and wrote it in the MD’s book. Staff C stated she was surprised about Resident l’s change of condition as he was "always healthy." Review of the facility policy titled "Notification of Unit PhysiciantFNP And/Or Health Services Specialist" reviewed October 2007, indicated the purpose of the policy is to provide a guideline in directing licensed staff (R.N., LV.N., P.T.) in the notification of the MDtHSS/FNP when a change of condition occurs. The policy indicated that licensed staff shall notify the MDtHSS/FNP of significant changes i.n client condition andlor when an IR is generated relating to client well-being. The policy further indicated a change in condition from baseline needs to be reported as soon as assessment is complete (current vital signs and complete "hands on" physical assessment). Notification is done by phone, digital pager or voice page through the operator. "*If you page via digital pager and do not receive a call back within 5 to 10 minutes (depending on severity of need) voice page via the operator. If you still do not receive a return call, voice page the ACNS." The policy reflected to consider client baseline during assessment and any acute conditions need to be reported to the MDtHSStFNP immediately (not via the Physician’s Log). Review of the Annual Nursing Evaluation Assessment dated 2/24t09, indicated that Resident 1 was at high risk for weight loss (he experienced a 10 pound weight loss between February 2008 through February 2009). Resident 1 was at risk for dehydration "due to dependence on staff for fluids, inability to communicate thirst, and meal refusal." Review of the Nutrition Note dated 9/9f09 at 6:35 p.m., indicated that Resident 1 had a 5 pound weight loss in the past month (8f2t09 to 912t09). The Dietician’s note pertaining NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000663 State of Cal.ifornia - Health and Human Services Agency .,SECTION t424 NOTICE CITATION NUN1BER: SECTIONS Department of Public Health Page 6 of 6 15-t592-0007257-S Date: 02/02/2011 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED to review of the resident’s ADL’s reflected "...meals were refused mostly at breakfast and lunch (better intake at dinner)." The Dietician documented "There is an order for ClB (liquid supplement) if meal refused." Review of the IDT Notes indicated a weekly summary dated 8/30/09, followed by a weekly summary dated 9t8/09. The weekly summaries do not address the resident’s intake, weight toss, or vital signs. The facility was unable to produce documented evidence of Resident l’s Activities of Daily Living (ADL) record for the month of September 2009, which would reflect his daily intakes. On 4/30/10 review the facility policy titled "Health Care Objective and Plan" reviewed May 2008, indicated health care objectives must be reviewed, revised and updated by licensed staff whenever there is a significant resident change of condition. Review of Resident l’s Medical Discharge After Death dated 9/24/09, indicated that Resident 1 "was in his usual state of health until around 9/9/09, when he was noted to be hypothermic. He also had hypoxemia and he was lethargic. His temperature was noted to be 91 to 92#. And he had seizures that evening. He had 3 seizures on 9/9/09, and prior to that he had 1 seizure in May 2009. Prior to that, he had 1 seizure in February 2008." Review of Resident l’s ServicelHealth Care Objectives and Plans reflected no revised or updated plans addressing recent weight loss, hypothermia, frequent seizure activity, and hypoxemia. There was no documented evidence of Resident l’s significant change of condition. On 4/12109 review of Resident 1 ’s Autopsy Report dated 9/18/09 indicated the "Cause of Death as Multi-system Organ Failure (days); Due To: Aspiration Pneumonia with Diffuse Alveolar Damage (days). Other Significant Conditions: Seizure disorder; atherosclerotic and valvular cardiovascular disease." Therefore, the facility failed to recognize a marked adverse change in Resident l’s health status which resulted in his transfer to an acute care hospital (Hospital 2) where he was admitted in critical condition and subsequently expired. These facility failures had a direct or immediate relationship to the health, safety, or secu. rity of residents. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR L~CENSE DPH POD 000664 State of, California- Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 3 CITATION NUI~IBER: 17-1324-0001697-S Date: 05121/2002 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAI~ STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) Incident/Complaint No.(s) : 1.70016379 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 170000771 SACRAMENTO, CA 95814 Type of Ownership: State Agency FAIRVIEW DEVELOPMENTAL CENTER D/P ICFDD 2501 Harbor Blvd Costa Mesa, CA 92626 7149575000 Intermediate Care FacilitytDevelopmentally Disabled 170001769 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $900.00 trebled to $2,700.00 .Capacity: 792 DEADLINE FOR COMPLIANCE 5/29102 12:00 a.m. CLASS. B CITATION -- PATIENT RIGHTS 76525. Clients’ Rights, (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free fl:om harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. An unannounced investigation visit was conducted on January 17, 2002, in response to a special incident received on January 15, 2002. The result showed that the facility failed to ensure that the clients are not subjected to abuse. Client A, a 17-year-old female, was admitted to the facility on July 2, 2001, with diagnosis of Mild Mental Retardation. On January 17, 2002, a review of the facility’s Name of Evaluator: Elna Ramos HFEN Without admitting guilt, f hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature " Title: NOTE: IN ACCORDANCE WITH CALIFORN]A HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000665 State of, California - Health and Human Services Agency Department of Public Health SECTION 1424’NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1324-0001697-S Date: 05t21t2002 Time: CLASS AND NATURE OF VIOLATIONS investigation report stated, "Consumer states that a male [Facility worker !] had sexual relations with her [Client A] x2 [two occasions]. Once in the shower and once in the bedroom, and now fears pregnancy." Client A, alleged that the shower room incident happened on a Wednesday during Christmas vacation. The facility report further indicated that Client A, described sex as, "He kissed me, touched my breast and put his penis in my vagina." Client A was interviewed on two separate occasions, January 28, 2002 and February 13, 2002. Client A stated during both interviews, that she had sex with the Facility Worker 1, on two occasions during Christmas break. Client A, further stated that the shower room episode, happened on a Wednesday before lunch and the bedroom episode, happened in the morning, around 9:00 am, but unable to give the specific date or day. Client A on the.two separate interviews did not change her declaration regarding her accounts of the incidents. During tour of the unit, Staff 4 stated that Christmas break was from DeCember 24, 2001 to December 31, 2001. On. January 23, 2002, an interview with Facility Worker 2 (General Maintenance Field Manager) was conducted. He stated that the facility does not keep written logs of work orders completed by Facility Worker 1 during work hours. The work schedule for Facility Worker 1 is Monday thru Friday from 6:30 am to 3:30 pm. On January 30, 2002, an interview with Facility.Worker 1(janitor/bulb man) was conducted. He confirmed that the general maintenance office does not keep a written record of the work order completed by him. The units also do not have a log indicating a work order done by him. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000666 Stat.e of California - Health and Human Services Agency Department of Public Health SECT]~)N t424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 17-1324-0001697-S Date: 05/21/2002 Time: CLASS AND NATURE OF VIOLATIONS A telephone interview with Staff 2 was conducted on March 1, 2002. Staff 2 stated that Client A made a positive identification of Facility Worker 1, from a pack of six pictures presented to her by Staff 2, in the presence of Staff 3. Documentation by Staff 3, dated February 21, 2002, stated, "1 attended a meeting with her [Client A] and [Staff 2] regarding her allegations of having sex with the [Facility Worker 1]. She was compliant and dealt wt [with] the meeting in a mature manner. She was calm and did as she was instructed. " Nursing documentation dated January 13, 2002, indicated that Client A, was taken to Facility 2 by emergency vehicle for evaluation and diagnostic procedures on January 13, 2002 at 8:35 pro., two weeks after the alleged sexual incident. The Pregnancy test indicated negative result. Client A, a minor and witha diagnosis of Mild Mental Retardation had sexual activity with Facility Worker 1 twice, in a period of one week. Client A had been consistent of her statement regarding the incident, where it happened, time and the person involved. Client A, had identified Facility Worker 1, at a six picture line up presented by Staff 2, approximately two months after the last incident. The facility is unable to provide written evidence indicating the whereabouts of Facility Worker I on the alleged days of sexual activity with Client A. Therefore, the facility failed to protect Client A from sexual abuse from Facility Worker 1. The above violation jointly, separately, or in any combination had a direct or immediate relation to patient health safety or security. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000667 State of California - Health and Human Services Agency Department of Public Health SECTIO~ 1424 NOTICE Page 1 of 3 C]TATtON NUMBER: 15-0786-0008930-S Date: 03/07/2012 Time: Type of Visit ¯ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number; Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS Incident/Complaint No.(s) ’ CA00265459 State of CA Dept of Developmental Services 1600~9"i-H STREET, RM340 150000089 SACRAMENTO~CA 95844 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care FacilityfDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $1,000.00 VIOLATED Capacity: 58t DEADLINE FOR COMPLIANCE 3/21/12 12:00 a.m. 76301(e) CLASS B 76525(a)(20) T22 DIV5 CH8 ART3 76301(e) Client care provided by all team members shall be safe and consi~lerate as ordered or CITATION -- PATIENT CARE indicated by the needs of the client and in accordance with acceptable standards of practice. T22 DIV5 CH8 ART4 76525(a)(20) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To. be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to comply with the above regulations when a client with a history of osteoporosis (bone loss disease) and multiple falls was not assessed .after each fall and subsequently sustained a fractured arm after a fall on 11127/11, as follows: According to the Individual Program Plan (IPP) for Client 1 datedIt11/11 the client had the identified problems of gait abnormality, and risk for falls and fractures. The client’s mobility was described as ambulatory and she used a four wheeled walker. She used a wheelchair when smoking to prevent falls due to possible lightheadedness and other Name of Evaluator: Antq Fitzgerald HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Narne : Evaluator Signature Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000668 State of California - Health and Human Services Agency Department of Public Health SEOT~OI’~ 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-0786-0008930~S Date: 03t07/2012 Time: CLASS AND NATURE OF VIOLATIONS times if unsteady or for community outings. Client 1 also had a history of impulse control and affect regulation difficulties. At this time the client’s supervision level was close, Per SDC Policy 460 close supervision indicated that staff must be in the immediate area to hear the client at all times and must make~isual~ontact aLleast every 5 minutes. On 3/23/11 at 11:20 a.m., Client 1 fell at her work site while walking into the bathroom and struck her head necessitating 5 stitches, The plan of care indicated that she could walk with or without her walker inside and preferred, not to use it. Also that she should be encouraged to use it as necessary. The client’s plan also indicated the use of a wheel chair for smoking outside due to increased fall risk. There were no changes recommended after this incident. Review of the Individual Program Plan dated 3/23tl 1 indicated that staff should remind Client 1 to ask for help, to look where she is going as she moves about. This information was not added to the plan of care. There was no evidence of a Fall Risk Assessment after this incident. On 5t25/11 facility documentation indica(ed that the client fell when maneuvering around a peer boarding the tram. She was in a hurry and not looking where she was going. She ignored or did not hear verbal prompts to slow down. She tripped and fell sustaining a scraped knee. The physical therapist assessed the walker as appropriate and stated they could not slow the wheels down. The recommendation was to have the HSS update the falls risk assessment and Staff watch her and remind her to slow down, making sure she has paid attention noting that extra careneeds to be taken when other peers are with her moving in a group. The plan of care was not updated to (eflect this recommendation, There was no evidence of a Fall Risk Assessment. On 7/18/t I a Falls Risk Assessment was completed. A note on the document indicated that there was a fall due to water on the floor and no change was indicated. On 10t15/11 another Fall Risk Assessment was done and a handwritten entry indicated that the client "slipped out of bed onto floor no injury". On 11/20/! 1 a physician’s note indicated that Client 1 fell on route to breakfast using her walker. Another fall risk assessment was completed with no apparent change in the plan of care. On 11/27/11 an Incident Report (IR) reflected that.Client 1 fell while using her walker outside the residence. Although staff had requested that the client sit and wait while they NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000669 State of California - Health and Human Services Agency Department of Public Health SECTION t424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-0786-0008930-S Date: 03/07/2012 Time: CLASS AND NATURE OF VIOLATIONS retrieved the client’s wheel chair, (as per the plan), the client got up arid fell while using her walker on the ramp. According to the plan of care Client 1 used a wheel chair for smoking outside. Client 1 was diagnosed with a right arm fracture. At this time the client’s supervision level was still "close". During observations, on 12/5/11 Client 1 was lying across her bed on her side looking at a magazine. A cord (telephone-like) was draped over her ankles. The client’s room . was cluttered with Objects on the floor near the bed. With staff present the client walked down the hallway and back to her room using the walker, The client’s shoes appeared large with space at the heel of the shoe; the client’s gait was shuffled and quick with heels almost touching. Upon return to her room the client lost her balance almost falling. During a concurrent interview the U..S. stated that the cord was part of the resident’s bed alarm and that her shoes were being evaluated currently. There was no name on the shoes she was Wearing during the 12/05/11 observations. Review of the client’s record on 12/5/11 failed to indicate that after each fall the recommendations of the team were documented on the plan of care to ensure client safety and on-going reassessment. In summary the facility failed to reassess Client 1 after each fall and revise the plan of care, to protect her from harm. This failure had a direct or immediate relationship to resident health, safety and security. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECTVIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000670 state of california - Health and Human Services Agency Deparlment of Public Health S~071" ON"1424 NOTICE Page 1 of 3 CITATION NUI~BER: 15-t28,~-0008724-S Dale: 04/10/2012 Time: Type of Visit " YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76301(e) Incident/Complaint No.(s) ’ CA00274314 State of CA Dept of Developmental Services t600-9TH STREET, RM 340 150000089 SACRAMENTO, CA 95812l Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD Eldridge, CA 95431 15000 Arnold Dr intermediate Care FacilitytDevelopmentally Disabled Capacity: 581 150000230 CLASS AND NATURE OF VIOLATIONS CLASS .B PENALTY ASSESSMENT $1,000.00 trebled to $3,000.00 DEADLINE FOR COMPLIANCE 4/24/12 12:00 a.m. CITATION -- PATIENT CARE T22 DIV5 CH8 ART-3 76301(e) Required Services Client care provided by all team members shall be safe and considerate as ordered or indicated by the needs of the client and in accordance with acceptable standards of practice. The facility violated the above regulation when the facility failed to. provide care that was safe and in accordance with acceptable standards of practice. A licensed staff member used excessive force and a potentially dangerous head and neck hold to physically restrain a client during a medical procedure, as follows; Client l’s clinical record reflected an Individual Program Plan (IPP) dated 11/9/10 documented Client 1 had diagnoses including mental retardation, autism spectrum disorder, and organic mood disorder. The IPP indicated Client 1 was believed to hear and understand everything that was said to him. Client 1 was fearful of rooms with bathtubs. Prior to admission, attempts to take Client 1 for medical and dental care were unsuccessful due to his behaviors. The IPP documented Client 1 complied better with female staff than male. Notes of an Interdisciplinary Team (IDT) meeting dated 5/1/11 documented Client 1 had a new medical diagnosis of cancer. Treatment plans included chemotherapy. A review Name of Evaluator: Linda Lucey HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evatuator Signature ’ Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000671 State of California - Health and Human Services Agency Department of Public Health SECTION’ 1424 NOTICE Page 2 of 3 ClTAT!ON NUI~BER: SECTIONS VIOLATED 15-1284-0008724-S Dale: 04/10/2012 Time: CLASS AND NATURE OF VIOLATIONS of Interdisciplinary Notes (IDNS) of 6/2/11 documented successful completion of five chemotherapy treatments at an acute care hospital. The chemotherapy was given through a vascular access port which was implanted in the right subclavian artery. IDN dated 6/3/11 documented Client 1 received chemotherapy at an oncology center and was combative during the procedure. Notes indicated treatment was only accomplished with staff assistance. An incident report dated 6/9/11 indicated nurses at the oncotogy center called the facility to report Client I was, "held down strongly", "put in a headlock", and not spoken to by an escorting facility staff member. The nurses felt the experience was "abusive" and there was a "lack of professionalism, sensitivity and respect" during the procedure. During an interview on 9/29tl 1, a Registered Nurse (RN) employed by the oncology center stated Client 1 arrived for his first chemotherapy treatment at the site on 6/3/11. The RN stated she planned to first use the access port to obtain blood for laboratory studies. After the physician reviewed the blood tests results, she would administer chemotherapy through the port. The RN stated two facility staff members were in attendance, licensed Staff A and licensed Staff B. The RN stated Client 1 was seated in a wheelchair and became agitated as staff wheeled him into the treatment room. Staff A stated she spoke softly to Client 1 to explain the procedure of the blood draw. The RN stated Staff B held Client l’s right arm and right leg as she prepared to start the procedure of the blood draw. Staff B spoke softly to Client 1. The RN stated Staff A stated in Client l’s presence, "He (Client 1) will hit you. He will bite you." The RN stated Staff A was asking how long the procedure would take and said, "Make it quick, t can’t hold him for long." The RN stated Staff A used his left arm to hold Client l’s left arm. Staff A wrapped his right arm around Client l’s neck and "cranked" Client 1 ’s head way to the left. The RN stated Staff A’s bent elbow was pressed against the underside of Client l’s neck and Client 1 was resisting vocally and physically. The RN stated the hold was, "very intense" and she heard Client l’s teeth grinding together. After the blood was drawn and the studies completed Staff A reapplied the same hold for approximately three minutes while the RN administered the chemotherapy through the access port. The RN stated Client 1 had not attempted to bite or spit. The RN stated she was upset by the experience and reported it to her supervisor. During an interview on 10/18/11, Staff A stated he had accompanied Client 1 on his trips to chemotherapy at the acute care hospital. Staff A stated there were signed informed consents for medical restraints to be used when Client 1 had procedures. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000672 State of California - Health and Human Services Agency Department of Public Health S_EOTION ’1424 NOTICE Page 3 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 15-I284-0008724-S Date: 04tl 0/2012 Time: CLASS AND NATURE OF VIOLATIONS During the chemotherapy treatments at the acute care hospital,. Client 1 was placed in a bed. If physical containment was necessary staff could easily hold the arms and legs. Staff A stated the initial chemotherapy treatments took hours and there were times when he had to position the palm of his hand on Client l’s forehead and apply_pressure to keep Client 1 still during the procedures at the hospital. Staff A stated Client 1 e0joyed treatment in the hospital because he had his own room with his own TV and remote. Staff A stated there was only an exam table in the room at the Oncology Center. Someone gave Client 1 a remote to hold, but there was no TV to go with it. Client 1 was in a simple transfer wheelchair with no headrest. Staff A demonstrated how he used his right arm to turn Client l’s head to the left away from the access port during the procedure. Staff A admitted he was never trained to physically contain a client in that manner. The application of pressure to the head and neck as Staff A was doing can cause unconsciousness and injury. C... unconsciousness from a vascular neck restraint is caused by a compounding effect of... Carotid Occlusion .... Carotid SinusNagal Stimulation, .,. Venous Compression .... (and) Valsalva ... Susceptibility ... Dislocation, fracture, and/or spinal cord injury can result from excessive force ... formation of a thrombus ... can result in a stroke ... cardiac arrhythmia ... can be triggered ..." www.persona]protectionsystems.ca/Safety_ArticleslNeck ... Restraints) During an interview on 10/7/11, the facility instructor for Management of Assaultive Behavior (MAn), stated more than two staff members would be necessary to safely physically restrain a client in a wheelchair. The instructor stated facility staff members are never taught to use any type of head and neck holds. The instructor stated the staff members are taught to back away and re-assess the situation if a ctient cannot be safely restrained using the methods taught in MAn. Therefore the facility failed to ensure client care was safe as indicated by the needs of the client and in accordance with acceptable standards of practice. Staff A used excessive force to apply a potentially dangerous head and neck hold to Client 1. These facility failures had a direct or immediate relationship to the health, safety, or security of long term health care facility clients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000673 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 4 CITATION NUNIBER: 15-2021-0008152-S Date: 04/13/2012 Time: Type of Visit;Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Stale of CA Dept of Developmental Services Address:--1600 9TH STREET, RM 3:40 License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED Incident/Complaint No,(s) ¯ CA00246812 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care FacilitylDevelopmentally DisaMed 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT " $10,000.00 Capacity: 581 DEADLINE FOR COMPLIANCE 4!27/!2 12:00 a.m. 76315(b) CLASS A CITATION -. PATIENT CARE 76525(a)(20) TITLE 22, SECTION 76315 (b) DEVELOPMENTAL PROGRAM SERVICES INDIVIDUAL PROGRAM PLAN (b) The individual program plan shall be implemented as written, TITLE 22, SECTION 76525 (a)(20) CLIENTS’ RIGHTS (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to comply with the above regulations by failing to keep Client 1 free from the potential harm by failing to follow Client l’s Mobility Plan, which indicates that Client 1 requires staff assistance while in her wheelchair for outdoor propelling in uneven terrain. Further, the facility failed to implement its’ own policy to provide close supervision for Client 1 during an outdoor field trip, as follows: On 10t21/10, the facility notified the California Department of Public Health by written notice that on 10t16/10, Client 1 had been injured during an outdoor field trip. The notice indicated ". .... Resident waiting for van while at Camp Villa, unlocked her brakes Name of Evaluator; Christina Mangum HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name: Evaluator Signature ¯ Title: NOTE: IN ACOORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000674 State of California - Health and Human Services Agency Department of Public Health SECTIO, N 1424 NOTICE Page 2 of 4 CITATION N UI~IBER: SECTIONS VIOLATED 15~2021-0008152-S Date: 04113/2012 Time: CLASS AND NATURE OF VIOLAT!ONS on her wheelchair and began rolling away. Staff was unable to stop her before her wheelchair rolled down an embankment and tipped over. Resident sustained nose bleed, abrasion to forehead and scratches to her left arm. She was transferred to an acute hospital by ambulance where she was diagnosed with C1 fracture, broken nose and facial bruising." Clinical record and document review starting on 11/8/10 indicated: Client 1 was a female, 60 years of age admitted to the facility on 7/31/1950, She had diagnoses that include Seizures, Osteoporosis, and Severe Mental Retardation. The facility’s assessment of Client 1 indicated that she lacked safety awareness and must be supervised when walking with her walker and her helmet. She was able to propel her own wheelchair however required assistance with long distances, going up and down hills or maneuvering on uneven terrain. Facility document titled Recreation/Leisure Evaluation dated 6t25/10 indicated that Client 1was at risk for falls and required staff assistance while in her wheelchair going up and down hills or maneuvering on uneven terrain and that Client 1 should be monitored closely by staff on outings as she is a risk for seizures. Facility document titled IPP (Individual Program Plan) Narrative dated 7/6/10 indicated that Client 1 lacks safety awareness and must always be supervised on outings. Under the title Bruises Easily indicated: "She is active in her wheelchair and not always aware of her surroundings, putting her at risk for bumps and bruises." Under the title of Mobility Risks indicated: "She is a risk for fractures due to Osteoporosis." Under the title of Supervision indicated: "She requires general supervision while on the unit. She requires close supervision while walking assisted and transferring. While on the grounds of the facility, she requires close supervisionand when she is in the community, she requires constant supervision. She requires staff assistance while in her wheelchair, going down the ramp of her home unit, going up and down hills and on uneven terrain." Facility document titled Health Care Objectives and Plans dated 7/31/10 indicated: "She will have assistance necessary for all safe mobility." NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000675 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 4 CITATION NUMBER: SECTIONS VIOLATED 15-2021-0008152-S Date: 04113t2012 Time: CLASS AND NATURE OF VIOLATIONS Under the title of Wheelchair indicated: "Footrests are to be used for transportation off unit. When not being pushed by staff on outings, should have her feet on the ground." On 2/2/11, at 11:30 a.m., Staff A was interviewed. Staff A stated that Client l’s footrests were to remain in the "up" position until staff could take control of her wheelchair. Staff A stated that there was no Accountability Log with supervision assigned during the outing. Staff A stated, "It was a group effort in supervising the clients." Staff A stated, "We should look at the environment at the campsite for making corrections." Staff A further stated, "As far as her footrest being in the "up" position, 1 really don’t think that she could have stopped herself even if her feet were on the ground. She needs staff assistance on uneven terrain." On 2/’8il 1, at 1 p.m., Staff B was interviewed. Staff B stated that she had attended the outing with the clients and several other staff. Staff B stated that {here were no specific assignments made for staff supervision of clients.. Staff B stated, "She released her brakes and no one noticed until she started to roll down the hill. Someone yelled to catch her - and I attempted to stop her, however i could not help her. She rolled approximately 25 feet down the hill, the wheelchair flipped forward and onto its side rolling down the embankment." Facility policy number 460 Supervision of Clients under the title of Assessment of Supervision Needs, was reviewed on 218tl 1, at 2 p.m. "Close Supervision" indicated: staff must be in the immediate area and must be able to see and/or hear the client at all times, making visual contact no less than every 5 minutes." "Constant Supervision" indicated: "Staff must maintain constant visual and verbal contact with each client and is in close enough proximity to intervene as necessary." Facility policy number 543 Transportation Safety was reviewed on 2t8/11, at 2:30 p.m. Under the title of Waiting for Transportation indicated: "Residential and vocational support staff will be responsible for the safety and supervision of passengers who are waiting for transportation," The facility failed to comply with the above regulations by failing to keep Client 1 free from the potential harm by failing to follow Client l’s Mobility Plan, which indicates that Client 1 requires staff assistance while in her wheelchair for outdoor propelling in uneven terrain. Further, the facility failed to implement its’ own policy to provide close NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000676 State of California - Health and Human Services Agency Department of Public Health SEO,’I’IQN 1424 NOTICE Page 4 of 4 CITATION NUI~IBER: SECTIONS VIOLATED 15-2021-0008152-S Date: 04/13/2012 Time: CLASS AND NATURE OF VIOLATIONS supervision for Client 1 during an outdoor field trip. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harEL~euld result NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS S GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000677 State of California - Health and Human Services Agency Department of Public Health SECTION" 1424 NOTICE Page 1 of 4 CITATION NUMBER: 15-0786-0008629-F Date: 06/0412012 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED IncidenttComplaint No.(s) ¯ CA00285658 State of CA Dept of Developmental Services 1600 9TH~STREET, RM~340 150000089 SAORAMEN-TOwCA 9581~ Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000 Arnold Dr Etdridge, CA 95431 Intermediate Care FacilitytDevetopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $10,000.00 Capacity: 581 DEADLINE FOR COMPLIANCE 6/26/12 5:00 p,m. CI~kSS A CITATION-- PATIENT RIGHTS W127 42 CFR 483.420(a)(5) (W127) Protection of Clients Rights The facility must ensure the rights of all clients. Therefore, the fac.ility must ensure that clients are not subjected to physical, verbal, sexual or psychological abuse or punishment. The facility failed to ensure that clients were not subjected to physical or psychological abuse or punishment when 9 of 27 clients on the Judah Unit, 1 Client on Malone Unit and 1 Client on Lathrop were found to have abrasions consistent with the use of a Taser device. In addition, the facility failed to prevent further potential abuse when the staff member who was accused of abuse was not immediately removed from client contact following knowledge of the abuse complaint. The facility also failed to implement its policy prohibiting weapons from being brought onto facility grounds when the staff member accused of abuse was found with a loaded gun and Taser device on facility grounds. Facility documentation reviewed on 1015tl 1 at I0 a.m., revealed that on 9f26tl 1 at approximately 4 p.m., an anonymous male caller left a message on the Executive Director’s answering machine. The anonymous caller alleged that Staff A, who worked on Judah in the Intermediate Care Facility for Developmentally Delayed Individuals (ICF/DD), had a stun gun and was using it on the clients. Name of Evaluator: Ann Fitzgerald HFEN Without admitting guilt, i hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS 1S GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000678 State of California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS VIOLATED 15-0786-0008629-F Date: 06/04/2012 Time: CLASS AND NATURE OF VIOLATIONS Review of the Office of Police Services (OPS) report indicated that officers went to the unit to make contact with Staff A on 9/26tl 1 at approximately 4:30 p.m., 30 minutes after receiving the anonymous call. Police were told that Staff A was not working at that time, but was scheduled to work the following morning, 9/27/11. The facility police investigation on 9/27/11 revealed that at 7:50 a.m., officers arrived at the client residence (Judah) to make contact with Staff A and were told that he was on break and would return shortly. The day shift began at 6:30 a.m. Officers were given a description of the vehicle Staff A was driving. A few minutes later the vehicle arrived in front of the residence where StaffA was returning after his break. The vehicle was searched with the consent of StaffA. The facility officer removed a black nylon handgun case from under the passenger seat. The case contained a Gtock semi-automatic pistol and a "magazine" containing live rounds of ammunition. The pistol was removed from the case and another magazine was secured in the receiver of the pistol that also contained live rounds. Upon searching the vehicle further a Taser C2 device was found in the driver’s side door storage compartment. Staff A had been working with clients for over one hour on 9/27/11 prior to being removed from client contact as per the facility’s abuse policy and procedures. According to facility documentation, Staff A was removed from client contact and placed on Administrative Time Off (ATO). On 10t5/11 review of the facility Abuse/Neglect Prevention and Reporting Policy 413 revised March 2009 indicated according to Section 4.3.1 that the Program Director shall: "Immediately remove the alleged perpetrator from client con.tact" and notify the Clinical Director. Review of facility documentation on 10/5/11 regarding Staff A revealed that the staff had worked at the facility, as a Psychiatric Technician Assistant (PTA) since 1995. The facility job description for a PTA included the following: the provision of general nursing care and training for clients, assists clients in all activities of daily living such as bathing, dressing, grooming and dining, on-going interaction with clients, participates as a member of the Interdisciplinary team in designated aspects of the development and implementation of the Individual Program Plan, and the performance of nursing procedures consistent with Certified Nursing Assistant (CNA) regulations. A PTA’s assignment usually involved supervision of a group of 6~12 clients depending NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000679 State of California - Health and Human Services Agency Department of Public Health SECT{ON 1424 NOTICE Page 3 of 4 CITATION NUMBER: SECTIONS VIOLATED 15-0786-0008629-F Date: 06/04/2012 Time: CLASS AND NATURE OF VIOLATIONS on the time of day or an assignment of one client i.e., providing constant or close supervision to protect the client from himself, from others or to protect others from the client. On 9/27/11, a day after the anonymous complaint that Staff A was using a Taser stun gun on clients residing on the Judah unit, registered nurses physically assessed all 27 clients on Judah for possible injury. Photographs of seven clients showed atypical appearing abrasions. The majority of these marks were found on the buttock, thigh, arm and back areas of clients. On 9128111 photographs were taken by the Office of Police Services (OPS) and were reviewed by a private forensic pathologist consultant. The forensic pathologist’s report dated 10t4tl 1 indicated that each injury was characterized by a pair of circular lesions ranging from 2-4 mm, some with small irregular central crater and others appearing as early scars,separated by 10 to 12 ram. The injuries of the seven clients were consistent with having been made by a very similar, if not identical device or weapon or instrument. The pathologist further opined that the patterned injuries on seven clients were strongly suggestive of and consistent with electrical thermal burns ranging in age of 36 to 48 hours up to greater than two weeks. The patterned (paired electrical-thermal) injuries were inflicted by another individual(s) on .to these seven clients and represented non-accidental trauma. The report concluded that the features of the injuries could not be specifically attributed to the recovered electronic control device (ECD) Taser C2 and test "firing" of this device onto skin-like material with varying durations of contact may be useful in determining the expected spread of the injury components. During an interview on 2t22t12, the forensic pathologist consultant stated that she was not as familiar with the C2 Taser as she was with the Taser used by Police Departments, and that marks from thermal injuries do not always match exactly the source of the marks. Ten of the eleven clients identified with electrical thermal injuries had limited or no ability to communicate verbally. According to the police investigation, Ciient 1 used the words "stun" and "[StaffA’s name]" during a recorded audio interview on 9/28/11 .Review of the Individual Program Plan dated 3/2/11 described the communication ability of Client 1 as able to carry on a. conversation, with ritualized social interactions and compulsivity that could interfere. The client was also described as able to verbalize his pain and his NOTE: IN ACOORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000680 State of California - Health and Human Services Agency Department of Public Heallh SECTI’O~ I424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS VIOLATE[3 15-0786-0008629-F Date: 06f04f2012 Time: CLASS AND NATURE OF VIOLATIONS needs. Review of reported incidents for all 11 clients for the prior year failed to yield any relevant information. No witnesses or the anonymous caller came forward with any information regarding this allegation. In summary, the facility failed to ensure the right of all clients to be protected from abuse when: 11 clients were found with abrasions consistent with the use of an electrical thermal device (Taser Gun); the facility failed to implement the abuse prevention policy and immediately remove Staff A from client contact upon knowledge of the allegation; and StaffA was four~d with a loaded gun and Taser on facility grounds. 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 3otentially for all clients with whom Staff A had contact or whom had access to his Vehicle. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000681 State of California - Health and Human Services Agency Department or Public Health SECTION’1424 NOTICE Page 1 of 7 CITATION NUI~IBER: ¯ 15-1872-0009623-S Date: 12112t2012 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS ¯ Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ]D: SECTIONS VIOLATED 76525(a)(20) incidenttComplaint No.(s) " CA00334122 State of CA Dept of Developmental Services 16~0~H STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP ICFDD 15000Arnold Dr Eldridge, CA 95431 Intermediate Care FacilitytDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $10,000.00 Capacity: 581 DEADLINE FOR COMPLIANCE 12/27/12 12:00 a.m. CLASS A CITATION-- PATIENT RIGHTS T22 DIV5 CH8 ART4-76525 (1) (20) CLIENTS RIGHTS (a) Each client has the right listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unne.cessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to prevent neglect by failing to implement policies and procedures (P&P) as well as the facility’s plan to prevent neglect for Client 1. The facility incident management system failed to identify and remove damaged clothing protectors, potentially hazardous items, resulting in Client 1 possibly ingesting a snap and resulting in exposing 57 of 57 clients with pica (persistent ingestion of nonnutritive substances) to potential harm. The facility failed to conduct pica sweeps and environmental rounds when 309 rounds sheets, initiated between 7/1/12 - 9/22/12, indicated 101 of 309 rounds sheets did not include evidence of pica sweeps or environmental rounds. 1. Review of the facility document titled, Pica, dated December 2011, included the following definition: "Pica is the persistent ingestion of nonnutritive substances Name of Evaluator: Edwin Hoffmark HFEMI Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name: Evaluator Signature ¯ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000682 State of California - Health and Human Services Agency Department of Public Health SECTIOI~ 1424 NOTICE Page 2 of 7 CITATION NUMBER: SECTIONS VIOLATED 15-1872-0009623-S Date: 12/12/2012 Time: CLASS AND NATURE OF VIOLATIONS including, but not limited to: clay, dirt, sand, stones, hair, feces, lead, gloves, plastic, paper, paint chips, wood, string, cloth, metal, andtor cigarette butts." On 9/20112, review ef facility documentation was-eonducted. The documenbrevealed an incident had occurred on Program 6 - Smith Unit on 8/23/2012 at 9:15 PM. The document indicated that staff found [Client I] chewing on the snap tab end of a clothing protector (adult bib) and the staff noted that part of the snap tab was missing. The staff had not witnessed if the client had swallowed the snap tab. The Unit Supervisor (US), Staff A, was notified of the incident on 8/23tl 2 at 9:40 PM The US documented a Level 1 review (an analysis of the event I~y the Unit Supervisor/Service Area Supervisor) dated 8t27/12, as follows: "...It is believed that the [clothing] protector had fallen off the snack cart and [Client 1] found it. When staffwas able to get the ’clothing protector from [Client 1] it was observed that a snap was missing. Most of the protectors do have missing snaps so it is not likely that [Client 1] actually did swallow the snap ... [Client 1] could have had the clothing protector for only a very short time so it is most iikely [the client] did not swallow any part of the clothing protector...Staff will now be trained to count the number of clothing protectors going out to the floor to be sure to count them when they are done with snack time." Theprogram director (PD) for Program 6, Staff E, documented the Level 2 review (documentation of all action taken to prevent recurrence), dated 8/28t12, as follows: "...The clothing protector had a snap missing on the tab on the co!lar of the [clothing] protector. It is not known if the snap had been missing prior to [Client 1] chewing on the protector, or if she chewed it off herself. Many of the clothing protectors do not have snaps intact.It is unknown if [Client 1] ingested the tab off of the snap...Clothing protectors will be accounted for before and after snack times and meals and will be checked for missing snaps..." On 9/20/12 beginning at 11:00 AM, the US, Staff A, stated that Smith Unit was home to 33 clients, 15 of whom had pica and three additional clients who chewed on cloth. Observations of the dining room on the Smith Unit revealed an unlocked cabinet with two shelves completely full of clothing protectors. Staff A and the surveyor removed 10 clothing proteotors that had obvious frayed edges, loose strings, tears and loose or missing snaps. When asked how long most of the clothing protectors had been in disrepair, the US, Staff A stated, "They have always had snaps missing." When asked what system was in place to assure clothing protectors, linens and other laundry items NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000683 State of California - Health and Human Services Agency Department of Public Health 8EOTIOIt~ 1424 NOTICE Page 3 of 7 CITATION NUMBER: SECTIONS VIOLATED 15~1872-0009623-S Date: 12/12/2012 Time: CLASS AND NATURE OF VIOLATIONS were free of hazardous pieces, such as loose snaps, frayed edges or loose strings, Staff A stated there.was no system for staff to follow. Staff A then called the laundry staff who told the StaffA that laundry staff did not check for deterioration. The US, StaffA, confirmedlhe facility had no_system in place4o assure4he repai~o~replacemen~of items in disrepair. When asked if he notified anyone regarding the missing snaps, Staff A stated not until after the incident with Client 1. StaffA, the US, made no comment when asked why he had not notified anyone. Clinical record review revealed that Client 1 was admitted to the facility on 10/04/85 with profound intellectual disabilities. Additional diagnoses include Cerebral Palsy (a disorder marked by. muscular impairment), Anxiety, and pica. The Staff A stated there was no Behavioral Support Plan (BSP) for pica in Client l’s record, when asked what the prevention plan related to pica was for Client 1. The US, Staff A stated, "She has lived on the Smith Unit since June 2012 without an ’open’ pica plan." When asked what the staff did to prevent non-edible items from being available on the Smith Unit, Staff A stated staff conducted "pica sweeps" each shift since January 2012, after the incident with Client 2. When asked why damaged clothing protectors were still on the unit, Staff A stated he was not sure if staff were actually checking the clothing protectors for wear or just counting them. When asked why, despite pica sweeps conducted three times per day since January 2012 and weekly monitoring rounds conducted by program management, the damaged clothing protectors were not identified as a potential choking hazard, the US, Staff A stated they should have been. 2. Review of the Environmental Safety Checks dated 1/25/12 included the following directions: "Environmental rounds will be done on AM shift, PM shift and NOC [night] shift..,No clothing items, attends, linen, towels, washcloths...will be left out in client areas...Staff must be vigilant and continuously monitor the area fo’r items that can be ingested...Staff must be familiar with pica plans and should ensure implementation at all times." Review of the pica Sweep Each Shift (Document on 24 hour log) sheet (no date) included the following directions: "1. making rounds first thing after priming as you tour the unit...4. Check for magazine and all little paper items, string, as your walking down the hallway check out the floors for small items and paper...8. When doing rounds check for broken furniture, locks doorknobs, dressers and lockers. Check equipment NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000684 State of California - Health and Human Services Agency Depadment of Public Health SECTION’ 1424 NOTICE Page 4 of 7 CITATION NUMBER: SECTIONS VIOLATED 15-1872-0009623-S Date: 12t12/20~12 Time: CLASS AND NATURE OF VIOLATIONS (wheelchairs) for broken parts..." When asked what training the Smith Unit staff had regarding environmental rounds/pica ~_weeps;ihe~US, Staff A stated~taff were4rained4o assure equipment was in good repair. He stated he did not know if staff was checking clothing protectors as part of this sweep. During observations on 9/20/12 beginning at 1:30 PM on Roadruck Unit, the Roadruck US, Staff F and surveyor looked at the clothing protectors which were stored in an unlocked cabinet in the dining room. Eight clothing protectors with obvious tears were randomly chosen. All eight had tears and the snaps had frayed fabric surrounding them so that the snaps could easily been torn off. The US, shift lead, and IPC (Individual Program Coordinator) stated the loose strings and snaps on the clothing protectors could be a hazard. The shift lead stated, "The clothing protectors tear very easily." Staff F stated eleven clients on Roadruck Unit had pica and all were at risk for choking. Review of the Windows Orientation worksheet (information for staff working with the clients) included the names of the clients and their preferred pica items; 5 of 11 clients preferred pica items included clothing, strings, cotton, torn cloth and metal. On the Smith Unit on 9/20/12 at 6:05 PM, a review of the diet cards with directions to staff included providing clothing protectors during meals to 30 of 33 clients. I5 of 33 clients Were at moderate to high risk for choking and/or had pica. During an interview on 9/20t12 beginning at 6:28 PM, when asked about the 8/23/12 incident for Client 1, the PD, Staff E stated that he asked staff to remove any clothing protectors that were missing tabs before taking them out to the floor, to count how many went out td the floor, how many came back, and to make sure all the clothing protectors were returned. Staff E stated Client 1 had a history of chewing cloth towels. When asked why the damaged clothing protectors continued to be on the Smith Unit, Staff E stated they should have been removed. On 9t26/12 at 5:20 PM, review of the Plan related to pica revealed the following under "Systemic Changes:" "Training curriculum for supervision and treatment of pica was developed. [Level of Care] LOC staff._and Central Program Services [CPS- offsite program] staff will attend this training and will complete a post-test by 8f29/12. Additionally staff assigned to NOTE: IN ACCORDANCE W!TH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000685 State of California - Health and Human Services Agency Depar[ment of Public Health ~EOTtOI~11424 NOTICE Page 5 of 7 CITATION NUI~BER: SECTIONS 15-1872-0009623-S Date: 12t12/2012 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED P[ograms 4 and 6 will receive the above training for supervision and treatment of pica. Daily the shift lead will ensure Environmental Safety Checks are completed every shift. Weekly the [Client Protection Program] CPP team will review all clients identified at risk for pica to ensure systems to :prevent harm are in place. Monthly the_Pzog~am Risk Management team will review, analyze, and determine if the corrective actions that were developed and implemented at the weekly CPP meeting were effective for all clients identified at risk for pica." On 9t26t12, review of the sign in sheets for 7t31/12, for Policy #-410, "Client Protection" included the following: "[The Facility] adheres to a practice that protects and promotes the safety of clients. A comprehensive system of client protection is in place, which provides for the thorough identification and assessment of potential risk, and immediate intervention when risk is presenL The system involves a thorough investigation of all incidents that cause harm, and has a risk management process that provides for tracking, monitoring, review and analysis of incidents by Unit, occurring, track and analyze patterns and trends of incidents, develop and implement prompt and effective measures to minimize or eliminate occurrence in the future." Concurrent interview and review of the monitoring rounds conducted by program management for the months of 8/12 and 9t12 revealed many of the monitoring rounds forms were incomplete. Additionally, review of the post test for pica revealed that for the day program, "Sunrise," 8 of 8 post-tests included a section for the psychologist and unit supervi.sors to complete. The section was blank. Staff B stated the rounds sheets should have been completed and the post tests for "Sunrise" day program should have been completed by the psychologists and US. There were 11 units where monitoring was conducted from 7tl/12 - 9t22/12. Of 309 rounds conducted, 10I of the sheets were incomplete and did not include monitoring of pica sweeps or environmental safety. At 12:32 PM on 9/20/12, the Unit Supervisor, Staff B, for Lathrop was asked to examine each of the clothing protectors stored in unlocked cabinets in the dining room of Lathrop. Staff B examined a total of 97 clothing protectors and removed 49 of the clothing protectors due to missing snaps, holes in the material, frayed edges and other damage which compromised the integrity of the clothing protector. Staff B indicated the 49 NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000686 State of California - Health and Human Services Agency Department of Public Health ~£ECTtON 1424 NOTICI~ Page 6 of 7 CITATION NUI~IBER: SECTIONS VIOLATED 15-1872-0009623-S Date: 12t1212012 Time: CLASS AND NATURE OF VIOLATIONS clothing protectors were "not serviceable." The Unit Supervisor, Staff B confirmed the clothing protectors in the cabinets were available for use for the evening meal. When asked if there were other clothing protectors at Lathrop, Staff B showed the surveyor a large laundry cart full Of clothinqprotectors in a linen storage area. After looking at some of the clothing protectors, Staff B said he would need to go through the cart and remove the damaged clothing protectors. When asked if there was a system in place to assure the clothing protects were "serviceable" prior to taking them to the dining room, Staff B said, "No." Staff B confirmed that some clients who lived at Lathrop were diagnosed with pica. 3. At 5:30 PM on 9/17/12, Client 3 was observed wearing a blue torn clothing protector while eating dinner in the Bentley dining room. At 1:15 PM on 9/20t12, the US, Staff C, for Bentley was asked to examine 9 of 9 of the clothing protectors stored in the unlocked cabinet in the Bentley dining room. Staff C examined a total of 9 clothing protectors and removed 9 of the clothing protectors due to missing snaps, holes in the material, frayed edges and other damage which compromised the integrity of the. clothing protectors. Staff C stated that the facility needed a better system as these clothing protectors are thrown in the laundry and are returned as observed, shredded, torn breaking apart, and breaking down. Staff C went on to say that the system for inspecting the condition of the clothing protectors before dining cabinets, as clean, so they would be available for use for the and stained, facility has no returning them to the evening meal. 4. On 9/20/12 at 1 p.m., during an observation of clothing protectors at the Turner B offsite building, 17 clothing protectors were observed. Five of the seventeen clothing protectors were noted with multiple tears. One clothing protector snap was noted to be dangling. During concurrent interview with Staff D, Staff D acknowledged that the clothing protectors were in disrepair. The following day, on 9/21t12, a follow-up observation of the clothing protectors was conducted at the same site and 4 additional clothing protectors were noted in disrepair. Therefore, by failing to implement policies and procedures, failure to prevent neglect, and failure of the incident management system to identify and remove potentially hazardous items, damaged clothing protectors, the failures resulted in Client 1 possibly ingesting a snap and resulted in exposing 57 of 57 clients with pica to potential harm. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000687 State of California - Health and Human Services Agency Department of Public He~Ith .SBCTION 1424 NOTICE Page 7 of 7 CITATION NUMBER: SECTIONS VIOLATED 15-1872-0009623-S Date: 12/12t2012 Time: CLASS AND NATURE OF VIOLATIONS 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. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000688 State of Galifornia - Health and Human Services Agency Departmenl of Public Health SECTIOb:] 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-0786-0009622-S Date: 1211212012 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: FaciIity Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76389(a)(3) 76393(a) IncidentfComplaint No.(s) : CA00327237 State of CA Dept of Developmenf.ai Services 1600 9TH STREET~RM 340 150000089 SACRAMENTO, CA 95814, Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD 15000Arnold Dr Eldridge, CA 95431 intermediate Care Facility/Developmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $10,000.00 Capacity: 581 DEADLINE FOR COMPLIANCE 12/27/12 12:00 a.m. CLASS A CITATION -- PHARI~IACY T22 DIV4 CH8 ART3 - 76389(a)(3) PHARMACEUTICAL SERVICES 76389(a) Pharmaceutical service shall include, but is not limited to, the following: (3) Monitoring the drug diStribution system which includes ordering, dispensing and administration of medications. T22 DIV5 CH8 ART3 - 76393(a) 76393(a) No drugs shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illness. The facility failed to ensure that pharmaceutical services had a system in place for monitoring the drug distribution system when the facility reported discovery of hundreds of Benadryl capsules (a sedating antihistamine) unaccounted for on the Bemis Unit and, potentially, on other residences. The pharmacy had no mechanism for tracking the use of sedating antihistamine medications. On 9t20/12 at 4 PM, the Coordinator of Nursing Services (CNS) reported to the survey team that on 9/19t12 administrative staff, while making environmental rounds on Bemis Residence at 2:40 PM, discovered emesis on the floor in a client bathroom that contained three capsules, later determined by the facility to be Benadryi (a sedating Name of Evaluator: Ann Fitzgerald HFEN Without admitting guitt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature ’ Title : NO’IE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000689 State of California - Health and Human Services Agency Department of Public Health SECTt~,N 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-0786-0009622-S Date: 12/12f2012 Time: CLASS AND NATURE OF VIOLATIONS antihistamine). The CNS stated that all client records on Bemis were reviewed for any indication of unusual signs or symptoms. Client 1 was identified as having increased lethargy and no order for Benadryl. Two clients on Bemis, Clients 2 and 3, had physician orders for PRN (i.e. as needed) Benadryl. Client 4, on Bemis, had an 1 t p.m. order for Benadryl to be administered daily. The initial review during facility investigation showed that the quantity of capsules remaining in the Benadryl bottle stored on the unit was inconsistent with how many should have remained based on the physician’s orders and documented medication administration for Benadryl. The CNS continued that at approximately 1:30 PM on 9/20/12, during the initial investigation, staff on Bemis also made an allegation that a licensed staff may have been administering Benadryl to clients without a doctor’s order. The CNS stated that all units were told to collect any stock sedating antihistamines which were to be picked up by the pharmacist and stored in the night locker. The facility reported they had also removed the alleged perpetrator from all client contact. On 9/21/12 at 4:30 PM, the survey team checked all medication carts on the residences and the day programs for any sedating over the counter medications and all had been removed. On 9/27/12 at9:30 AM, the Chief of Pharmacy met with tl~e survey team and explained that the facility did not track the number of Benadryl used on each unit, The pharmacist stated that they had no way to assess PRN (as needed) orders. Although each residence had a medication audit every month there was no evidence that the pharmacist inventoried over the counter stock including sedating antihistamines. On 9/28/12, during an interview, the CNS stated that the pharmacist who picked up all of the Benadryl did not document how many bottles were removed from each unit or the number of capsules left in each bottle. On 9t28/12, review of the requested pharmacy data for orders of bottles of Benadryl sent to Bemis and client specific medication documentation records on Bemis residence revealed the following: Between 6/20/12 and 9/13t12, six bottles containing 100 capsules each or totaling 600 capsules had been sent by the pharmacy to Bemis. Three clients (Clients 2, 3 and 4) on Bemis had orders for Benadryl during this period of time. Review of the Medication and Treatment Administration Records for these three clients during this same period of time indicated that only 9 capsules were administered to these clients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000690 State cf California - Health and Human Services Agency Department of Public Health SEC’]’fC.N 1424 NOTICE Page 3 of 3 CITATION NUI~1BER: SECTIONS VIOLATED 15~0786-0009622-S Date: ’12/12/2012 Time: CLASS AND NATURE OF VIOLATIONS None of the above mentioned clients (Clients 2, 3, and 4) had orders for 75 mg of Benadryl, the amount that was observed in the emesis. When the CNS initially inspected the medication supply on 9f20/12 on Bemis, 1 bottle and 2 additional capsules were recovered. The total number of capsules accounted for were 114 capsules (including the 3 identified capsules in the emesis on 9/19/12) out of a stock of 600 delivered between 6/20112 and 9tl 3/12. The facility is unable to account for 486 capsules out of 600 delivered by the pharmacy to Bemis residence, between 6/20/12 and 9/13/12. The facility’s failure to have a tracking mechanism to ensure drug accountability for sedating antihistamine medications resulted in an unknown Bemis client having three 25mg Benadryl in their emesis without a physician’s order for 75 mg of Benadryl and hundreds of sedating antihistamines being unaccounted for. 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. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OI= YOUR LICENSE DPH POD 000691 State of California - Health and Human Services Agency Department of Public Health SB,..CTION ~’424 NOTICE Page 1 of 3 CITATION NUI~IBER: 15-1116-0009606-S Date: 12/12/2012 Time: Type of Visit ¯ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name’. Address; License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) IncidentfComplaint No.(s) : CA00332704 State of CA Dept of Developmental Services t600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814- Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000Arnold Dr Eldridge, CA 95431 Intermediate Care Facility/Developmentally Disabled 15000023.0 CLASS AND NATURE OF VIOLATIONS Capacity: 581 PENALTY ASSESSMENT $10,000.00 DEADLINE FOR COMPLIANCE 12/27/12 12:00 a.m. CLASS A CITATION -- PATIENT RIGHTS T22 DIV5 CH8 ART4-76525(a)(20) CLIENTS RIGHTS (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld exceptas provided in (c) of this seCtiOn. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to comply with the above regulations by failing to ensure that Client 1 with a severe life threatening behavior, pica (the persistent ingestion of nonnutritive substances including, but not limited to: clay, dirt, sand, stones, hair, feces, lead, gloves, plastic, paper, paint chips, wood, string, cloth, metal, and/or cigarette butts) who was on 1:1 (one to one) constant observation, was not neglected by failing to supervise Client 1 in accordance with his individual program plan; and the facility failed to have his safety adequately protected when his designated 1:1 staff fell asleep while on duty, as follows: Review of Client l’s record on 11113/12 at approximately 1:45 p.m., showed Client 1 had diagnoses of pica, autism, and severe intellectual disabilities. Review further revealed that Client 1 had a history of ingested inedible objects such as "coins, gloves, plastic ware, candy wrappers, paper, etc." Name of Evaluator: Gregory Hannan HFEN Without admitting guiltl I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name: Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000692 State of CaJifornia - Health and Humao Services Agency Department of Public Health SECTION ~i424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1116-0009606-S Date: 12/12t20t2 Time: CLASS AND NATURE OF VIOLATIONS A report received from the facility on 11t13/12, revealed that on the morning of 11/11112, program management made rounds at 3:55 a.m. The program manager stopped by C, lient l’s room.~he door was~pen and~h~staff person assigned4o provide individual supervision, Staff B, appeared to be sleeping, sitting in a chair with head bent to the side and eyes closed. Per the report, the manager had to knock on the door twice before the staff person awakened. Further review of Client l’s record revealed an annual psychological evaluation update with functional analysis dated 11t2/12, which described four incidents of severe life threatening pica: 1. July 1987 - bowel obstruction caused by 1 inch x 8 inch rag, metal foreign body also noted; 2. October 1990 - bowel obstruction caused by bezoar ("a hard mass of entangled material ...", Tabers Edition 15) consisting of string, plastic wrapper, and paper, there was also a wad of material in the rectal sling; 3. an incident in January 2009 where plastic cuttery, candy wrappers and gloves were found in the client’s bowel, foreign.matter was found in the stomach, there was a tear of the esophagus near the stomach, a fistula was noted between the esophagus and lung, and there was infection in greater than half of one lung. Further review showed that on 5/17/12, Client 1 was sent to an acute care hospital due to a large bloody emesis. Review of records from the acute care hospital showed that on 5t18/12, Client 1 underwent an upper endoscopy (the placement of a tube into a patient’s stomach) which revealed plastic gloves in the stomach. The procedure was unsuccessful in removing all of the gloves, only one glove was removed, so it was decided that a Laparoscopic gastrostomy was required. An operative report from the acute care hospital dated May 18,2012 showed that during the laparoscopic procedure 2 more gloves were removed as well as a shoelace. Client 1 returned to the facility on 5/27/2012 from the acute care hospital. On 5/30/12, a special meeting was held to review the client’s Individual Program Plan (tPP). Review of the IPP revealed, "This full team special meeting was held regarding the recent pica episode that resulted in hospitalization and surgery. A shoelace and three gloves were removed from his stomach. He was admitted to [acute care hospital] on 5/17/2012 and returned to Smith on 5127/12. Upon return he was assigned individual supervision for his safety to prevent further pica episodes." Review of Individual Supervision (1:1) Guidelines for Client 1 dated 5t31/I2, under main points revealed, "1. Staff must provide direct, full line-of-sight supervision within arm’s NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000693 State of California - Health and Human Services Agency Department of Public Health SECTIO,N I~424 NOTICE Page 3 of 3 CITATION NUI~18ER: SECTIONS VIOLATED t5-1116-0009606-S Date: 12/12t2012 Time: CLASS AND NATURE OF VIOLATIONS reach at all times to prevent life-threatening pica. And "2. Staff must first obtain a substitute staff to be designated as 1:1 before taking a break." Review of the Individual Plan Behavior Obje~li~es and £fan~howed4hatlheplan was updated on 6/4/12 for Individual Supervision. Under Prevention the plan showed: "1. Supervision: [Client 1] is on Individual Supervision = provide direct, full line-of-sight, within arm’s reach at all times to ensure his safety .... know what his hands are doing at all times..." During interview of a supervisory staff (Staff A), on 11/13/12 at 2:30 p.m., Staff A stated that Client 1 had been on 1:1 status since May 2012 and was to be on 1:1 supervision at all times for pica. The facility failedto ensure that Client 1, who has severe life threatening behavior, pica, who is on 1 ’1 constant supervision, was not neglected, failed to supervise the client in accordance with his individual program plan, and failed to have his safety adequately protected when his designated 1:1 staff fell asleep while on duty. These failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physicat harm would resuit. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000694 State of California - Health and Human Services Agency Department of Public Health SEC~’ION 1424 NOTICE Page 1 of 3. CITATION NUMBER: 15-1284-0009503-S Date: 12/12/2012 Time: Type of Visit : YOU ARE HEREBY FOUND III VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a}(20) Incident/Complaint No.(s) : CA00314599 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP ICFDD 15000Arnold Dr Eldrid,qe, CA 95431 Intermediate Care FacilitylDevetopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $10,000.00 Capacity: 581 DEADLINE FOR COMPLIANCE 12/27/t2 12:00 a.m. CLASS A CITATION.-. PATIENT RIGHTS Title 22 DIV 5 ART4 76525 (a) (20) CLIENTS’ RIGHTS 76525 (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility Shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to comply with the above regulations by failing to ensure that facility staff used appropriate interventions to manage inappropriate client behavior with sufficient safeguards and supervision to ensure that the safety, welfare and civil and human rights of clients were adequately protected. Qn 6t13/12, a staff member used excessive force and a potentially injurious physical hold to redirect Client 1. A review of Client l’~medical record on 6t13t12 revealed that Client I had diagnoses including severe mental disability, Intermittent Explosive Disorder, and a seizure disorder. Client 1 was non-verbal and made his needs known by pointing, gestures, and facial expressions. Name of Evaluator: Linda Lucey HFEN Without a~lmitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature : Title: NOTE.* IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000695 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0009503-S Date: 12/12/2012 Time: CLASS AND NATURE OF VIOLATIONS Observations on 6/13/12 at 4:25 p.m., revealed Client 1 at the unit entrance with a distressed expression on his face. The Unit Supervisor, (Staff A) stated, "He might hit you," and the supervisor enter.ed the unit while the surveyor waited in the foyer of the unit. A fewseconds later Staff A returned to escort the suryeyo[ into~heunit. Staff Bwas ............. observed propelling Client 1 down the hall, with Client 1 bent forward with arms rotated inward and rigidly hyperextended behind Client 1. Staff B was holding Client 1 at the wrists and steering Client 1 down the hall toward the door to the outside patio. During a concurrent interview when asked if physical containment was part of Client l’s behavior plan, StaffA stated Client 1 had attacked her in the hall and had grabbed her clothing and her hair. The US stated she had restrained Client 1 by the wrists to gain release of her hair and to protect herself. Staff A stated she had been on the unit only a few months and did not have the behavior plans memorized. Review of Client l’s behavior support plan for assault dated 9/2/09, indicated behavioral antecedents included whining, distressed facial expression, raising a fist above his head, and charging at staff or another client. Interventions included asking him to stop, asking what he might need, and offering him choices regarding what he wanted. If he was still escalating staff were to verbally prompt him to sit down away from other clients. The plans indicated Client 1 would typically cry as he calmed down. After the incident he enjoyed physical reassurance such as shoulder pats and hugs which could help in preventing another episode. The behavioi" plan did not include physical prompts, or physical compliance such as the containment method used by Staff B. At 4:30 p.m., Staff B and Client 1 were at the nurses’ station counter. Client 1 was sobbing with tears and runny nose. During concurrent interview, when asked if he learned that hold in Management of Assaultive Behavior, Staff B said, "No. Well maybe a version of it. There was no one to help me out." When asked if such a hold could injure a client’s joints, Staff B demonstrated a "safer hold" by putting his hands on Client l’s upper arms. During an interview at 5 p.m., with StaffA and the unit psychologist (Staff C), Staff C stated a safe physical containment required at least two people and might take four people to provide a safe physical containment. Staff A stated Staff B had no way to summon help for an emergency physical containment. StaffA stated the unit was large and there was no way to hear a staffs cries for other staff to assist. If other staff did come to help, the clients for whom they were providing supervision would be left alone. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000696 State of California - Health and Human Services Agency Department of PubJic Health SECT, ION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VfOLATED 15-1284-0009503-S Date: 12/12/2012 Time: CLASS AND NATURE OF VIOLATIONS Review of the facility document, on 6/13/’12, entitled, "Self Defense and Management of Assaultive Behavior," dated. July 2010, indicated, "There are no one-person escort techniques. AT LEAST two staff members are required to safely transport an individual from one pla£e to another." The docum~ent indicated that one persQn physical containment was prohibited as of January 1, 2010. Therefore, the facility failed to comply with the above regulations by failing to ensure that staff used interventions to manage inappropriate client behavior with sufficient safeguards and supervision to ensure that the safety, welfare and civil and human rights of clients were adequately protected. A staff member used excessive force and a potentially injurious physical hold to redirect Client 1. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTE¥ CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000697 State of California - Health and Human Services Agency Department of Public Health ¯ SECTION 1424 NOTICE CITATION NUMBER: Page 1 of 3 15-1284-0009501-S Date: 12t12/2012 Time: Type of Visit : YOU ARE HEREBY FOUND IN V OLAT ON OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: AddresS: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) IncidentlComplaint No,(s) ¯ CA00312003, CA00298801 State of CA Dept of Developmental Services 16009TH STREET~ RM 340 . 150000089 SACRAMENTO, CA 9,5814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DiP tCFDD Eldridge, CA 95431 15000Arnold Dr Intermediate Care Facility/Developmentally Disabled Capacity: 581 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $10,000.00 DEADLINE FOR COMPLIANCE 12/27/12 12:00 a.m. CLASS A CITATION-- PATIENT RIGHTS T22 DIV 5 ART4 76525(a)(20) CLIENTS’ RIGHTS (a) Each client has the rights listed in (a) of this section which shall not be denied or withhel~ except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility violated the above regulation when it failed to ensure clients were not subjected to physical, sexual, and psychological abuse. The facility failed to ensure Clients 1 and 2 were free of physical, sexual, and psychological abuse when a male staff member exposed his genitals, grabbed the female clients’ hands, forced and attempted to force the clients to touch his penis, and masturbated in their presence. 1. Review of Client l’s medical record on 6/1t12, revealed that Client 1 was admitted to the facility in 1989 with diagnoses including Severe Intellectual Disability and Bipolar Disorder. Client 1 had good receptive language skills and could follow simple directions. Her expressive communication consisted mainly of gestures and guiding people to what she wanted. She also used simple verbalizations. Client 1 required staff Name of Eva}uator: Linda Lucey HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR’REVOCATION OF YOUR LICENSE DPH POD 000698 State of California - Health and Human Services Agency Department of Public Health SEOTI~3N 1424 NOTICE Page 2 of 3 CITATION NU]VlBER: SECTIONS VIOLATED 15-1284-0009501-S Dale: 12/12/2012 Time: CLASS AND NATURE OF VIOLATIONS supervision for completion of activities of daily living. On 5t29/12, review of a facility document, dated 5/25/12, revealed Staff A was observed facing Client 1 about two feet awayfrom Client 1, Staff A wassitting on the~ink c~ounter in the bathroom and had his shorts down and his penis out. The report indicated Staff A was immediately removed from client contact and a short while later arrested on felony charges by the county Sheriff Department. 2. Review of Client 2’s medical record on 6f1112, revealed that Client 2 was admitted to the facility in 1991 with diagnoses including intellectual disability and aggressive behaviors. Client 2 had good receptive language skills. She expressed herself with gestures and could verbally mimic phrases of others. She indicated choices with hand gestures or.by leading staff. She required general supervision in familiar environments. On 5/29/12, a review of a second facility document dated 5126t12, revealed that a county Sheriff’s deputy stated that Client l’s roommate, Client 2 was also a victim of sexual abuse by Staff A. On 6tl/12, a review of Client 2’s Physician Progress Notes (PPNs) dated 5/26/12, indicated StaffA, !’.o. admitted to masturbating in the presence of ... (Client 2). He reported wanting (Client 2) to touch him. It is unclear to me whether employee asked (Client 2) to touch him + (and) she refused, or whether he placed her hand on his genital area + (and) she pulled away. This episode occurred sometime within the past 1 - 2 weeks." 3. Review of a "CRIME\INCIDENT REPORT," dated. 9/5112, documented Staff A told a Sheriff’s Department detective that he [Staff A] did,"something perverted." Staff A told the detective that he had Client 1 "fondle me." StaffA explained that he brought Client 1 into the bathroom where he was alone with her and then exposed his penis to her and took the victim’s hand to place it on his penis. Staff A admitted to the detective that about one to two weeks ago, he attempted to have the victim’s roommate, Client 2, fondle his penis by having his pants partially down, penis exposed, and he grabbed Client 2’s hand ... however she pulled back refusing to touch his penis. The report indicated the detective interviewed a psychiatric technician assistant who stated approximately two months earlier (approximately April 9, 2012) Client 2 appeared so happy and said, ’(Staff A) is not here." The PTA indicated Staff A was not at work that day. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000699 State of California - Health and Human Services Agency ¯ SE~3TItON 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Depadment of Public Hea}th Page 3 of 3 15-1284-0009501-S Date: 12/12/2012 Time: CLASS AND NATURE OF VIOLATIONS Therefere the facility failed to ensure clients were not subjected to physical, sexual, or psychological abuse. Staff A confessed to physically and sexually abusing Clients 1 and Client 2. 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. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VlOLATtONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000700 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page+ 1 of 10 CITATION NUI’~ BER: 15-1284-0009498-S Date: 12/12/2012 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR lncidentlComplaint No.(s) ’ CA00322951 APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76301(e) State of cA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care Facility/Developmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $25,000.00 caPacity: 581 DEADLINE FOR COMPLIANCE 12/27/12 12:00 a.m. CLASS AA CITATION -- PATIENT CARE T22 DIV5 CH8 ART3 - 76301e Required Services (e) Client care provided by all team members shall be safe and considerate as ordered or indicated by the needs of the client and in accordance with acceptable standards of practice. The facility violated the above regulations when Client 1 suffered in pain and then died from peritonitis when physicians and nurses failed to identify and treat an incorrectly positioned gastrostomy tube, when nursing policies pertaining to care and use of gastrostomy tubes did not reflect safest practices and manufacturer’s instructions, and when nursing staff failed to implement policies related to replacement of gastrostomy tubes after traumatic removal as follows: On 6/20/12 at 11:30 a.m., Client 1’s clinical record was reviewed. The record reflected the following: A review of Interdisciplinary Notes (IDNs) dated 5t9/12 at 11:10 p.m., documented Client 1 was found in his room by night shift staff during change of shift rounds. Client 1 was pale, cool to the touch and unresponsive with no pulse and respirations. Physician Progress Notes (.PPNs) of 519/12, indicated Client 1 was found in a recliner at 10:35 p.m. Cardiopulmonary resuscitation was not successful and Client 1 was pronounced Name of Evaluator: Linda Lucey HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name ; Evaluator Signature Title : NOTE: 1N ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000701 Slate of California - Health and Human Services Agency Department of Public Health SECTION t424 NOTICE Page 2 of I0 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0009498-S Date: 12ti2/2012 Time: CLASS AND NATURE OF VIOLATIONS dead at 11:10 p.m. At the time of the investigation the autopsy report was not available. During interview on 6/25/12 at 11:30 a.m., a representative of the coroner’s office stated the cause ofdeath was; "Acute Peritonitis": (Aninflammation of the membranew~ich lines the inside of the abdomen and all of the internal organs. This membrane is called the peritoneum.) An Individual Program Plan (tPP) dated 515fl I, documented Client l’s diagnoses included profound mental retardation, obsessive-compulsive disorder, hearing loss and visual impairment. Client 1 was non-verbal and communicated with body language, facial expressions, and gestures. He had compulsive behaviors of spinning and twirling while walking and would sit on the floor instead of a chair. He also would lick poles, trees, and doors: The IPP documented Client 1 had a gastrostomy tube placed 4/13tl 1, due to swallowing problems, and recurrent aspiration pneumonia. A special meeting note dated 12/8/I 1, indicated Client 1 pulled his gastrostomy tube out on 12/4/11. An X-ray report dated t2t5/11, indicated contrast injected through the tube was seen in the stomach and duodenum with no extravasation (leaking) of contrast fluid. A review of IDNs of 3f5/12, documented Client 1 was seen in surgical clinic where a skin level gastrostomy tube was inserted. A review of PPNs dated 3t7t12, documented Client l’s primary physician (Physician A) administered acupuncture treatments in physical medicine clinic for a diagnosis of Gastroesophageal Reflux Disease (GERD) and pain. [GERD is a condition in which the stomach contents (food or liquid) leak backwards from the stomach into the esophagus, the tube from the mouth to the stomach. This can irritate the. esophagus causing heartburn and other symptoms.] A review of tDNs of 3/26/12, indicated a coffee ground residual was noted of I25 cc. PPNs indicated the primary physician documented an emesis with the appearance of coffee grounds in the amount of 120 cc. The notes did not document an examination of the gastrostomy tube. The physician’s impression was a probable recurrence of a bacterial (H. Py]ori) gastritis. A review of IDNs of 3f30/12, indicated Client 1 was having a morning formula nourishment via bolus when he screamed for about 10 seconds and then had a seizure. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTE¥ CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000702 State of California - Health and Human Services Agency Depar[ment of Public HeaIth SECTION 1424 NOTICE Page 3 of 10 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0009498-S Date: 12112t2012 Time: CLASS AND NATURE OF VIOLATIONS Notes indicated Client 1 had been seizure free since 1977, Notes of 3/31/12, indicated Client 1 seemed restless and tolerated his gastrostomy feeding but was tucking his arms under his seatbelt (a form of self-restraint). A review of PPNs of 3/30/12, documented a visit by Physician A and the impression that the seizure could be an isolated incident or a reaction to the antibiotic treatment for gastritis. A review of IDNs of 4t4/12, indicated Client I had 2 cc of clear residual at 3 a.m. At 8:45 a.m, Client 1 was noted to be short of breath with a pulse of 104 and a respiratory rate of 14..At 9 a.m., a Medical Emergency was called when staff noted Client 1 was tired and pale and had a decreased respiratory rate. Notes of 4/5/12 at 2:45 a.m., documented Client I had an elevated heart rate of 129 beats per minute and increased respiratory rate of 26. A review of PPNs dated 4/4/12 at 9:10 a.m, documented the primary physician examined Client 1 and noted the gastrostomy tube was patent and clean. PPNs of 4/5/12 at 10:15 a.m., indicated the physician’s impression of possible aspiration pneumonia. Notes indicated the gastrostomy was clean and the abdomen was not distended. A review of notes by a Health Services Specialist (RN) of 4/5f12 at 11:50 a.m., indicated a pulse of 129 and respirations of 30. Notes at 7:45 p.m., indicated staff noticed dried blood around the gastrostomy stoma site and blood in the residual. A review of IDNs of 4/6/12 at 4 a.m., indicated a small amount.of bleeding and dried amount of blood at the stoma Site. IDNs of 4/6t12 at 12:30 a.m., documented a visit by a Health Services Specialist (RN) who noted a small amount of dried blood at the stoma site with an area of pink tissue surrounding the stoma. Staff reported the tube seemed tight. There was an odor to the stoma site. The physician was notified. A review of PPNs did not indicate a visit by the physician. A review of IDNs of 4/6t12 at 2:30 p.m., indicatedstaff again noted dried blood around the stoma and Client 1 was exhibiting distress with behaviors of licking his fingers during feedings. Notes of 4t7/12 at 4 a.m. showed Client 1 was agitated during the feeding and licking at his fingers. Acetaminophen (Tylenol) elixir was given via the tube . for discomfort. Notes indicated there continued to be dried blood around the stoma. Notes of 419t12, indicated the stoma had an area with a greenish color and slight NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000703 State of California - Health and Human Services Agency Department of Public Heatth SECTION 1424 NOTICE Page 4 of 10 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0009498-S Date: 12/12/2012. Time: CLASS AND NATURE OF VIOLATIONS redness around the stoma. A review of IDNs of4/11/12, indicated Client 1 was receiving acetaminophen elixir via the gastrostomy for pain. Notesiiidicated he was exhibiting Ioudvocalizations and restlessness. Notes of 4/12/12, indicated Client 1 was very agitated during the 9 a.m. feeding. Staff administered acetaminophen with hydrocodone (Norco is used to relieve moderate to severe pain). Notes of 4/13/12, indicated the stoma area was red with dried blood around it. Notes of 4115t12, indicated there was no residual noted at 8 a.m. and .5 cc noted at 12 noon. The stoma area was continued to be red and bleeding continued. There was no indication of a visit by the physician. A review of IDNs of 4t16/12 at 4:30 a.m., indicated Client 1 had two days of loud vocalizations and no sleep. He was given medication for pain with no reduction in vocalizations. At the time of feeding there was coffee ground residual of 1 0 cc. Staff continued to give medications and formula through the gastrostomy tube. Notes at 2 3.m., indicated Client 1 continued to be restless and exhibiting loud vocalizations. Notes of 4/17/12, documented Client 1 continued to be restless with vocalizations. There was no indication of a visit by the physician. A review of ]DNs of 4t18/12, indicatedClient 1 was receiving Norco for pain. Crusty matter was noted around the stoma. During the 9 a.m. feeding Client 1 was very vocal with Pain noticed in his facial expression. Notes of 6:30 p.m., indicated Client 1 was having discomfort exhibited by vocalizations and moving arms and hands up and down. Norco was given at 7 p.m. because Client I continued to exhibit ’cry-like vocalizations. When gastric residuals had the appearance of coffee grounds, staff administered Maa]ox via the gastrostomy tube. A review of PPNs of 4/19/12, documented a visit by the primary physician, Physician A. The previous visit was on 4t5t12. The notes indicated the physician was notified of the residuals with the appearance of coffee grounds seen the previous evening. Notes documented the physician’s impression of gastritis, causing nocturnal agitation and insomnia. A medication for sleep was prescribed. In addition, notes indicated Client 1 was receiving an antidepressant and a medication to reduce the production of stomach acid. Medications were being given via gastrostomy tube. A review of IDNs of.4/21/12, documented Client I was itching himself all over and making disturbing loud vocalizations. He occasionally would start to cry. Posey mitts were ordered to protect his skin from self-injury. He continued to vocalize loudly. On NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000704 State of California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page 5 of 10 cI’rATION NUMBER: SECTIONS VIOLATED 15-1284-0009498-S Date: 12112t2012 Time: CLASS AND NATURE. OF VIOLATIONS 4/23/12, Client 1 continued to require mitts due to self-abusive behaviors of hitting himself. He was receiving Norco for pain as well as Maalox via the tube in addition to his regular medications and feedings. He was crying. On 4/24/12, Client 1 was writhing and restless_ Notesof-4/24t12 at 4:3(3 p.m.; documented that Client1 wasvocalizing loudly during the feeding and sweating profusely throughout the afternoon. A review of PPNs dated 4/24/12, indicated Client 1 had increased agitation, was sweaty, and vocalizing. The physician’s impression was probable gastritis and possible constipation. A review of special meeting notes dated 4/25/12, indicated Client 1 recently had become combative during the feedings. A review of IDNs of 4t25/12, indicated Client 1 continued to perspire excessiveiy during the day and was fidgety. At 9 p.m. Client 1 was yelling and rubbing his face so Posey mitts were applied and Norco was given. On 4t26/12, Client I was awake all night and restless. Staff administered two tablets of Norco every six hours for pain. On 4/27/12, Client 1 was awake all night and continued to be restless a~d fidgeting during gastrostomy feedings. Two staff were required to complete the feedings. At 9:15 a.m. he was-restless and sweaty during the gastrostomy feeding. Staff administered the sedative medication Lorazepam. A review of PPNs dated 4/27/I2, documented Client 1 was having severe agitation with self-injurious behaviors. The physician prescribed the sedative Lorazepam to be administered through the gastrostomy tube. The note documented the primary physician spoke with Client l’s relative who, according to the physician, did not understand his simple explanation of why (Client 1) was agitated and symptomatic. The note documented the physician told the relative that Client 1 had a behavior of licking his shoes and the floor and reinfected himself with the H. pylori organism there-by needing repeated treatment every so often. The physician told the relative that Client l’s body may not tolerate the recurrent gastritis. A review of I DNs of 4/28t12, indicated that Client 1 was writhing constantly and resistive to care. On 4129/12 Client 1 was unsteady with erratic movements and anxious. There was marked sweating over his body. He was exhibiting painful facial grimacing during the 12 noon feeding and was given two tablets of Norco. A review of lDNs of 5/2/12 at 2 a.m., showed Client I was very agitated and was NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000705 State of California - Health and Human Services Agency Department of Public Heaith SECTION I424 NOTICE Page 6 of 10 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0009498-S Date: 12112/2012 Time: CLASS AND NATURE OF VIOLATIONS rubbing his skin constantly causing the skin of the abdomen and thighs to be bright red. Acetaminophen was given but wasnot effective so the physician on call ordered a sedative. A review of PPNs of 5/2/12, documented Client 1 received acupuncture treatment from his primary physician for his GERD. A review of IDNs of 5t2/12 at 11 a.m., documented that during the morning feeding, both of Client l’s legs were shaking and he was self-restraining both hands and arms behind him in the back of the wheelchair. A review of special meeting notes dated 5/3/12, indicated the team met to discuss Client l’s increase in agitation over the past months. The team identified that Client l’s behavior began escalating around 4/25f12. Although he had always exhibited these behaviors, they had never been so severe. Client 1 was not sleeping at night. It was very difficult to feed him due to his resistiveness. He continued toreceive his medications by gastrostomy tube. He frequently dropped to the floor and then licked the floor. He often pressed his fists into his eyes. It was not uncommon for him to moan. He often writhed and perspired. The meeting notes documented the unit physician stated Client- 1 was experiencing significant discomfo~ and pain due to a severe case of gastritis and Client I had recurrent gastritis as a result of his repeated licking of the floor. A review of IDNs of 5t2t12 at8 p.m., indicated Client 1 was resistive to receiving medications and gastrostomy feedings. Notes of 5/3/I2 at 1:30 p.m., indicated the skin of his thighs and thorax was scratched from Client 1 putting his hands down his pants for self-restraint. Notes written at 2:15 p.m., indicated he tipped his wheel chair over and was pushing staff away from him, vocalizing loudly, flailing his arms and legs, and trying to hit his head on the floor. Two staff were necessary to intervene. He continued out of control behavior trying to hit his head. The physician ordered a sedative to be given through the gastrostomy. Notes indicated the physician changed many orders. The last PPN by the primary physician, Physician A, dated 5/4t12 at 10:30 a.m., indicated, "Client hada good night last night. Slept very well ... (illegible) ... 1 believe clientscratching himself greatly today, required Posey mitts. The notes did not indicate a physical examination of Client 1¯ A review of IDNs of 5/4/12 at 5:15 p¯m., indicated Client 1 was given a sedative NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION ORREVOCAT ON OF YOUR LICENSE DPH POD 000706 State of California - Health and Human Services Agency Deparlment of Public Health SECTION "1424 NOTICE Page 7 of 10 CITATION NUI~BER: SECTIONS VIOLATED 15-1284-0009498-S Date: 12112t2012 Time: CLA,~S AND NATURE OF VIOLATIONS because he was trying to hit his head on the floor and was scratching his body, hitting and kicking at staff. He refused to stop these behaviors and Posey mitts were applied. IDNs of 5/5112 at 3p.m_, it~dicated the morning feeding was very difficult dueto Client l’s uncontrollable behaviors due to his pain. He required physical restraint in the wheelchair and received sedation. Notes of 5/6t12 and 5/7/12, indicated Client 1 continued the same behaviors. Notes of 5t7t12, indicated he grabbed at staff hand during his 12 noon feeding. At 9 p.m. he hit his head and sustained a laceration on the top of the scalp. A review of PPNs from 3/7t12, 3/26/12, 3/30/12, 4/4f12, 4/5/12, 4/19tl 2, 4/24/12, 4/25t12, 4/28/12, 5/2tl 2, 5/3/12, and 5/4ti2 did not document any evidence Physician A considered ordering any test to ensure proper placement of the gastrostomy tube. A review of Client l’s Physician’s Orders indicated, "Since 3/5/12,. on feeding tube with a low profile mini one button GT. Size 20 FR wt3.5 cm w/10 m] balloon." A review of the "INSTRUCTIONS FOR USE" for the AMT MINI ONE skin level indicated, "VERIFY THE MINI ONE IS WITHIN THE STOMACH ... "Attach a catheter tip syringe with 5 ml of water into the Mini ONE button feeding set. Aspirate for contents. Spontaneous return of gastric contents should occur. WARNING: NEVER INJECT AIR INTO THE MINI ONE BUTTON." On 6/21/12 at 2 p.m., a review of the facility document entitled, "GASTROSTOMY TUBE" dated February 2011, under the heading of, "Residual and Placement Checks" indicated, "Attach a feeding syringe to end of tube, lower the syringe below stomach level to allow gravity to fill syringe ..." and "... If there is no return do one of the following: ... Auscultation: Inject 10-20 ml (milliliter) of air in the GT (gastrostomy tube) while listening for a loud whooshing or gurgling sound in upper left quadrant of abdomen using a stethoscope." Auscultation is the act of listening to sounds arising within organs (as the lungs or heart) as an aid to diagnosis and treatment. Aspiration is breathing in a foreign object or liquid. Reference review on 6/21/12, indicated: ("... Do not use an auscultation method to check tube placement: it is not reliable." Preventing Aspiration Du~ing ... Gastrostomy Tube Feedings. Janice L. Palmer, MS, RN: Norma A. Metheny PhD, RN, FAAN. American Journal of Nursing, February 2008. Volume 108.") NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY COD’E, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000707 State of California - Health and Human Services Agency Deparlment of Public Health SECTION 1424 NOTICE Page 8 of 10 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0009498-S Date: 1211212012 Time: CLASS AND NATURE OF VIOLATIONS A review of Client l’s clinical record reflected the facility document, "ENTERAL FEEDING LOG". In the log, the area for tube placement verification indicated, "Verify placement~oh ~hift by r~idual ~he~ks ..: If no residua = U~stethoscope to ~h~k w/10 cc (with 10 cc) air injected to check via auscultation." A review of the logs from January 2012 to May 2012 indicated gastric residuals were frequently recorded to be zero and there were initials in areas indicating confirmation of placement by injection of air. On 6/21/12 at 2 p.m., a review of the facility document entitled, "GASTROSTOMY TUBE" dated February 2011 indicated in bold underlined print, "... If the tube comes out and the balloon is intact (inflated), and with signs of trauma (e,.g.bleeding) and with missing parts, notify the physician immediately." On 6/20/12, a review of Client l’s IDNs by a Psychiatric Technician (PT), (Staff C)on 5/8/12 at 7:15 p.m., indicated, "(Client 1) flailing his arms around. Client rec’d (received) stat programmed Iorazepam (a sedative) 1 mg (milligram) GT for pain. He pushed staff away while staff was attempting to give medication and formula causing the GT to come out of his stomach. GT replaced (with) Foley GT. Some oozing of blood that was minimal." The notes did not indicate a physician was called immediately after the tube came. out traumatically with bleeding. On 6/21/12 at 2 p.m. a review of the facility document entitled, "GASTROSTOMY TUBE" dated February 20t 1 indicated, "Balloon Gastrostomy Tube Placement. Performed by: Licensed level of care staff. (This means a Registered Nurse, a Licensed Vocational Nurse, or a Psychiatric Technician). On 6/2~1/12 at 6:15 p.m., a review of a revised procedure entitled, "GASTROSTOMY TUBE" dated June 2012 indicated, "Purpose: Direct licensed staff to appropriately place a gastrostomy tube ..." Neither the former or current policy described the limits of the conditions under which a Psychiatric Technician (PT) may insert a replacement ga~trostomy tube. During a phone interview on 713/12, a representative of the California Board of Vocational Nursing and Psychiatric Technicians stated a PT may reinsert a gastrostomy tube in accordance with a physician’s order into a well-healed, non-problematic tract. In all cases, the PT must possess the knowledge, skill and abilities to perform safely and NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000708 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 9 of 10 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0009498-S Date: 12t12/2012 Time; CLASS AND NATURE OF VIOLATIONS competently. A review Client l’s clinical record reflected notes by a HSS dated 5t9/’12, with no time indicated documented the Registered Nurse (RN) (Staff [3) remove8 the Foley catheter. There was a small amount of dark red blood expelled with bile. The RN inserted a size 20 French 3.5 cm button (skin level tube). Notes indicated, "... button inserted [with] some resistance (tight abd muscles) then easily inserted again [with] bleeding noted@ ... stoma site. placement [check] via ausc (auscultation); scant blood in residual check. abd soft. balloon instilled [with] 10 cc water- tolerated well Covering MD notified. Plan monitor site." A review of subsequent IDNs of 5/9/12, indicated Client 1 seemed to be comfortable and not in apparent pain. Notes indicated he was found in his room without pulse or respirations at 11:10 p.m. During an interview on 7/2tt2 at 3 p.m., the facility physician who attended the autopsy (Physician B) stated Client 1 had a tense abdomen and as the abdomen was incised about 1500 cc of undigested formula came out. A skin level gastrostomy tube was positioned in the peritoneal cavity and not in the stomach. The physician stated Client 1 had peritonitis with the entire anterior wall of the abdomen inflamed with pus pockets around the internal organs. The physician described a congealed area by the liver and spleen. There were multiple pocket,s of pus. The physician stated .there was an area of scars and pus next to the stomach. The physician described a formation between the abdominal wall and the stomach that looked like omentum (a fold of peritoneum extending from the stomach to adjacent abdominal organs.) The physician stated the peritonitis must have been going on for longer than a few days, possibly from a leak in the area of the stoma with part of the formula going into the stomach and part going into the peritoneal cavity. Physician B indicated this was most likely the reason for Client l’s pain and anxiety. Therefore the facility failed to provide the physician services necessary to diagnose and treat Client l’s misplaced gastrostomy tube. Nursing policies did not provide for nursing services to ensure correct gastrostomy tube placement and nurses did not follow the policies in effect for tube replacement after traumatic removal. Client 1 suffered in pain for months and then died of acute peritonitis when staff continued to use his misplaced gastrostomy tube. The facility failures presented an imminent danger to the patient and was a direct NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000709 State of California - Health and Human Services Agency Department of Public Health SECTION "1424 NOTICE Page t0 of t0 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0009498-S Date: ’12/12/2012 Time: CLASS AND NATURE OF VIOLATIONS proximate cause of the death of the patient. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000710 State o!,CalifornJa -¯Health and Human Services Agency Department of Public Health ’SECTION 1424 NOTICE CITATION NUMBER: Page 1 of 4 15-1594-0009497-S Date: 1211212012 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) IncidenttCompla[nt No.(s) " CA00314985, CA003i1982 State of CA Dept of Developmental Services 1600’9TH STREET, RM 340 150000089 SACRAMENTO, CA ~fype of Ownership; 95814 State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD 15000Arnold Dr Eldddge, CA 95431 Intermediate Care Facility/Developmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMEN’T $I0,000.00 Capacity: 581 DEADLINE FOR COMPLIANCE 12/27/12 12:00 a.m. CLASS A CITATION -- PATIENT RIGHTS T22 DIV 5 ART4 76525(a)(20) CLIENTS’ RIGHTS ¯ (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to prevent neglect by failing to implement policies and procedures (P&P) related to pica (persistent ingestion of nonnutritive substances) for 2 clients (Clients 1, 2): 1. Client 1 ingested gloves and other items requiring surgery to remove the items from his stomach and.subsequently obtained piec&s of a wooden bed frame while on individual supervision; 2. Client 2 required emergency surgery after ingesting sunglasses, despite a long history of attempting to ingest them. A review of the facility’s Administrative Directive titled, "Abuse/Mistreatment/Neglect Prevention & Reporting," effective 3/09, included the following definition of neglect: Any willful act or lack of action that causes or may cause harm which may include but is not Name of Evaluator: CAROL DEVITA HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : --valualor Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000711 Stale of California - Health and Human Services Agency Department of Public Health SECTION ’1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS VIOLATED 15-1594~0009497-S Date: t2/1212012 Time: CLASS AND NATURE OF VIOLATIONS limited to failure to provide medical care, mental health needs, assistance with personal hygiene, adequate clothing and nutrition, protection from health and safety hazards, required habilitation and training services, or sleeping while on duty. A review of the facility policy and procedure (P&P) titled, "PICA," (sic) dated December 2011, indicated, "Pica is the persistent ingestion of nonnutritive substances including, but not limited to: clay, dirt, sand, stones, hair, feces, lead, gloves, plastic, paper, paint chips, wood, string, cloth, metal, and/or cigarette butts_.AII clients asSessed by the unit Psychologist to have a PICA (sic) condition shall have a Behavior Plan and a Health Care Plan and Objective to address prevention strategies and intervention requirements." The P&P indicated that the purpose was "To protect clients from harm related to the ingestion of nonnutritive items..." 1. Review of Client l’s medical record on 6/14/12, revealed that Client 1 was admitted to the facility on 5t4/87 and had diagnoses that included pica and severe intellectual disabilities. The record revealed that Client 1 had a long-standing history of pica and the facility had a plan of care regarding Client l’s pica behaviors. Review of a Behavior Support Plan for pica, dated 4/18/12, indicated Client I was on close supewision on his residence (visual. checks every 5 minutes). He was to be visible in public areas unless he was in the bathroom or in his room. For any off-residence activity (offsite/outing) he was on constant supervision (Staffwas required to be able to see and or hear each client and be in close enough proximity to intervene as necessary). On 5/17/12, facility documentation indicated that Client 1 vomited coffee ground emesis (an indicator of bleeding in the stomach) and was sent to the community hospital. On 5fi8/12, the client underwent a procedure to extract a button, button pieces, a shoelace and two calcified gloves. Upon return to the facility, the client was placed on Individual Supervision at all times. Review of a subsequent Behavior Support Plan for pica, dated 6/1t12, indicated Client 1 was on Individual Supervision, (Staff mu~t be able to see their assigned client at all times and be in close enough proximity to protect them and others from injury. Staff must not leave the client unattended at any time or be distracted by other issues). A facility document, dated 6/13/12, indicated that on 6/9/12, staff noted that the client, while on individual supervision, had collected pieces of wood from hisbed frame under NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAI=TEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000712 State of California - Health and Human Services Agency Departmeni of Public Health SECTION 1424 NOTICE Page 3 of 4 CITATION NUMBER: SECTIONS VIOLATED 15-1594-0009497-S Date: 12ft2f2012 Time: CLASS AND NATURE OF VIOLATIONS his covers. An interdisciplinary note indicated that no ingestion was witnessed. 2. A review of Client 2’s medical record on 6/14/12, indicated that Client 2 was re-admittedfofhe facility on 8/26fl 1. with diagnoses that included pica, Intermittent Explosive Disorder, and severe mental retardation. Review of facility documentation dated 6/13/12, indicated that Client 2 presented with symptoms of a possible bowel obstruction and was transferred to the acute care hospital for evaluation and treatment. The documentation also revealed that the Computerized Tomography scan showed the presence of a "V" shaped wire type foreign body with small rounded metallic ends traversing his small bowel. The Computerized Tomography scan indicated that Client 2’s small bowel appeared to be perforated. Emergency surgery was performed and the "V" shaped item was removed as well as two arm pieces from a pair of eye glasses. The facility document indicated that Client 2 had a history of ingestion of non-food items, specifically sunglasses. The documentation further indicated that this was the second incident involving the ingestion of sunglasses with Client 2 within the past 12 months. In March of 2009, Client 2 had an esophageal perforation due to ingestion of a linear object. A review of Client 2’s Behavior Support Plans, dated 5/11/12, indicated that Client 2’s Target Behaviors included property destruction (breaks medical equipment, electronics, windows, sunglasses .... ) and pica ( putting hazardous objects in his mouth or ingesting such objects (may’ include toys, blankets, paper clips, light bulbs, sunglasses ..... and other objects that he breaks). Client 2’s behavior plans listed sunglasses as "Preferred Items." Psychology Progress Notes, dated 1/11/12, indicated that in the 4 months since the client’s return to the facility on 8126/11, there were 17 incidents of pica or attempts. On 6/20/12, review of a facility document relating to an "Endangering Event- ingestion," indicated the following Issue/Concern: "Poor planning by the ID Team (Interdisciplinary Team) regarding client needs and supports." Client 2’s level of supervision was changed from individual supervision to general supervision on 3/11/12, following his dismantling a pair of sunglasses and ingesting a piece of the lens on 10129/11. "No denial of rights was put in place to monitor his possessions for ingestible type items and NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS 1S GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000713 State of.Califom;a - Health and Human Services Agency Department of Public Health ~ECTION 1424 NOTICE Page 4 of 4 CITATION NUMBER: SECTIONS VIOLATED 15-I594-0009497-S Date: 12/1212012 Time: CLASS AND NATURE OF VIOLATIONS followi.ng the 10/29/’11 incident, the client was still allowed to have sunglasses despite his long history of attempting to and actually ingesting them." Observations on 6/’12/12 at 4:45 p.m., revealed a housekeeping cart parked inthe doorway of an activity room on Client 2’s residence, accessible to clients ambulating in the hallway who potentially had pica. The housekeeping employee had his back to the cart ashe cleaned in the room. The garbage container was not covered and an open container of disposable gloves was on the top of the cart. StaffA stated there were clients with pica behaviors on the unit. On 9/18/12, review of the operative report, dated 6/13/12, indicated that the post-operative diagnosis was a perforated small bowel secondaryto ingested foreign body. The procedures performed were as follows: 1. Exploratory lap (an incision through the abdominal wa]l). 2. Excision of foreign body from the small bowel. 3. Small bowel resection (excision) with side to side functional end to end stapled anastomosis (surgical connection between two structures). 4, Abdominal washout. On 9/’18/12, a physician’s general surgery note indicated: Routine follow up 3 weeks status post emergency exploratory laparotomy for small bowel perforation secondary to swallowed glasses which was complicated by post op abscess requiring [unable to read] drainage. Therefore, by failing to protect clients from health and safety hazards and by failing to implement pica related policies and procedures, Client I ingested gloves and other items requiring surgery to remove the items from his stomach and subsequently obtained pieces of a wooden bed frame while on individual supervision. Client 2 required emergency surgery after ingesting sunglasses, despite a long history of attempting to and actually ingesting them. These faitures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result NOTE; IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000714 State of California - Health and Human Services Agency Department of Public Health SEO’~iON 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-1284-0009314-S Date: .12/12t2012 Time: Type of Visit ¯ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number; Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76301(e) Incident/complaint No.(s) " CA00290249 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD 15000Arnold Dr Eldridge, CA 95431 Intermediate Care FacilitytDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $10,000.00 Capacity: 581 DEADLINE FOR COMPLIANCE 12/27/12 12:00 a.m. CLASS A CITATION -- PATIENT CARE T22DIV5CH8ART3 76301 (e) Required Services (e) Client care provided by all team members shall be safe and considerate as ordered or indicated by the needs of the client and in accordance with acceptable standards of practice. The facility violated the above regulation when it failed to provide the safe diet as ordered. Client 1 had difficulty swallowing and .choked on pizza after staff failed to ensure all his food was chopped and his bread was soaked as follows: On 3tl 2/12, a review of an incident report dated 10/29/11 at 12:10 p.m. indicated Client I was sitting next to his relatives during a family pizza party when he began choking. The report indicated Client 1 was at high risk of choking because of missing teeth. The report indicated a staff member applied abdominal thrusts (a thrust that creates and artificial cough forceful enough to clear the airway) and the food was dislodged. The code team arrived and assessed Client 1 who did not have complications from the incident. On 4/10/12 at 2 p.m., Client 1’s clinical record was reviewed. Name of Evaluator: Linda Lucey HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000715 State of California - Health and Human Services Agency Department of Public Health SEOflON 1424 NOTICE Page 2 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 15-1284-0009314-S Date: 1211212012 Time: CLASS AND NATURE OF VIOLATIONS A review of Client l’s interdisciplinary notes reflected notes of 10/29/11 at 12:12 p.m., "While eating lunch at Parent Party, (Client 1) began to choke on pizza. His sister yelled for help and staff immediately assisted. (Client 1) was starting to become pale and limp as staff gave multipleabdominal thrusts to dislodge food item ... "; A review of Client l’s clinical reflected an individual program plan (IPP)dated 12/7/10 identified Client l’s swallowing problems and high risk for choking. Plans included a chopped textured diet, with moistened and Cubed bread and with no tough chewy foods. He dined independently with supervision at the dining table. A health care plan for dining included written interventions implemented on 1/23t09 which indicated, "Diet consistency Chopped diet, cubed bread are (sic) moistened Thin fluids Avoid tough, chewy foods ... Cut into bite size pieces if food is prepared otherwise ... remind (Client 1) to eat slowly; and to eat small bites ..." During an interview on 5/7/12 at 2 p.m., Client l’s mother stated Client 1 has had difficulty swallowing since childhood. The mother stated she served Client 1 little pieces of food during home visits. At home, she cut his toast into little squares and soaked them with milk. The mother stated she usually arrived at the facility’s family party in time to fix Client l’s plate for him, but that day traffic was heavy and she arrived a little late. Client 1 had already been served several oblong pieces of pizza about 4 inches tong and 2 inches wide. The pizza was not bite sized, it was not chopped and the bread was not soaked. The mother stated Client 1 took one bite and became very red faced. The mother stated she was very upset by the experience. On 5t5/12, a review of a "MEDICAL EMERGENCY REPORT", dated 10/29/11 at 12:15 p.m., indicated a staff member intervened and dislodged the pizza piece after application of over twenty abdominal thrusts. During an interview on 5/7/12 at 2 p.m., Client l’s sister stated staff gave Client i a whole piece of pizza. By the time she and her mother arrived, Client 1 had been served and had already picked up a piece of pizza. The sister stated she noticed Client 1 turned red, his eyes were watering and he was drooling. The sister stated she started screaming, "He’s choking" and everybody came running. A staff member, Staff A, worked vigorously and finally dislodged a gummy piece of pizza crust about the size of a quarter. Therefore the facility failed to ensure implementation of physician’s orders for a chopped diet with soaked bread for Client 1 who had swallowing difficulties since childhood. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000716 State of California - Health and Human Services Agency Department of Public Health SEO’TION 1424 NOTICE Page 3 of 3 CITATION NUIWBER: SECTIONS VIOLATED 15-1284-0’009314-S Date: 12/1212012 Time: CLASS AND NATURE OF VIOLATIONS Facility staff served Client 1 and intact piece of pizza and Client l’s airway became obstructed after.one bite. More that twenty abdominal thrusts were necessary to dislodge the food bolus. 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. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000717 State of Calffornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page I of 4 CITATION NU~ilBER: Ig-1284-0009262-S Date: 12t1212012 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VlO LATED 76301(e) ]ncidenttComplaint No.(s) ’ CA00283444 State of CA Dept df Developmental Services 1600 gTH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care FacilitytDeve!opmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $10,000.00 Capacity: 581 DEADLINE FOR COMPLIANCE 12/27/12 12:00 a.m. CLASS A CITATION -- PATIENT CARE T22 DIV5 CH8 ART3-76301(e) Required Services (e) Client care. provided by all team members shall .be safe and considerate as ordered or indicated by the needs of the client and in accordance with acceptable standards of practice. The facility violated the above regulation when it failed to ensure clients were safe from injury when Client 1 was biting others. After multiple incidents of hitting and biting staff and peers, Client 1 was placed on individual (one-to-one) supervision prior to an administrative transfer to a different unit. Seven days after the transfer, staff discontinued the individual supervision without a team assessment. Client 1 began to bite peers and continued to bite peers until the team conducted an assessment and increased supervision twenty days later as follows: On 11/16111, a review of an incident report dated 9/12/11 indicated Client 1 ran down the hall and bit Client 2, who was in a wheelchair. Client 2 sustained a bite mark on the left upper arm with bruising, abrasions, and tooth marks. On 11/16/11, Client 1’s clinical record was reviewed. Name of Evaluator: Linda Lucey HFEN Without admitting guiIt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000718 State of California - Health and Human Services Agency Depadmenl of Public Health SECTION t424 NOTICE Page 2 Of 4 CITATION NUI~BER: SECTIONS VlO LATED 15-1284-0009262-S Date: 12/12/2012 Time: CLASS AND NATURE OF VIOLATIONS A review of Client 1 ’s interdisciplinary notes (IDNs) dated 9/12/11 .at 12:25 p.m. indicated Client 1 hit a peer while at day program. IDNs, at 2:40 p.m., indicated Client 1 bit Client 2 after returning to the unit from day program. The IDNs indicated staff providedf1:1 (individual) supervision for Client 1 until thepsychologist came t6 evaluate him. IDNs at 3 p.m., indicated the psychologist recommended constant supervision (staff close enough to intervene if necessary). Notes of 9/12fl I at 9 p.m., indicated Client 1 was placed on close supervision (staff in the area with eye contact every 5 minutes) at 8 p.m., and was back on general supervision at 9 p.m. On 11/16111, a review of the facility document entitled, "SU PERVISION OF CLI ENTS" dated February 2011 indicated, "General Supervision: Staff must make visual andlor verbal contact with each assigned client no less than every 15 minutes ... Close Supervision: Staff must be in the immediate area, hear the client at all times, and must make visual contact at least every 5 minutes ... Constant Supervision: Staff must be able to see and/or hear each client and be in close enough proximity to intervene, as necessary ... One-to-One (1:1) Supervision ... Staff must be able to see their assigned client at all times and be in close enough proximity to protect them and others from injury ... Staff must not leave client unattended at any time or be distracted by other issues." A review of IDNs of 9/13/11 at 2:40 p.m., documented Client t bit.Client 3 on the back while at day program. Staff provided 1:1 supervision after the incident. A review of IDNs of 9tl 3111 at 3:47 p.m., documented the use of sedatives for Client 1 due to extreme agitation. IDNs of 9/14/I 1, documented Client I hit a peer while at the worksite and then hit another peer before a 1:1 staff member could intervene. IDNs of 9/16tl 1 at 8:30 a.m., documented Client 1 bit Client 4. Client 4 sustained a bleeding circular wound on the right forearm. A review of IDNs dated 9/16111, documented Client 1 hit a staff member several times. iDNs of 9/26/11 at 6 p.m., indicated Client I reached out and bit a staff member on the shoulder while on 1:1 supervision. Client 1 hit the psychologist who came to assist. IDNs of 9/27/11 at 10:30 a.m., indicated Client 1 bit a staff member. A review of Client l’s clinical record reflected an annual Individual Program Plan (IPP) dated 10/14/11, which documented Client t had diagnoses including severe mental retardation, autism, intermittent explosive disorder, and bipolar disorder. The record showed that Client 1 was hospitalized for multiple surgeries in 2010. The IPP documented Client 1 was having episodes of severe agitation and bit staff in May of NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS 1S GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000719 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 4 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0009262-8 Date: 12/1212012 Time: CLASS AND NATURE OF VIOLATIONS 2011. Physicians had adjusted Client l’s behavioral medications multiple times. Client l’s IPP of 10/14/11, documented Client 1 was on 1:1 individual supervision. A review of IDNs of 10tl 8tl 1, documented Client 1 was transferred to another unit of the facility due to closure of his home unit. During an interview on 11/16/11 at 3 p.m., the Unit Supervisor (US) stated Client l’s 1:1 (individual) supervision had been discontinued on 10/25/t 1. The US stated she was new to .the unit and did not know why Client 1 was taken off individual supervision and put on genera[ supervision seven days after the transfer. On 4/3/12, the clinical records of Clients 5, 6, and 7 were reviewed. A review of Client 5’s IDNs dated 10125/11 at 5:10 p.m., indicated Client 1 was seen with his mouth on Client 5’s right shoulder. Staff discovered a human bite wound with bruising, teeth indentations, and abrasions on Client 5’s right shoulder. A review of Client 6’s IDNs dated 10/25/11 at 5:50 p.m., indicated staff observed Client 1 was in the area just before staff discovered Client 6 had a bite mark with redness and some peeled back skin present in multiple areas. During the interview on 11/16/11 at 3 p.m., the US could not explain why supervision was not increased after Client I bit two peers the evening of 10t25/11, just hours after 1:1 supervision was discontinued. A review of Client 7’s IDNs dated 10/30tll at 6 p.m., indicated staff discovered a bite wound on Client 7’s left back with abrasions, swelling and discomfort to touch. Client 7 was Client l’s roommate. A review of Client 5’s IDNs dated 11/8/11, indicated staff discovered an abrasion on his right shoulder. The assessment of the injury indicated it could possibly be a bite attempt by a peer. Client l’s IDNs of 11/12/11 at 2 p.m., indicated staff observed Client 1 bite Client 5 on the left bicep. Client 5’s IDNs for that time indicated Client 1 bit Client 5 before staff could redirect Client 5 away from Client 1. A review of Client l’s Special Team Meeting notes dated 11ti4tl 1, indicated Client l’s level of supervision had been "general" during the twenty days since 10t2511 I. The notes did not reflect discussion of the reason Client 1 was taken off 1:1 supervision and NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AN]D SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000720 State of California - Health and Human Services Agency ’ SECTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health Page 4 of 4 15-1284-0009262-S Date: 12112/2012 Time: CLASS AND NATURE OF VIOLATIONS put on general supervision seven days after he was transferred to a new unit. Notes documented Client 1 subsequently inflicted bites on four occasions, with one peer sustaining two bites. The meeting notes documented the interdisciplinary team’s decision to increase Client t% level of supervision on 11t14/11 : Therefore the facility failed to ensure safety of clients when Client l’s individual supervision was discontinued without a team assessment. Client 1 inflicted four bites on three peers before increased supervision was resumed twenty days later. The above violations presented either imminent danger that death or serious harm would result or a substantial harm would result or a substantial probability that death or serious physical harm would result. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000721 State pf California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 4 CITATION NUI~IBER: 15-1284-0008849-S Date: 12/1212012 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) lncidentfComplaint No.(s) ’ CA00277548 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD 15000 Arnold Dr Eldddge, CA 95431 Intermediate Care Facility/Developmentalty Disabled Capacity: 581 150000230 CLASS AND NATURE OF VIOLATIONS CLASS A PENALTY ASSESSMENT $10,000.00 DEADLINE FOR COMPLIANCE 12/27/12 12:00 a.m CITATION .- PATIENT CARE T22 DIV5 ART4-76525 (a) (20) CLIENTS’ RIGHTS (a) Each client has the rights listed in (a) of.this section which.shall not be denied or withhe d except as provided in (c) 0f this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or. isolation, excessive medication, abuse or neglect. The facility failed to comply with the above regulation when it failed to ensure protection of clients from a violent peer. Client l’s aggressive behaviors toward other clients increased in intensity of violence without changes in plans or supervision, until Client 1 caused life-threatening injuries to Client 3, a medically fragile client. On 9/20/11, a review of an Individual Program Plan (IPP) dated 5t5/11, indicated Client 1 had mild mental retardation and intractable epilepsy. The IPP documented Client l’s ability to plan his behavior and his history of violence to peers with the potential for causing severe injuries to others. The IPP documented Client I required close supervision on the residence due to his seizures. The IPP indicated close supervision of Client 1 meant, "visualtverbal contact at least every five minutes ...". A review of a Name of Evaluator: Linda Lucey HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name: Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000722 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 4 CITATION NUI~IBER: SECTIONS VIOLATED 15-1284-0008849-S Date: 12112t2012 Time: CLASS AND NATURE OF VIOLATIONS direct caregivers’ guide entitled, "Windows" last revised 6/20/11 indicated, "(Client 1) continues to be monitored closely due to frequent seizures." On 9/23/11, a review of the facility document entitled; "Supervision of Clients" dated February 2011 indicated, "Close Supervision: Staff must be in the immediate area, hear the client at all times, and must make visual contact at least every 5 minutes." On 9/23/11, a review of Client l’s behavior plans revised 3/17tt 1 and 5tl 0/11, identified Client l’s assaultive behaviors but did not.describe Client l’s level of supervision. The fPP, Windows, and behavior plans did not indicate Client 1 required increased supervision due to behaviors. On 9/23/11, a review of Client 3’s special meeting notes dated 8/25/11, documented a summary of significant acts of aggression by Client 1 between Spring of 2010, and July of 2011, included, "...1) grabbing a female peer, placing her in a headlock, choking her and injuring her back; 2) forcefully pushing a peer and exhibiting threatening behavior toward staff; 3) elbowing a peer in the eye; 4) punching a peer in the face causing swollen lip, bruising and scratches to R eye; 5) striking a female Peer on her head, face and trunk; 6) pushing a female peer into a wall resulting in a R ankle fracture; 7) punching a female peer inthe face and abdomen resulting .in a bruise to cheek; 8) kicking a female peer’s right hip, slapping her forehead and hitting her back; 9) charging at a female peer threatening to choke her and assaulting staff who tried to intervene; 10) pushing female peer to the floor, grabbing .her hair and attempting to hit her head against the floor ...". On 9/27/t 1, a review of an incident report dated 7/23/11, documented Client 1 chased Client 2 down the halt, knocked her down, grabbed her by the ears and banged her head on the floor. Client 2 sustained lacerations to both ears requiring six sutures to a deep gaping laceration behind the right ear. During an interview on 9t27/11 at 3:30 p.m., a licensed staff member, (StaffA) stated Client 1 had to be pulled off Client 2. Staff A stated Client 2’s external ear was nearly separated from her head. Staff A stated Client 1 had been on close supervision and should have been placed.on one-to-one (individual) supervision after the violent attack on Client 2. On 9/14/11, review of an incident report dated 7/25fl 1 at 3:30 p.m., (two days after Client 1 attacked Client 2) documented that Client I appeared at the nurses’ station with NOTE: tN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000723 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 4 CITATION NUI~BER: SECTIONS 15-1284-0008849-S Date: 12/12t2012 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED blood on his arms and reported he had beaten Client 3. Staff members found Client 3’s face down in a pool of blood. The report documented facial and nasal lacerations and bruising and a visible deformity of Client 3’s nose as well as a full thickness laceration of the left ring finger~onsistent with a bite wound: On 9t14/11, a review of Client 3’s interdisciplinary notes (IDNs) dated 7t25/11, indicated Client 1 had a history of sneaking into peers rooms and beating them up when he feels that individual has slighted him in some way. A review of Client 1 ’s notes dated 7125tl 1 at 6:20 p.m., indicated, "(Client 1) sneaked into (Client 3’s) room and assaulted him as he was relaxing in his bed." On 11/4/11, a review of Client 3’s clinical record reflected consultation reports from an acute care hospital dated 7t25/11, and documented Client 3 had a history of pulmonary embolism and was taking an anticoagulant medication. The reports documented Client 3 sustained a loss of sensorium (mental awareness), a broken nose, and multiple contusions (bruises) over his face. He was transferred to an acute care hospital where a head CT scan (Computed Tomography Scan) showed a traumatic subarachnoid hemorrhage (bleeding into the area between the brain and the thin tissues that cover the brain) and a right temporal hemorrhagic contusion (bleeding within the brain tissue). Client 3 was then transferred to the nearest trauma center for services: Client 3 also sustained multiple contusions over his forehead and a severe human bite on the left ring finger. A review of Client 3’s case management notes dated 7/26/11, documented Client 3 had a clotting.disorder which required lifelong anticoagulation. Notes of 7t27tl 1, documented Client 3 had stabilized in intensive care where he received services to prevent thrombosis after the need to reverse anticoagulation. Notes of 7/29/11 indicated Client 3 returned to the facility.. On 11/4/I 1, a review of IDNs from 7/29tl 1 until 8/15/11 indicated Client 3 refused to eat most meals and isolated in his bed in hi.s room most of the days. On 8/4/11 he was lying on the floor and stated, "1 fell." On 8/5111 Client 3 returned to the acute care hospital to have the nasal fracture reduced. On 8/7tll he appeared unsteady and required assistance getting in and out of bed. On 8/8tl 1, the bite wound to the left ring finger was found to be wet and macerated. On 8/9tl 1 Client 3 refused to get up and walk around, exhibited episodes of anger, but was eating meals. On 9t27/1 I, a review of staffing records for 7/25tl 1, documented Staff A was in charge NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE,FAtLURE TO CORRECT VIOLATIONS IS GROUNDS I=OR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000724 State,of California - Health and Human Services Agency Depar{ment of Public Health SECTION 1424 NOTICE Page 4 of 4 CITATION NUI~IBER: SECTIONS VIOLATED 15-1284-0008849-8 Date: 12112/2012 Time: CLASS AND NATURE OF VIOLATIONS and Staff B was assigned to Family II. Both Clients 1 and 3 were in Family 11. When Staff B left the residence to escort three other clients to the store at 3:15 p.m., Staff A was responsible to supervise the remaining Family II ctients in addition to passing medicationsand performing other charge duties for the entire unit. During an interview on 9/27tl 1 at 3:30 p,m., StaffA stated she saw Client 1 close the doubledoors to the hallway and go into his room. StaffA stated staff members had been allowing Client I to close the double doors to his hallway because the noise around the nurses’ station bothered him. Staff A stated Client 3 had been upset earlier in the day and was in his room calming down. Client 3’s room was in the same hallway as Client l’s room. Staff A stated there was a hole in the staffing coverage and Client 1 sneaked into Client 3’s room unseen by staff. On 9/’27/11, a review of Client l’s Special Meeting notes of 8/’25/11, documented, "Due to (Client 3%) existing health condition, this life-threatening incident could have resulted in tragedy ..." Therefore, the facility failed revise Client l’s program plans to ensure clients rights to be free from abuse after Client 1 exhibited a series of increasingly violent attacks on other clients. The facility failed to.change program plans after Client 1 chased Client 2 down the hall, held Client 2 by the ears, and banged her head on the floor nearly separating Client 2’s external ear from her head. Two days later, staff failed to provide the planned supervision to keep Client 1 within sight or hearing of staff at all times. When staff allowed Client 1 to shut the doors to his hallway, Client 1 was not within sight or hearing of staff. Client 1 sneaked into the room of Client 3 (a medically fragile client on blood thinners) and beat and bit Client 3 who sustained life-threatening injuries. 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. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000725 State of California - Health and Human Services Agency Department of Public Health SECTIdN 1424 NOTICE Page 1 of 2 CITATION NUI~BER: 15-1594~0009315-S Dale: 02103/2014 Time: Type of Visit ¯ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facil;ty Name: Address: Telephone: Fad lity Type: Facility ID: SECTIONS VIOLATED 76301 (e) tncidentlComplaint No.(s) - CA00305360 Stale of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D!P ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care FacilitylDevelopmentaIly Disabled 15000023O CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 trebled to $3,000.00 Capacity: 581 DEADLINE FOR COMPLIANCE 3/5/14 12:00 a.m. CITATION-- PATIENT CARE T22 DIV5 CH 8 ART3- 76301e REQUIRED SERVICES (e) Client care provided by all team members shall be safe and considerate as ordered or indicated by the needs of the client and in accordance with acceptable standards of practice. The facility failed to provide safety for a client, Client 1, by failing to ensure maintenance of a safe worksite environment. A client with a long history of breaking windows "punched" a cubicle window at the day program and sustained "severe lacerations" to his left hand requiring surgical repair at the acute care hospital. Record. review on 4/t6t12 indicated that Client 1 had diagnoses that included lED (Intermittent Explosive Disorder). Client 1 had behavior plans for property destruction that included hitting and breaking windows and plans for self injurious behaviors that included hitting windows t hard surfaces with injuries to his hand. The facility IR (Incident Report), signed on 3/28/12, indicated on 3/28/12 at 10:30 a.m,, Client 1 was sitting in a quiet area away from his peers when he began hitting the table. Staff immediately intervened and attempted to refocus him as he lifted a chair above his head to throw. He then quickly turned and struck the window with his left hand. The IR indicated that Client 1 had a long history of property destruction with the focus on Name of Evaluator: CAROL DEV1TA HFEN Without admitti0g guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature Title ,: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000726 State of California - Health and Human Services Agency ..SECTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health Page 2 of 2 15-1594-0009315-S Date; 02/03/2014 Time: CLASS AND NATURE OF VIOLATIONS breaking windows. Physician’s Progress Notes, dated 3/28!12, indicated that Client 1 sustained "severe lacerations" to his left hand ................................................... Documentation from the Emergency Department indicated that Client I underwent "complicated repair" for full thickness lacerations to the left index, middle, and ring fingers, a During an observation of the worksite on 4t20/12 at 9 a.m., the cubicle where the incident occurred was separated from an adjoining cubicle by large glass windows with wire type reinforcement in the glass. During an interview with Site Staff A on 4/23/12 at 2:15 p.m., Staff A stated that Client 1 was all alone in a cubicle when he got up and started banging on the table. Staff A stated that she walked into the cubicle and he picked up a chair. Staff A was standing in front of him and grabbed a leg of the chair. Client 1 then proceeded to hit the glass. Staff A stated, "1 was standing right there. It went through so quickly." The facility failed to maintain a safe worksite environment for a client with a known history of hitting and breaking windows. These failures had a direct or immediate relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000727 State of California - Health and Human Services Agency Department of Pubiic Health SEGTION 1’~424 NOTICE Page 1 of 3 CITATION NUI~IBER: 15-1116-.0009703~S Date: 02/11/2014 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND. REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76363(b)(3) 76369(a)(t) 76371 Incident/Complaint No.(s) : CA00334861 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 1500~0089 SACRAMENTO, CA 95814 Type of Own~,rship: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000 Arnold Dr Etdridge, CA 95431 Intermediate Care FacilitytDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS Capacity: 581 PENALTY ASSESSMENT $10,000,00 DEADLINE FOR COMPLIANCE 2/25/14 t2:00 a.m. CLASS A CITATION -- DIETARY Title 22-CH 8-ART 3-76363(b)(3) Food and Nutrition Services-Food Service. (b) Food services shall include: (3) Nourishment or between meal snacks shall be provided as required by the dietary plan. Bedtime nourishments shall be offered to all clients unless countermanded by the interdisciplinary team, attending physician or dietician. Title 22-CH 8-ART 3-76369(a)(1) Food and Nutrition Services-Modified Diets (a) Modified diets shall be as fotlows: (1) Specified by the client’s interdisciplinary team with a copy in the kitchen. Title 22-CH 8-ART 3-76371 Food and Nutrition Services-Therapeutic Diets Therapeutic diets shall be provided as prescribed by the attending physician and shall be planned, prepared, and served with supervision or consultation from the dietician. Persons responsible for therapeutic diets shall have knowledge of food values in order to make appropriate substitutions when necessary. The facility failed to comply with the above regulations when facility staff failed to send a Name of Evaluator: Gregory Hannah HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000728 State of California - Heatth and Human Services Agency Departmen! of Public Health SF_X;TION 1"424 NOTICE Page 2 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 15-111g-0009703-S . Date: 02ftlt2014 Time: CLASS AND NATURE OF VIOLATIONS physician’s order countermanding Client l’s HS (Hour of Sleep) nourishment to the kitchen so that the appropriate therapeutic diet was provided to the client. This resulted in Client 1 receiving a diet in which the client choked on the HS nourishment, requiring staff to perform abdominal thrusts to clearthe client’s obstructed airway. Facility documentation dated 11129/12, revealed that on 11/28/12, Client I was given her designated HS dried prune snack. Staff then noticed that the client was short of breath and the client’s lips became cyanotic. Staff suspected choking and initiated an abdominal thrust with finger sweep. Staff was able to extract the prune out of the client’s mouth. Review of Client l’s"Client Face Sheet" on 12t12t12, revealed that the client was 48 years old with diagnoses that include dysphagia (difficulty swallowing), profound intellectual disabilities, and microcephalus (an abnormally small head and under developed brain) with motor dysfunction. Client l’s record showed that Client l’s physician wrote an order to discontinue Client l’s HS dried prunes snack on 07/13f12. Staff A stated during an interview on 12tl 2/12 at 4:30 p.m., that Client l’s physician’s order of 7/13/12 was not sent to the kitchen, so the kitchen staff kept sending the prunes to Client 1 at HS. StaffA stated that the. regular PM staff knew not to give the prunes to Client 1 but gave the prunes to another client who could tolerate them. Staff B stated during an interview on 12/12112 at 4:35 p.m., that registry float staff passed the PM snacks on 11/28/12, and did not know that they were not to give the prunes to Client 1. Review on 12/12/12, of the facility’s "General Event Reports" (GER) for the above incident, revealed that "[Client 1 ] had choking incident from prunes that were served to her at HS (hour of sleep) snacks. Food service had set up snacks and sticker on tray indicated that she is to get prunes. Registry staff gave her prunes according to food service tray not her diet order ..." The GER revealed that "There was a previous diet order for 3 each dried pitted prunes for HS snack; however the order was discontinued on 7t13/12. Staff failed to enter the order phange in the kitchen log book or process the diet change by making necessary adjustments to the snack trays." The facility’s failure to ensure that Client.l’s diet order of 7113/12 was appropriately implemented for a period of 19 112 weeks placed Client 1, who has a diagnosis of dysphagia, at risk of food aspiration, which occurred on 11/28/12. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000729 State of California - Health and Human Services Agency Department of Public Health SBGTIO’N i424 NOTICE Page 3 of 3 CITATION NUI~IBER: SECTIONS VIOLATED 15-’1116-0009703-S Date: 02/11/2014 Time: CLASS AND NATURE OF VIOLATIONS The facility’s inaction presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000730 State of California - Health and Human Services Agency Department, of Pub}ic Health S~.CTION’~1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-1594-0009611-S Date: 02/21/2014 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE L;censee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: FaciliW ID: SECTIONS VIOLATED 1418.91 (a) 1418.91 (b) Incident/Complaint No.(s) : CA00310066 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D!P ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care FacititylDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B I P ENALTY Capacity: 581 ASSESSMENT $800,00 DEADLINE FOR COMPLIANCE 3/7/14 12:00 a.m. CITATION-- ADMINISTRATION Health and Safety Code - HSC DIV 2 CH 2,4 - Quality of Long-Term Health Facilities 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. The facility failed to report an allegation of abuse to the Department of Public Health immediately, or within 24 hours. On 5/16/12, review of the facility fncidenttUnusual Occurrence Report, dated 5/8/12, indicated that an allegation of verbal abuse occurred on 4/30112 at 10:40 a.m. when a worksite food service technician was banging.pans and raising her voice at another staff member in the presence of 11 clients. On 5/16/12 at 1:45 p.m., during an interview with Staff A, who witnessed the alleged incident, Staff A stated that she spoke to the supervisor on duty (Staff B), on 4/30t12, regarding the incident. StaffA stated, on 5/3t12, Staff B told StaffA to speak with her direct supervisor, Staff C, Name of Evatuator: CAROL DEVITA HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name: Evaluator Signature Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000731 State of California - Health and Human Services Agency Deparlment of Public Health SECTION’1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1594-0009611-S Date: 02/2112014 Time: CLASS AND NATURE OF VIOLATIONS the Food Service Supervisor 1. Staff A stated that Staff C told her to write a report and forward it to Staff D, the Food Service Supervisor 2., which she did. On 5/5/12, Staff A stated that Staff D told her ’~o speak with the Director of Dietet!cs, Staff E, and to the Assistant Director0f Dietetics (Staff F). Staff A stated that, "they asked if l thought or felt it was abuse." StaffA further stated, that she "thought it was inappropriate behavior." Review of the Incident Report on 5/I 6/12, indicated that the alleged incident that occurred on 4/30/12 was not reported to the facility administration until 5/8/12, eight days later. The Department of Public Health was also notified of the allegation, via facility correspondence, on 5/8/12. The policy for AbusetMistreatment/Neglect Prevention and Reporting, # 413, effective 3/09, included the following entry under ’.’Staff Responsibilities": "Any staff witnessing, having knowledge of, or suspecting that abuse, mistreatment, or neglect of a client has occurred shall: Immediately report to histher supervisor. Complete an Incident Report (IR) as soon as possible and forward the IR to his/her immediate supervisor." The policy for "Incident Reporting (IR) & Investigation System,"# 346, effective 7/2010, included the following entry: "When an event occurs that has an adverse effect on the safety, care, treatment, and habilitation of an individual living at [facility name] and/or the operation of [facility name], the staff are required to complete an Incident Report (IR), DS-2506, as soon as they become aware of the incident.., it is required that the staff observing an incident; having first knowledge; or in all cases of abuse, "first suspicion," must begin the IR form and must complete Page 1 of the DS-2506 Form within 24 hours... When an IR is to be completed, the staff member will immediately notify their Supervisor. The Supervisor will immediately contact the Program Manager or .Designee, and the Program Manage~" will immediately determine if the incident is to be reportable as an Incident Brief." This failure in reporting created a delay in the investigative process potentially putting all NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000732 State of California - Health and Human Services Agency Department of Public Health S£CTION’t424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1594-000£611-S Date: 02/21/2014 Time: CLASS AND NATURE OF VIOLATIONS clients at risk. The violation of this regulation had a direct or immediate relationship to the health, safety~ or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000733 State of California - Health and Human Services Agency Department of Public Health SECTION ’~424 NOTICE Page 1 of 8 CITATION NUMBER: 15-1284-0009607-S Date: 02f21f2014 Time: Type of Visit ¯ YOU ARE HEREBY FOUND IN VIOLATION OF APPL]CABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) IncidenttComplaint No.(s) ’ 0A00332710, CA00331305, CA00306099 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA Type of Ownership: 95814 State Agency SONOMA DEVELOPMENTAL CENTER DIP ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care Facility/Developmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $10,000.00 Capacity; 581 DEADLINE FOR COMPLIANCE 3/7/14 12:00 a.m. CLASS A CITATION-- PATIENT RIGHTS T22 DIV5 CH8 ART4-76525 (a) (20) (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to ensure clients’ right to be free from harm when it failed to implement systems designed to identify risk and prevent harm. Over a period of six months, Client 1 inflicted bites with increasing seriousness of tissue damage to Clients 2, 3, and 4 as follows: Review of a social history evaluation, dated 12/5/11, documented Client 1 had diagnoses i]~_cluding Post-Traumatic Stress Disorder (PTSD) (a mental health condition that is triggered by a terrifying event with symptoms including flashbacks, nightmares, Name of Evaluator: Linda Lucey HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name: Evaluator Signature Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY’ CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000734 State of California - Health and Human Services Agency Department of Public Health S,ECTION ’1424 NOTICE Page 2 of 8 CITATION NUMBER: SECTIONS VIOLATED 15-1264-0009607-S Date: 0212112014 Time: CLASS AND NATURE OF VIOLATIONS severe anxiety, and uncontrollable thoughts about the event) and Moderate Intellectual Disability. The evaluation indicated Client 1 had a history of biting individuals who intruded into her personal space and was on general supervision, meaning that staff monitored her whereabouts at least every 15 minutes: The document indicated Client 1 was sensitive to loud noises, such as yelling, and had a history of reacting by biting. A review of an incident report, dated 4/4f12, documented Client 1"attacked Client 2 during dinner. Client 2 sustained a bite wound of the left forearm. The skin was not broken but there were visible teeth impressions with sweliing and bruising. The report indicated the team identified the absence of familiar staff as a possible antecedent to Client l’s outburst. The report documented Client 1 had had four previous incidents of biting peers over the past twelve months and remained on general supervision. An incident report of 6/16/12, documented Client 2 surprised Client 1 while Client 1 was alone watching TV. Client 1 jumped up, grabbed Client 2 by the neck, and started to bite Client 2 on the arm. It took several attempts for staff to successfully separate the two clients. Client 2 sustained four obvious bite marks with full mouth impressions and bruising. Three bites had broken the skin. In addition Client 2 sustained scratches under the left eye and left neck. The report identified that the staff member with Client 2 did not know.Client 1 was relaxing in the TV room: Staff opened the door and Client 2 startled Client 1. The report indicated that the Unit Supervisor determined Client t was safe and resumed her status of general supervision. On 11/29112, a review of an incident report, dated 10/23/12 at 4:30 p.m., documented that Client 1 inflicted five bite wounds to Client 3 while Client 3 was sitting on the toilet in their shared bathroom. The report indicated the bites were severe in that they caused broken skin and tissue damage. Client 3 sustained bite wounds to her third finger, left upper outer thigh, left inner thigh, left lower anterior thorax, and right inner thigh. Client 1 was on general supervision at the time and was placed on close supervision after the incident until she cairned about an hour later. Observations of copies of photographs of Client 3’s wounds revealed five skin openings ’with a large area of bruising surrounding a bite wound on the right thigh. A review of Interdisciplinary Notes (IDNs), dated 10/23/12, documented swelling of all the wounds with the right thigh wound measuring 5 centimeter (cm) with a 10 cm purple bruise surrounding the opening along with a large amount of swelling. A review of Client 3’s individual Program Plan, dated 12/13/11, documented Client 3 NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000735 State of California - HeaJth and Human Services Agency Department of Public Health S’ECTION ’1424 NOTICE Page 3 of 8 CITATION NUI~IBER" SECTIONS 15-1284-0009607-S Date: 02121/2014 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED had diagnoses including.PTSD and Mild Intellectual Disability. A review of a psychology progress note, dated 10/24/12, indicated, "Yesterday evening, client was bitten seven times by a peer ... This morning...She stated that she was very upset ...was ’very scared,’ ’in a lot ofpain~’ and, ’1 don’t wantto live here anymore.’ :.: Shestated that she ’Couldn’t stop crying last night.’ ..." During an interview on 11/30/12 at 12:15 p.m., 42 days after the incident, Client 3 exhibited her five healing bite wounds. Observations revealed two wounds were still open but scabbed over. ’Client 3 stated the’wounds had become infected and she had needed antibiotics. During the interview on 11/30/12, Client 3 stated she and Client 1 were friendly neighbors who recently were moved to bedrooms next to each other with a shared bathroom in between. Client 3 sta~ed Client I had PTSD and justsnapped, all of a sudden. Client 3 stated there were two new clients screaming in the hall outside their rooms when Client 1 became agitated on 10/23/12. Client 3 stated she was on the toilet when she saw Client l’s feet under her stall door. Client 3 stated she told Client 1 that she was using that toilet, but Client 1 did not respond as Client 1 usually did. Client 3 stated the latch on the stall door was broken and Client 1 entered the stall and attacked her. Client 2 stated.she became tangled in her lowered trouser legs and both she and Client I fell to the floor. Client 3 stated she was crying and screaming for help, but the new clients were still screaming in the hallway and staff did not immediately respond to her calls. Client 3 stated Client 1 had her teeth latched on one of her fingers and she feared Client I would bite her finger off. Client 3 stated she bent her finger to prevent a complete amputation. Client 3 stated during the struggle, the fingers of her other hand ended up in Client l’s eye socket, but she did not want to hurt Client 1, so she put a knee in Client l’s chest and moved her hand down to grab Client 1 around the throat. Client 3 stated she pressed on Client l’s Adam’s apple area and Client 1 finally released her bite on the finger. After that, a staff member arrived to take Client 1 to her room. During the interview on 11/30/12, Client 3 stated that "a couple of.days ago" Client 1 had come at her again. Client 3 stated she was awakened in her sleep by the sounds of an agitated Client 1 rattling the knob on the locked door between Client 3’s bedroom and the shared bathroom. Client 3 stated, "1 was screaming...I got up and left my room." "l told them (staff) I was scared." During the interview on 11/30/12, Client 3 stated, "1 don’t feel safe with her being right by NO’[E: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000736 State of California - Health and Human Services Agency Department of Public Health S, ECTION ’1424 NOTICE Page 4 of 8 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0009607-S Date: 02/21/2014 Time: CLASS AND NATURE OF VIOLATIONS me." Client 3 stated Client 1 did not have extra staff supervision at night. Client 3 stated there was a Io~k on the door between the shared bathroom and her bedroom. Client 3 stated staff expected her to unlock that. door, enter the bathroom, lock the door to Client l’s room, use the toilet; then unlock the door to Client l’s room, exit the bathroom and lock the door to her bedroom. Client 3 said, "I’m scared. What if I accidentally forget a lock? I’m scared for my life...What am I supposed to do? Next time I might have to hurt her ba~l. I don’t want that. I don’t want to kill someone in self-defense." During the interview on 11130t12, Client 3 said, "Maybe that’s why I am having panic attacks at night." Client 3 stated she had nightmares, "...every night ..." that somebody was choking her. Client 3 stated she had a nightmare where somebody was biting her on the neck. On 11/30/12 at 2 p.m., observations in the bathroom shared by Clients 1 and 3 revealed the latch to the stall where the incident occurred was broken. During concurrent interview, Client 3 stated the latch was fixed after she was bitten, but Client 1 broke it again. Observations revealed a handmade sign on Client 3’s interior door, "Don’t forget to lock it l[" During concurrent interview, Client 3 stated she made the sign herself, but still staff members sometimes forgot to lock the door. Observations on. 11t30t12 at 2 p.m. revealed Client. 1. had a full set of intact straight. teeth. Observations of her room revealed a bed position alarm (triggered if the client got up) known as an RN+ on her bed. During concurrent interview, a direct care staff (Staff C) stated Client 1 had individual 1:1 supervision during the day and evening shifts. At night, the bed alarm would sound at the nurses’ station if Client 1 got out of her bed. Observations revealed a device attached to the exterior bedroom door. During concurrent interview, Staff C stated the device would trigger an audible alarm at the nurses’ station if Client 1 left her room at night and entered the hallway. During concurrent interview, Staff D stated the device on the door kept falling down. When asked to demonstrate the bed and door devices, Staff C and Staff D could not make them work. During interview on 11t30t12 at 3:30 p.m., when inquiry was made regarding Client 3’s safety at night, the Unit Physician (Staff B) stated, "1 have no idea if it’s safe. It’s a behavioral issue." During interview at the same time, the Unit Supervisor (Staff E) stated Client 3 was safe because Client 1 has an RN+. Staff E stated Client 3 has to remember to lock her door. Staff E stated she was the one who was afraid and, "She knows how to lock her door." When inquiry was made as to the possibility that Client 3 might open the bathroom door to find Client 1 in the bathroom and possibly surprise NOTE: IN ACCORDANCE WITH CALIFORNIA HI~ALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000737 State of California - Health and Human Services Agency Department of Public Health SECTION ~1424 NOTICE Page 5 of 8 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0009607-S Date: 02/21/2014 Time: CLASS AND NATURE OF VIOLATIONS Client 1 in the night, Staff E stated Client 3 should just back out, close the door, and lock it. When asked if surprising Client 1 in the bathroom might trigger another PTSD attack, Staff E stated, "There is always that potential." During the interview on 11t30/12, Client 3 stated that a few weeks after she was bitten, Client 1 bit Client 4 and locked her teeth on him. Client 3 stated Client 4 told her he was scared. A review of Client 4’s clinical record reflected diagnoses including Moderate Intellectual Disability and Diabetes. An Annual Medical Summary dated 4t30t12 documented Client 4 was at risk for cellulitis (infections of the skin) due to his insulin dependent diabetes. During an interview on 11130/12 at 11 a.m., the Unit Supervisor of a day program (Staff A) stated he was present when Client 1 inflicted bite wounds on Client 4 on 11/9/12 at 1:40 pom. StaffA stated Client 4 was upset about not having ice cream so program staff escorted Client 4 back to the unit early. Upon entering the unit, Client 4 dropped to the floor and continued screaming for ice cream. StaffA stated he left Client 4 alone to calm down, because the area seemed quiet. Staff A stated Client 4% behavior plans clearly stated to ignore the outbursts and leave him in a quiet area. A review of Client 4’s behavior support plans (BSP) dated 9126tl 1. indicated, "If (Client 4) drops to the ground during the (physical) escort, clear area of peers and back away ... Once in a quiet area .... follow (the) intervention steps ..." A review of the interventions listed in the document indicated, "Ask (Client 4) to ’stop’ and separate him from peers ...Work to resolve the conflict ... Praise (Client 4) for relaxing ... When he is ready, encourage him back into his schedule ,.."o A review of Client 4’s BSP of 9/26/11 did not indicate Client 4 should be left alone, unsupervised, during an outburst. During an interview on 11/29t12, the Unit Supervisor, Staff E, stated staff should not leave any client alone during a tantrum. Staff E stated, "it is not safe to leave. A client could engage in self-injurious behaviors when agitated." During the interview on 11t30/12 at 11 a.m., Staff A stated program staff were not aware Client 1 was at home in her room located on the hallway where Client 4 had dropped to the floor. Staff A stated he went around the corner to the nurses’ station and seconds later heard Client 4 screaming for help. Staff A returned and saw Client 4 covered in blood with Client 1 on top of Client 4. Client 1 had her teeth latched on Client 4’s NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000738 State of Cafifornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 6 of 8 CITATION NUMBER: SECT}ONS VIOLATED 15-1284-0009607-S Date: 02/21t2014 Time: CLASS AND NATURE OF VIOLATIONS shoulder. Blood was spurting from Client 4’s front scalp. Out of the corner of his eye, Staff A saw a chunk of scalp tissue and hair on the floor. During an interview on 11/29/12 at 3 p.m., the Health Services Specialist (Registered .Nurse Staff B) stated she was on the team that responded to unit staff calls of a medical emergency. Staff B stated there was blood squirting from Client 4’s scalp above the forehead. The bleeding was so heavy Staff B could not visualize the wound. In addition Client 4 had a bite wound on the front of the left shoulder area. Staff B stated she made arrangements to have Client 4 taken to a nearby emergency room. Observations of copies of photographs .of Client 4 and the scene of the incident revealed an open wound to the frontal scalp at Client 4’s hairline, a large open bite wound with bruising of the left shoulder, and a third smaller skin opening at an unidentifiable site. In addition photographs documented evidence of blood loss with spatter patterns on the walls and ceiling. A review of interdisciplinary notes (IDNs), dated 11/I0/12 at 9 p.m., documented the presence of two bite wounds to the left shoulder. A review, of emergency room reports dated 11/9/12 documented a plastic surgeon reattached the piece of scalp over a denuded area measuring 7 cm by 5 cm on Client 4’s head. The report documented, "Scalp degloving from human bite obviously at great risk for infection and the flap of tissue may or may not revascularize." A review of I DNs starting 11/15/12, documented Client 4’s onTgoing treatment with oral antibiotics. Notes of 11/15/12, indicated an overwhelming foul odor from the scalp wound. Notes of 11/I9/12, documented symptoms of tissue necrosis (death), with a foul odor. Notes of 11t21/12, indicated Client 4 developed a fever and there was an increase in necrosis of the wound and an increase in odor. Notes of 11/21/12 at 5:50 p.m. documented removal of the necrotic graft earlier in the day. Notes by a wound care nurse on 11/27/12, indicated slow healing of the wound which measured 6 cm by 4 cm with an area of necrotic tissue measuring 2.5 by 1.9 cm. A review of Client 4’s Physician Progress Notes (PPNs) dated 11/21t12, documented necrosis of the graft. PPNs of 11/21/12 indicated the graft was removed on that date. PPNs of 11/30/12 indicated the area was now a granulating wound that was healing slowly. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000739 State of California - Health and Human Services Agency Depar~menl of Public Health ..eECTI~)N 1424 NOTICE Page 7 of 8 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0009607-S Date: 02f21/2014 Time: CLASS AND NATURE OF VIOLATIONS A review of an incident report dated 11t9/12 documented an initial review of the incident between Clients 1 and 4 and plans to place Client 1 on a "modified" constant supervision. Staff would enter her room when there was any disturbance to see if she was OK; Plans included staff posting themselves close to the areato be able to intervene as needed. The report indicated the BSP would be modified as needed and staff would be trained. On 11/30112, a review of the clinical record reflected the most recent changes to Client l’s BSP were dated 11t7/12, two days before the incident with Client 4. Under the heading of, "Supervision level", interventions did not include those recommended in the above administrative reviews of the incident. The interventions did not include the individual supervision on the day and evening shifts, the RN+ bed alarm, and the door alarm at night, or the plans to lock the door to the bathroom shared with Client 3. On 11/30/12, a review of the, "Windows" for Client 1 did not reflect the planned interventions. The document, which was used by direct care staff continued to indicate, "... general supervision." A review of the facility document entitled, "CLIENT PROTECTION & PREVENTION FROM HARM", dated January 2012, indicated that a system of client protection was in place, which provided for, "thorough identification-and assessment ofpotential risk, and immediate intervention when risk is present ..." The goal of the s~)stem was to, "...prevent incidents from occurring, track and analyze patterns and trends of incidents, develop and implement prompt and effective measures to minimize or eliminate occurrence in the future." Therefore, the facility failed to ensure implementation of policies designed to identify and intervene when risks were present resulting in the harm of neglect to Clients 1, 2, 3, and 4. Staff did not implement plans to redirect noisy clients away from Client 1 or check on Client t when other peers were having outbursts. Staff did not follow Client 4’s plans When he was left alone during a tantrum. Client l’s written behavior plans were not updated to minimize the risks identified during administrative reviews including the risk of startling Client t. When PTSD reactive episodes were triggered, Client 1 attacked Clients 2, 3 and 4, inflicting eleven open bite wounds as well as psychological harm. Clients 3 and 4 had deep wounds that became infected, required on-going medical treatment, and were slow to heal. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000740 State of California - Health and Human Services Agency Department of Public Health S.EC, TION’1424 NOTICE Page 8 of 8 CITATION NUMBER: SECTIONS VIOLATED 15-1284-0009607-S Date: 02f21t2014 Time: CLASS AND NATURE OF VIOLATIONS These facility failures presented either imminent danger that death or serious harm would resu]t, or a substantial probability that death or serious physical harm would result. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTFY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000741 State of California - Health and Human Services Agency Deparlment of Public Health SECTION 1424 NOTICE Page 1 of 5 CITATION NUMBER: 15-1594-0010293-S Dale: 02/27t2014 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Addt-ess: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) lncident/Comptaint No.(s) ¯ CA00353537, CA00353;I 18, CA00352754, CA00351571 Stale of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 . Type of Ownership: State Agency SQNOMA DEVELOPMENTAL CENTER D/P ICFDD 15000Arnold Dr Eldridge, CA 95431 Intermediate Care FacilitytDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B Capacity: 58.1 PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 3/13/t4 12:00 a.m. CITATION-- PATIENT RIGHTS Title 22 DIV5 CH 8 ART 4 - Clients’ Rights 76525(a)(20) (a) Each client.has the right listed in.(a) of this section which shall not be denied or. withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to prevent neglect by failing to ensure implementation of facility policies for neglect prevention. Pills were found on the floors of multiple units, some housing clients with profound intellectual disabilities and some with pica behaviors (ingestion of non-edible items) placing those clients at risk. Some pills were identified as those belonging to clients who potentially did not receive medication as prescribed. Pills were found under furniture in client rooms and outside a unit front door on 4118tl 3, 4/19/13, 4t23/13, 4/24/13, 4/26/13, 5/t/13, 5/4/13, 5/5113, 5/6/13, 5t7/13, and 5t9/13, available to any client, staff, or visitor. This failure affected the clients on six of six certified Intermediate Care Facilities for the Intellectually Disabled (ICFtl]D) units (Units: Stoneman, Poppe, Malone, Cohen, Roadruck, and Bentley). Name of Evaluator: CAROL DEVITA HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000742 State of Catifornia - Heatth and Human Services Agency Department of Public Health SECTION I424 NOTIG .F- Page 2 of 5 CITATION NUll/IBER: SECTIONS VIOLATED 15-1594-0010293-S Dale: O2/27/2014 Time: CLASS AND NATURE OF VIOLATIONS On 4/18/13, the facility submitted written reports to the Department that on 4/18/13, a housekeeper performing duties on Roadruck Unit found a pill, identified as 300 milligrams (rag) of Lithium (a mood stabilizer) mixed with some clothing in Client 1 ’s room, The facility reported that Client 1 was not prescribed Lithium, but two other clients who reside on the unit currently had orders for Lithium. The facility also reported that on 4t18/13, another housekeeper on Roadruck Unit found four additional pills on the floor behind a couch near the nursing station. The pills were identified as two Metaglycemix tablets (nutritional supplements), one Lithium capsule and another unidentified tablet which appeared to be a vitamin. During an interview on 4/19t13 at 2:34 p.m., Supervising Housekeeper (SH) B stated Housekeeper A found the first pill in Client l’s room while performing routine cleaning duties. SH B stated that she went to the unit to cover for Housekeeper A while that housekeeper, completed documentation for the pill found in Client l’s room. SH B stated that when pulling out the couch by the nursing station next to the medication room, she noticed four more pills and notified the shift lead. SH B stated housekeeping staff were expected to perform "detailed cleaning" of the units two times per week but no.less than one time per week~ She stated.’.’detaited. cleaning" included moving furniture to clean behind and under furniture, clean floors and walls and wipe the furniture down. SH B stated there was no log being used to track or monitor this procedure to ensure that staff completed the "detailed cleaning" as required however, housekeeping supervisors could tell if it was done when they came to do their daily checks. SH B stated she spoke with housekeeping staff following this incident and stated no one had reported additional ongoing problems with finding pills on the units. On 4/’19/13, the facility submitted a written report to the Department that a housekeeper found a pill on 4t19t13, identified as DVPA (Depakote - an anti-seizure medication) on Roadruck Unit in Client 2’s room. The pill appeared old .but was intact. The facility reported Client 2 had current orders for that medication, but the two other clients in that room did not. The report documented that the room had been thoroughly cleaned by housekeeping and that housekeeping would continue to do a thorough cleaning of the unit. During record review on 4tl 9/13, the facility provided a list that identified 12 clients with NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000743 State of California - Health and Human Services Agency Department of Public Health SEC’TION 1424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1594-0010293-S Date: 02f27f2014 Time: CLASS AND NATURE OF VIOLATIONS pica behaviors (a behavior of ingesting non edible items) on Roadruck. During an interview on 4/22t13 at 2 p.m,, Unit Supervisor (US) C stated the pill found in Client l’s bedroom on 4/18113 and near the nursing station looked old and it could not be determined how long it had been there. US C stated the pill found in Client 2’s room was found against a walt behind a dresser and said housekeeping conducted a thorough cleaning and no other pills were located. US C stated staff would continue to identify, and assess clients for medication administration issues and swallowing problems, She stated at this time, all clients now received their medication in the medication room pending review at the next client protection plan (CPP) meeting. Unit observation, accompanied by US C, on 4122113 from 3 p.m. to 3:10 p.m. revealed multiple items on the floor that could potentially be hazardous to cfients with Pica. The items included a nickel sized button under Client l’s bed; a small piece of paper/tape material under a couch in room 155, and a small black battery, approximately 1/2 inches long, in family room 3. During an interview at 3:10 p,m,, US C stated clients in this group were high functioning and the items found were not preferred pica items for clients in that group. During a meeting .on 4t24/13 at 3:30 p.m., Administrative Staff (Staff X) stated the facility took the issue of pills being found on the floor very seriously and was working very hard to correct the situation. During a follow up interview at approximately 4:30 p.m., Staff X stated that staff would be conducting medication pass observations that evening to ensure safe administration of medications. On 4/24113 the facility submitted a written report to the Department that on 4/23/13 and 4/24ti3, staff found additional pills on Bentley and Cohen units during facility wide environmental sweeps implemented in response to prior incidents of pills foundl The reports documented the following: a.) On the evening of 4/23/13, an unidentifiabie old white pink pill with thickened dry fluid stuck to it was found beneath a dresser in a client room. b.) On the afternoon of 4t24t13, housekeeping staff found an old capsule behind a dresser belonging to Client 3, The capsule was identified as ProEpa (a nutritional supplement). The facility reported Client 3’s physician had changed the prescription two NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000744 Slate of California - Health and Human Services Agency Depaitment of Public Health SECTION 1424 NOTICE Page 4 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1594~0010293-S Date: 02/27/2014 Time: CLASS AND NATURE OF VIOLATIONS months ago from capsule form to liquid form due to Client 3’s behavior of chewing on the capsule to drink the liquid and spitting out the capsule. The facility reported the capsule found under Client’s dresser appeared old and dried and chewed. On 4/26/13 the facility submitted a written report to the Department and indicated that on 4/26/13 at 12:30 p.m. housekeeping Staff found pills in two client rooms. The pills were identified as Vitamin B12, Thera-M (vitamin), Triazolam (a benzodiazepine), and another supplement, possibly Sinuplex. Two other pills could not be identified. During a medication pass observation and monitoring visit on Stoneman Unit, on 5/1/13 beginning at 7 a.m., the following was observed: At 7:50 a.m., a round white pill was observed in the corner of a client’s room, room 149. At 8:20 a.m., a white pill, which was in two pieces, was in the corner of another client room, room 128. During an interview with Licensed Staff D on 5/1/13 at 2 p.m., Licensed Staff D stated she did environmental rounds between 6:45 a.m. - 7 a.m. and did not see the pills. Review of a facility report, received on 5/2t13, documented a pill found during the medication pass observation, on the floor in room 128 on the Stoneman Unit on 5tltl-3. The report further revealed another pill identified as a Vitamin was also found on the floor of the unit. Concurrently on 5/1/13 a pill was found on a bathroom floor on the Poppe unit by a housekeeper. Continued cleaning of the Poppe unit revealed a second pill in the wheel of a hospital bed. Interview with Staff E on 5/7/13 at approximately 1 p.m., revealed that that the facility did not know at the time how this problem was still happening. Facility documentation further revealed that a thorough search of all the ICF/IID units at the facility resulted in the finding of 4 pills on the Cohen unit and 5 pills on the Malone unit. Review of a facility report, received 5/6!13, documented that on 5t4/13, 5/5/13, and 5/6113, pills were.found on the Bentley and Stoneman units. A Nifedipine pill (a calcium channel blocker used for chest pain [angina] and hypertension [high blood pressure]) was found on the Bentley unit; and, a Levothyroxine pill (a thyroid replacement or ¯ supplemental therapy) was found on the Stoneman unit. Review of a facility report, received 5/7/13, documented that on 5/7/13 a small brownish NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000745 State of California - Health and Human Services Agency Department of Public Health SEC’fiON 1424 NOTICE Page 5 of 5 CITATION NUIV[BER: SECTIONS VIOLATED ’15-’1594-0010293-S Date: +02/27t2014 Time: CLASS AND NATURE OF VIOLATIONS pill was found on the Poppe unit by a housekeeper. The pill was identified as Senosides (a laxative). Interview with Staff F on 517/13 at 2:35 p.m., revealed that there were two clients on the unit who took this medication, one in the evening and one in the morning. Staff F further stated that it was believed that the pill was from the client who took this pill in the morning. Review of a facility report received 5/9/13, documented that on 5/9/13 a pill was found on the ramp outside the front door of the Cohen unit. A second pill was found by the outside door. One of the pills was marked DSS (a stool softener) and the other pill was marked Keppra (an anti-seizure medication). Further review of the facility report showed that there was only one client on the unit that took Keppra and that client also was on DSS. Review of the facility Administrative Directive titled "Abuse!Mistreatment/Neglect Prevention and Reporting," dated July 2012, revealed the definition of neglect included: Failure to provide goods and services necessary to avoid physical harm ... lack of action that causes or may cause harm which may include but is not limited to failure to provide medical care, mental health needs ... protection from health and safety hazards ..." The above incidents indicated the failure to provide services and goods to avoid physical harm, the failure to provide medical care by failing to ensure clients received their medications as ordered, and the failure to provide protection from health and safety hazards by failing to ensure that objects and medications were not available for those clients with pica and when medications were accessible on the floors and under furniture for any client, staff, or visitor in the area. These failures had direct or immediate relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000746 State of California - Health and Human Services Agency Deparlment of Public Heatth ~ECTION 1424 NOTICE Page t of 3 CITATION NUMBER: 15-1594-0010t51-F Date: 02t27t2014 Time: Type of Visit : Complaint Investig. YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORN IA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: "~etephone: Facility Type: Facility ID: SECTIONS VIOLATED Incident/Complaint No.(s) : CA00358226 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP ICFDD 15000 Arnold Dr Eldrid.qe, CA 95431 Intermediate Care FacilitytDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS Capacity: 581 PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLI~kNCE 3!13t14 12:00 a.rn. CLASS B CITATION -- PATIENT RIGHTS W149 W149 483.429(d)(1) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, or abuse of the client. The facility failed to ensure a client’s right to be free from neglect. A client with PICA behavior (persistent ingestion of nonnutritive substances), requiring close supervision, was observed with a wad of fabric in his mouth. Staff providing supervision was observed using his cell phone in the presence of two clients. On 6t5113, review of the IPP (Individual Program Plan), dated 1/31t13, indicated that Client 1 was blind and was diagnosed with profound intellectual disability, kyphoscoliosis (curvature of the spine), and external hip rotation. He moved about in a squat position using his hands to sweep the area for obstacles. Client 1 was nonverbal and communicated with distinctive vocalizations, body language and posture and occasional words. During a monitoring visit on 6/5/13 at 2:35 p.m., the surveyor entered the Family Two group room, room 130, and observed Staff A, seated at a table in front of Client 1. Staff A was observed looking down at his cell phone. When the surveyor entered the room, Staff A, who was not observing Client 1, Name of Evaluator: CAROL DEVITA HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name: Evaluator Signature ’ Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000747 State of California - Health and Human Services Agency Department of Public Health ~ECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-1594-0010151-F Date: 02/27/2014 Time: CLASS AND NATURE OF VIOLATIONS immediately put the phone in his. pocket. The surveyor asked, "What are you doing?" Staff A replied, "checking my e-mails." Concurrently, Client 1, who was seatedin front of StaffA, was observed to have a wad of fabric material in his mouth. Staff A immediately reached over and removed the fabric. The surveyor asked Staff A if the cell phone that he was using was his own persona] cell phone and he stated,"Yes." StaffA also stated that he should not be using his cell phone. The IPP indicated that Client 1 had a behavior plan for "Harm to Self-PICA." Additional documentation in the IPP indicated that Client I wore non rip shirts and denim jeans due to property destruction and PICA and he would tear clothing to obtain strings to place between his cheek and gums. Further IPP documentation indicated that Client 1 was visually impaired and required close supervision (staff must be in the immediate area and must make visual contact at least every five minutes) at the residence and day program to ensure his whereabouts and to prompt him to safely move away from obstacles he may bump into. The GER (General Event Report), dated 6/5t13, indicated that Client 1 had a preference to mouth items with cloth and strings being his preferred items and he liked having a ball of the material between his cheek and gum. The GER further indicated that Client 1 had access to his preferred item, a cotton cloth shirt, as staff had not dressed him in adaptive clothing. Additional GER information indicated that the item Client 1 chewed upon was one of Client 1 ’s T-shirts, as the T-shirt had a label on it, when all of the pieces were found they matched exactly with no pieces missing. The GER documented that it was possible that unfamiliar staff did not know that Client I was not to have such garments. The facility policy for "Code of Conduct and Professional Behavior, #102, effective 12/2011, contained the following entry: "Use of personal equipment must not be on state time unless prior approval is given by the employee’s Program Director or Department Head or during a major emergency. Examples of personal or state equipment include but are not limited to: Cell phones _." NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000748 State of California - Health and Human Services Agency Department of PubIic Health ~ECTION 1424 NOTICE Page 3 of 3 CITATION NUI~BER: SECTIONS VIOLATED 15-1594-0010!51-F Date: 02127t2014 Time: . CLASS AND NATURE OF VIOLATIONS The failure to protect Client 1 from neglect had a direct or immediate relationship to the health, safety, or security of patients, NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000749 State of California - Health and Human Services Agency Department of Public Health SECTION., 1424 NOTICE Page I of 2 CITATION NUtV1BER; 15-2691-0009862~S Date: 03/14/2014 Time: Type of Visit ’ YOU ARE HEREBY FOUND tN VIOLATION OF APPLICABLE CALIFORNIA S~FATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGOLATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(14) Incident/Complaint No,(s) : CA00352217 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care FacilitytDevelopmentally Disabled Capacity: 581 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000,00 DEADLINE FOR COMPLIANCE 3/28/14 12:00 a.m. CITATION -- PATIENT RIGHTS T22 DIV5 CH8 ART4 76525 (a)(14) Clients’ Rights (a) .Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (14) To dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs. The facility failed to implement policies and procedures when it failed to provide a client (Client 1) with dignity and privacy, by administering oral medications to the client while that client was on the toilet. On 4/25/13 at 3:37 p.m., a review of Client l’s "IPP NARRATIVE" (Individual Program Plan Narrative) dated 9t26t12, indicated that Client 1 was a 57 year-old male with diagnoses of profound intellectual disability and autism. Cfient 1 would respond when staff initiated interaction with him, and he would respond to praise and positive attention. During medication pass, on 4/24/13 at 8:15 a.m., Psychiatric Technician A (PT A) entered Client l’s room holding a medication cup in her hand. Client 1 was sitting on the toilet in a bathroom attached to the client’s bedroom. PT A walked directly into the Name of Evaluator: Constance Whyte HFEN Withoul admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature : Title : NOTE’. ]N ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000750 State of California - Heatlh and Human Services Agency Depadment of Public Health SECTION 1424 NOTICE Page 2 of 2. CITATION NUI~IBER: SECTIONS VIOLATED 15-2691~0009862-S Date: 03114/2014 Time: CLASS AND NATURE OF VIOLATIONS bathroom without pausing and administered the medication to Client 1, who remained on the toilet. During an interview on 4/24/13 at 12:50 p.m., PT A stated that giving medications to Client 1 while he was on the toilet was a "judgment call," since the medications had already been prepared for administration. PT A stated that Client 1 was known to spend a long time on the toilet, and PT A wanted to be certain that Client 1 received his medicine before leaving for the day program. PT A stated she knew this was a dignity issue. A review on 5/2/13 of the facility’s "RIGHTS ASSURANCE PROGRAM 415" policy and procedure (dated October 2010), indicated that it is the responsibility of every person who provides services to clients of [facility name] to ensure that all clients have the opportunity to enhance their wellbeing, preserve their human dignity, and be respected as citizens. The facility failed to implement their policies and procedures to protect client’s rights to dignity and privacy when PTA gave Client I his medications while on the toilet. These failures caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to clients. NOTE: tN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS tS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000751 State of California ~ Health and Human Services Agency Department of Public Health S]SCTIG’N t 424 NOTICE Page 1 of 5 CITATION NUMBER, t5-2021-0010136-S Date: 03t21/2014 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) Incident/Complaint No.{s) ’ CA00360971, CA00359524~ CA00356106, CA00351058, CA00349989, CA00349453 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP ICFDD 15000 Arnold Dr E{dridge, CA 95431 Intermediate Care Facility/Developmentally Disabled Capacity: 581 150000230 CLASS AND NATURE OF VIOLATIONS CLASS .B F~ENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 4/4/14 12:00 a.m. CITATION -- PATIENT RIGHTS T22 - DtV5 CH 8 ART 4 - 76525 CLIENTS’ RIGHTS (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm,, including .unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to ensure that four clients were protected from immediate threat to their safety and failed to prevent harm from a client with identified assaultive behaviors when: 1) staff did not provide sufficient supervision for Client 1, and 2) staff failed to immediately intervene when Client 1 exhibited precursor behaviors which included running down the hallway, tapping walls excessively, screaming, agitation, restlessness and banging on walls prior to harming others which resulted in four peers being assaulted by Client 1. Name of Evaluator: Christina Mangum HFEN Without admitting guilt, hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name : Evaluator Signature ¯ Title : NOTE: 1N ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000752 State of California - Health and Human Services Agency ,SECTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health Page 2 of 5 15-2021-0010136-S Date: 03/21/2014 Time: CLASS AND NATURE OF VIOLATIONS Review of Client l’s record revealed that he was a 27 year old male with multiple diagnoses that included moderate intellectual disability and bipolar disorder. He had a history of aggressive, assaultive behaviors (hitting, kicking and pushing others to the floor) and manic (disordered mental state of extreme excitement) behavior. Client 1 was ambulated independently. He had good balance and gait and ran very quickly. Client 1 preferred to pace and run quickly down the unit’s halls, pushing peers out of his way. He was nonverbal however communicated through vocalizations and gestures. A General Event Report (GER) was reviewed on 7/15/13. The GER indicated on 3/28/13 at 3:50 p.m., Client 2 was in the hallway and Client 1 was pacing back and forth (a precursor behavior) in the same area where Client 2 lived. Staff opened the dining room door and observed Client 1 push Client 2 against the wall. Client 2 fell to the floor. Client 2 was not injured. The GER further revealed that Client 1 was on close supervision (staff must be in the immediate area, hear the client at all times, and must make visual contact at least every 5 minutes) and was known to "Wander about the unit." There was no documented evidence in the GER that a staff person was in the immediate area when Client 1 pushed Client 2. A General Event Report (GER) was reviewed on 7/I5113. The GER indicated on 3129f13 at 2:35 p.m., Client 1 was walking quickly in the hallway, suddenly became aggressive, and pushed Client 3 who was also walking in the hallway with a staff person. The staff person prevented Client 3 from falling. A General Event Report (GER) was reviewed on 7/16/13. The GER indicated on 4/14113 at 10:15 a.m., Client 3 reached for Client l’s shirt. Client 1 pushed Client 3 down to the floor and then pushed him twice as he was walking down the hall. Client 3 was not injured. The GER further ¯ revealed that Client 1 was on close supervision. There was no documented evidence in the GER that a staff person was in the immediate area when Client 1 assaulted Client 3. A General Event Report (GER) was reviewed on 7t16/13. The GER indicated on 5120113 at 3:30 p.m., Client 1 was pacing UP and down the hallway, a precursor behavior. Client 4 was in the hallway at the same time. Client 1 pushed Client 4 up against the wall at the nurses’ station and was NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS tS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000753 State of California - Health and Human Services Agency . .SECTION 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health Page 3 of 5 15-2021-0010136-S Date: 0312112014 Time: CLASS AND NATURE OF VIOLATIONS holding him firmly until staff intervened. The GER further revealed that Client 1 was on general supervision (staff must make visual and}or verbal contact with each assigned client no less than every 15 minutes. This is the most common level of supervision). Client 4 was not injured. A General Event Report (GER) was reviewed on 7/I7/13. The GER indicated on 6/20f13 at 9 a.m., Client 1 became agitated when Client 5 became upset. Client 1 bolted out of his room and pushed Client 5 forcefully with both hands throwing Client 5 against the wall in the hall. Client 5 hit the hand rail with his back and then fell to the floor resulting in a reddened area to his back. At 9:30 a.m., Client 1 was waiting to go to offsite with his peers including Client 3. Without warning, Client 1 pushed Client 3 into the wall resulting in a reddened area to Client 3’s elbow. A General Event Report (GER) was reviewed on 7/17/13. The GER indicated on 713/17 at 11:55 a.m., Client 1 had returned from an outing. Client 1 became agitated, a precursor behavior, and pushed Client 3 to the floor. Client 3 fell on his right knee. Client 3 became agitated and went toward Client 1 and was pushed down again by Client 1 resulting in Client 3 hitting his head against the wall. While staffwas attempting to help Client 3, Client 1 attempted to hit Client 3. Staff prevented Client 3 from being injured. After this incident, Client 1 was placed on constant supervision (staff must be able to see and/or hear each client and be in close enough proximity to intervene as necessary). On 7/17/13, at 11 a.m., during interview Staff A stated that Client 1 could be an extremely dangerous client and that his aggressive behaviors posed a severe-risk of injury to himself and to others. Staff A stated, "We do the best that we can to keep him and the other clients safe. Sometimes, we cannot provide close supervision as we are working with another aggressive )eer. We need to look at increasing his activity. When he paces, this is an indication that he needs to be more physically active. We attempt to keep him engaged in group activities, however most of the time he walks out. We are trying to find the right medication for him, having a problem with this also. He is a challenge to keep the other peers safe from him. Often there are no visible antecedents observed at the time he assaults. He probably would do better if he was on constant supervision, but he goes from general to constant depending upon what he has done. We should look at his NOTE: IN ACCORDANCE.WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000754 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 4 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-2021-0010136-S Date: 03/21/2014 Time: CLASS AND NATURE OF VIOLATIONS supervision level closer." The facility document titled, "Supervision of Clients" policy #460, dated February 2011, reviewed on 7/17/13, revealed the following: Close Supervision: Staff must be in the immediate area, hear the client at all times and must make visual contact every 5 minutes. Constant Supervision:. Staff must be able to see and/or hear each client and be in close enough proximity to intervene as necessary. General Supervision: Staff must make visual and/or verbal contact with each assigned client no less than every 15 minutes. This is the most common level of supervision. The fatility document titled, "Behavior Support Plan," dated 7tl 6tl 3, reviewed on 7/17/13, revealed that Client 1 ’s chain of aggressive and assaultive behaviors were observed during a manic state and he would engage in assaulting peers as a means of disrupting the environment or .seeking attention from staff. He might push or strike a peer, run.quickly down the hall and then watch as staff intervened. Staff were to physically block Client 1 if he attempted to assault a peer. Staff were to clear the hallway of potential victims when Client 1 was running up and down. Staff were to remove an agitated peer away from Client 1 to prevent Client 1 from assaulting the peer. On 9t12/13, at 11 a.m., during interview StaffA stated, "We will be moving the client to another unit. We have no idea why this client acts the way he does and constantly assaults other peers. There are many peers on this unit that he can target and they are unable to get out of harm’s way." During review of Client l’s medical record, under the section titled ’Psychologist Evaluations," there were missing written evaluations by the psychologist addressing Client l’s assaultive behaviors on the following dates: 3/28/13, 3129/13, 4/14/13, 5/20II 3, 6/20/13 and 7/3/13. On 9/12/I3, at 1 p.m., during interview Staff B stated that after each peer to peer altercation, the unit psychologist was to do an evaluation and to chart it NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000755 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 5 of 5 CITATION NUI~IBER: SECTIONS VIOLATED 15-2021-0010136-S Date: 03t21t2014 Time: CLASS AND NATURE OF VIOLATIONS in the Psychologist Evaluation and Progress Notes, Staff B stated, "This is important information for the staff to know in taking care of these assaultive clients." On 9/12/13, at 1:30 p.m., during an interview Staff C stated, ~’Well, most of the time we try; sometimes we miss getting the evaluations into the chart. 1 know that we are to do the evaluations when there is an altercation between clients." The facility document titled "Sonoma Developmental Center Policy Behavior Support & Intervention Services," dated June 2006 and reviewed on 9/12/13, revealed that a psychologist or other person trained in behavior analysis was to complete a behavior analysis and include results in a written evaluation. The behavior assessment should have been sufficient to understand and treat the behavior problem. The facility failed to ensure that four clients were protected from immediate threat to their safety and prevented from harm by a client with identified assaultive behaviors when: 1) staff did not provide sufficient supervision for Client 1, and 2) staff failed to-immediately intervene when Client 1 exhibited precursor behaviors which included running down the hallway, tapping walls excessively, screaming, agitation, restlessness and banging, on walls prior to harming others which resulted in four peers being assaulted by Client 1. These violations had a direct or immediate relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WlrH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS ]S GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000756 State of California - Health and Human Services Agency Department of Public l:4eaith f~EC’[ION t424 NOTICE Page t of 5 CITATION NUMBER: ¯ Date: 03/2112014 Time: 15-2021-0010135-S Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name; Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) incident/Complaint No.(s) : CA00363050, CA00362958, CA00359544, CA00346807, CA00342860, CA00341231 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA Type of Ownership: 95814 Slate Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000Arnold Dr Eldridge, CA 95431 Intermediate Care FacilityfDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS A Capacity: 581 PENALTY ASSESSMENT $10,000.00 trebled to $30,000.00 DEADLINE FOR COMPLIANCE 4/4/14 12:00 a.m. CITATION-- PATIENT RIGHTS T 22. DIV5 CH 8 ART 4 - 76525 (a)(20) CLIENTS’ RIGHTS (a) Each client has the rights listed in (a) of.this section which shall not be denied or withheld except as provided in (c) of this section. " Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to ensure that five clients were free from immediate threat to their safety and failed to prevent harm from an assaultive client when: 1) staff did not implement Client l’s written individual program plan for providing individual supervision (staff must be able to see their assigned client at all times and be in close enough proximity to protect them and others from injury .and staff must not leave the client unattended at any time or be distracted by other issues) and, 2) staff did not immediately intervene when Cfient 1 exhibited precursor behaviors prior to harming others which resulted in five peers that were injured by Client 1. Review of Client l’s record revealed that he was a 30 year old male with multiple diagnoses that included moderate intellectual disability disorder, autism (failure to relate in the ordinary way to people and situations and by repetitive activities, developmental Name of Evaluator: Christina Mangum HFEN Without admitting guilt, I hereby acknowIedge receipt of this SECTION t424 NOTICE Signature : Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000757 State of C, al[forria - Health and Human Services Agency Depar~ment of Public Health ,~ECTION 1424 NOTICE Page 2 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-2021-0010135-S Date: 03/21/2014 Time: CLASS AND NATURE OF VIOLATIONS language disorders and inability to adjust socially), intermittent explosive disorder (marked by alternating periods of hyperactivity and inactivity) and post-traumatic stress disorder (a reaction to traumatic or catastrophic event- examples of symptoms include anger, depression, and rage). He had a history of aggressive and destructive behaviors which included pinching, scratching, hitting and pushing others. Client 1 was ambulatory, a large man and capable of moving quickly towards others. He was non-verbal, however communicated through body language and gestures. A General Event Repor~ (GEE) was reviewed on 6/21/13. The GER indicated that on 1/20/13 at 5 p.m., Client 1 was coming into the hallway of his home unit..Client 2 was standing in the hallway. Without any visible antecedents, Client 1 pushed Client 2. Client 2 fell to ~he floor hitting his head. Client 2 sustained a contusion to his forehead and bleeding was noted from his left nostril. A General Event Report (GER) was reviewed on 6/21/13. The GER indicated on 2/22/13 at 6:10 p.m., Client 1 was being escorted from the dining room by a staff person. Without any visible antecedents, Client I ran ahead of his staff escort and pushed Client 3 from the back. Client 3 fell and hit his head on the floor. Client 3 sustained a laceration to his head. A General Event Report (GER) was reviewed on 7/23/13. The GER indicated on 3t8/2013 at 5:30 p.m., during a group activity Client 2 left the group area to use the restroom. Client 1 stood up and pushed Client 2 without warning. Client 2 fell, face-down onto the floor which resulted in a jagged deep laceration to the bridge of his nose and fractured nose. Client 2 was transferred to an acute hospital for treatment. A General Event Report (GER) was reviewed on 7123/13. The GER indicated on 6/19/13 at 4:40 p.m., Client 4 and several other peers were on a community outing, During the van ride, Client 1 became agitated and assaulted the staff sitting next to him and Client 4 who was seated in front of him. Client 4 sustained scratches on his face, neck a.nd upper back and a bruised area on his back. A General Event Report (GER).was reviewed on 7/26/13. The GER indicated on 7t19t13 at 10:15 a.m., during a day activity at worksite, Client 5 began socializing with loud vocalizations. Client 1 became upset, stood up from his activityand.walked towards Client 5 and pushed her in the back. Client 5 fell.to the floor and landed on her left knee and left elbow. She sustained an abrasion to the ]eft knee and a bruised area on her left elbow. NOTE: IN ACCORDANCE WITH CALII=ORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000758 State of California - Health and Human Services Agency Department of Public Health .~ECTION 1424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-2021-0010135-S Date: 03t2"U2014 Time: CLASS AND NATURE OF VIOLATIONS A General Event Report (GER) was reviewed on 7/26/13. The GER indicated on 7/19t13 at 4:50 p.m., Client 1was sitting outside next to his 1:1 staff (staff must be able to see their assigned client at all times and be in close enough proximity to protect them and others from injury. Staff must not leave client unattended at any time or be distracted by other issues) person. Client 1 stood up from his chair and without warning he stepped towards Client 6 who was. also outside, and pushed him down without any provocation. Client 6 fell into the grass and dirt area. He sustained an abrasion above his left eyebrow area. The GER also revealed that, "...This is the second time which this client has pushed a peer today." On 6/24/13, at 1 p.m., during interview Staff A stated thatthe team had met multiple times to address Client l’s "serial pushing." Staff A stated, "We have met to discuss new preventative strategies to hopefully prevent him from injuring his peers. He has a long history of assaults on his peers. Staff needs to have heightened awareness of his potential to harm others. Staff needs to monitor him closely and keep him away from his peers. If he thinks that he is being crowded, he will assault. He is young, strong and fast and can definitely hurt others. Sometimes there are no antecedents prior to his assau]ting a peer. Staff needs to watch him constantly." On 7/23t13, at 12:30 p.m., during interview, Staff B stated, "1 have done a timeline on his aggressive behaviors - there is a pattern developing. I have addressed this issue with staff on the Bemis Unit and I believe that active treatment is not being provided for him like it should be which is possibly resulting in his aggression to his peers." On 7/23/13, at 2 p.m., during interview Staff C stated, "The client is having problems because he was moved from his previous unit which closed into a more crowded environment on the Bemis Unit. We are constantly changing his reeds to prevent his aggression toward other clients. We have not found the i-ight medication yet and he is taking out his frustrations by attacking other clients. He is a challenge. He was on a 1:1 supervision level with one staff on the day shift and evening shift for a Long time. However, a 1:1 staff person is very expensive. He is now on a 1:1 supervision level on the evening shift only. Staff needs to watch him closely. He is a big guy and he is very fast." On 7/25/13, at 2:15 p.m., during interview Staff D stated, "Staff needs more training on how to care for this client and monitor him properly. For example, I don’t understand why ’a small framed female staffwas assigned to monitor this big, fast client when he was NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODEI FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCA’r]ON OF YOUR LICENSE DPH POD 000759 Sta~e of California ~ Health and Human Services Agency ,~SEO’~[ON 1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health Page 4 of 5 15-2021-0010135-S Date: 03/21/2014 Time: CLASS AND NATURE OF VIOLATIONS outside. The end result was that the client injured a peer and there is nothing that she could have physically done to prevent the assault. Another problem is that this client’s 1:1 staff person was stopped on the day shift and only continued on the evening shift, t think that the staff is more of a challenge than this client. Staff needs to be more appropriate with him and not trust him when he stands up to move to another area. This is the time he will probably assault a peer. Staff is not providing good supervision for him and protecting the other clients. Staff is aware that all this information is in his behavior plan.and they are not following it very well and the end result is that peers are being injured." The facility document titled, "Individual Program Plan" (IPP) dated 3t2/12 reviewed on 6/24/13 revealed that Client l’s self- injurious behaviors pose a risk of injury to himself and his assaultive behaviors pose a risk to harm others. The facility document titled "Behavior Objectives and Plans" dated 7/1 t/13 reviewed on 6t24t13 revealed the following: 1. Client 1 - target behavior is aggression, resulting in pinching, scratching, hitting and pushing peers andtor staff. 2. Precursor behaviors: Getting up from his chair and moving quickly towards peers (pushing) and reaching toward others (pinching, scratching andlor hitting). 3. Preventative Strategies: Staff is to seat Client 1 away from peers in a group setting so that he is Jess likely to push them and if Client 1. begins to exhibit precursor behaviors, staff is to immediately intervene and attempt to redirect him. 4. Guidelines for Individual Supervision: Individual sup.ervision is to be provided at all times to prevent him from harming others. The facility failed to ensure that clients were free from immediate threat to their safety and failed to prevent harm from an assaultive client when: 1) staff did not implement Client l’s written behavior program plan for providing individual supervision (Staff must be able to see their assigned client at all times and be in close enough proximity to protect them and others from injury and staff must not leave the client unattended at any time or be distracted by other issues) and, 2) to immediately intervene when Client 1 exhibited precursor behaviors (getting up from his chair and moving quickly toward a peer and reaching toward a peer) to prevent harming others which resulted in 5 peers NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000760 State of California - Health and Human Services Agency Department of Public Health "SECT’ION 1424 NOTICE Page 5 of 5 CITATION NUI~IBER: SECTIONS VIOLATED 15-2021-0010135-S Date: 03f21t2014 Time: CLASS AND NATURE OF VIOLATIONS being injured by Client 1. These violations presented risk that either imminent danger or serious harm would result or a substantial probability that death or serious harm would result. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAI=TEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000761 bta[e of ball[ornla - HealtP, and Human ~ervlces Agency Department of Public Health SECTION "1424 NOTICE Page 1 of 2 CITATION NUMBER: Date: 04t02/2014 Time: 15-0786-0010294-S Type of Visit: YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE IncidentlComplaint No.(s) " CA00360084 CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facitity Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20) State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership; State Agency SONOMA DEVELOPMENTAL CENTER DIP ICFDD 15000Arnold Dr Eldridfle, CA 95431 Intermediate Care Facility/Developmentally Disabled Capacity: 581 150000230 PENALTY ASSESSMENT $1,000.00 CLASS AND NATURE OF VIOLATIONS CLASS B DEADLINE FOR COMPLIANCE 4/16/14 12:00 a.m. CITATION -- PATIENT CARE T-22 CH 8 ART 4 76525 (a) (20) CLIENTS’ RIGHTS (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shallestabliSh and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To .be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to ensure client safety and protection from potential serious harm when Client 1, with a history of elopement and limited safety awareness, eloped from the facility campus. The client traversed through rugged terrain and crossed a busy highway prior to being found by the county Sheriff. Client 1 was a 35 year old, with intellectual disability admitted to the facility on 9/16/08. Review of the facility incident report dated 6/27/13, indicated that on that date at approximately 10 a.m., as staff exited a van with Client I and others., at the day program site (Sunrise building), Client 1 ran to the opposite side of the building, out the door, and Name of Evaluator: Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOT1C E Ann Fitzgerald HFEN Signature: Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE W:fTH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000762 ota[e u~ ba~.ornla - Health and Human Services Agency Departmen! of Public Health SECTION ’1424 NOTICE Page 2 of 2 , C ’I"AT’iON NUI~IBER: SECTIONS VIOLATED 15-0786-0010294-S Date: 04f02/2014 Time: CLASS AND NATURE OF VIOLATIONS over a hill out of sight as staff pursued him. The client was returned to the facility unharmed, by the county sheriff’s department. Review of the client’s record indicated that the day prior to this incident, on 6/26/13 at 2:30 p.m., Client 1 exited a van, jumped a fence into another yard, jumped a second fence and then was on the main campus and roads. Client 1 was kept in line of sight and returned home shortly thereafter though, per staff, Client 1 was highly agitated. The same day, Client 1 eloped twice from his residence, via an unlocked the back door. An Interdisciplinary Note (iDN), at I p.m. indicated that the client exited the back door (#149) twice. The client’s record indicated a long history of elopement. According to a 2011 annual psychological evaluation: "Elopement carries the most significant risk as he has injured himself severely in the past and placed himself at risk this past year primarily due to.lack of hazard awareness, and impulsive behavior." The client’s behavior plan dated 3/12/12, described Client l’s behavior of elopement as "quickly bolts from supervised area..." The plan included: "Caution.: client’s limited safety awareness while eloping places him at serious risk of iniury (e.g. cars) ..." and directed under the behavior of elopement, "if unsuccessful with verbal redirect physically block him and consider the use of physical escort, if necessary." A document dated 2/20/13 titled: Review of the Individual Program Plan (IPP) indicated that Client t lived on a locked residence and was "on constant supervision when off of the residence...constant supervision requires staff to be able to see and/or hear the client and to be in close enough proximity to intervene as necessary." During an interview on 9t10/13 at 2:15 p.m., the Licensed Staff (Staff A) who had been supervising Client 1 at the time of this incident stated the staff were very familiar with the client and that he had also attempted to elope the day before. Staff stated that the staff were especially alert to his behavior that day, because of elopements the day before. The facility failed to ensure the safety of a client with a known long history of elopement, and lack of hazard awareness, (particularly around cars), when he eloped a long distance and crossed a heavily trafficked highway before being found. This failure had a direct or immediate relationship to resident health, safety and security. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FORSUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000763 btate OT Ualltornla - Health and Human Services Agency Deparlment of Public Health SECT’tON 1424 NOTICE Page 1 of 3 CITATION NUMBER: 15-2021-0009937-S Date: 04/02t2014 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525(a)(20} Incident/Complaint No.(s) ’ CA00355044 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 State Agency Type of Ownership; SONOMA DEVELOPMENTAL CENTER DIP ICFDD 15000 Arnold Dr Eldridge, CA 95431 intermediate Care FacilitytDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 Capacity: 581 DEADLINE FOR COM PLIANCE 4/16/14 12:00 a.m. CITATION - PATIENT RIGHTS T 22 CH ;8 ART 4 76525 (a) (20) CLIENTS’ RIGHTS (a) Each client hastherights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to protect Client 1 from harm and neglect when staff failed to provide close supervision (staff must be in the immediate area and must make visual contact every five minutes) which resulted in. Client 1 leaving his room, climbing over a peer’s bedroom wall and obtaining a bottle of alcohol-based hand sanitizer. Review of Client 1 ’s chart revealed that he was a 57 year old male with diagnoses that included profound intellectuaf disability and autism (abnormal introversion and egocentricity; acceptance of fantasy rather than reality). He had a history of alcohol abuse, alcohol-seeking elopement, and ingesting alcohol-based hand sanitizers. During an elopement, Client t was at risk for ingestion of life-threatening amounts of Name of Evaluator: Christina Mangum HFEN Withoul admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS tS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000764 State of California - Health and Human Services Agency Department of Public Health SEEO~ION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED .15-2021-0009937-S Date: 04/02/2014 Time: CLASS AND NATURE OF VIOLATIONS alcohol. He was fully ambulatory with a steady gait and balance. He was able to climb over.walls and fences easily. He was a large man and able to bolt from his living unit or group. He was essentially non-verbal, however communicated with a limited vocabulary and used gestures. He was capable of understanding what was said to him. On 4117/13, Client 1 was involved in a day program activity with his worksite program. Staff failed to provide Client 1with close supervision (Staff must be in the immediate area, hear the client at all times, and must make visual contact at least every 5 minutes) while he was off of the unit. Client 1 left the group unattended. He entered the facility lab and obtained a bottle of hand sanitizer and a bottle of rubbing alcohol which he ingested. The facility document titled, "Psychological Evaluation" dated 12t17/12 revealed that Client 1 drank a potentially fatal amount of alcohol in 2002 which resulted in a coma for more than one day. The facility document titled, "IPP (Individual Program Plan) Narrative" dated 12/18t12, revealed under Section P5-2 Alcohol Dependency that Client 1 had a history of abusing alcohol and that he was at risk for alcohol poisoning. The facility document titled, "Behavior Support Plan" dated 5/16)13 revealed that Client 1 was at risk for ingestion of life-threatening amounts of alcohol and his primary sources of alcohol had been hand sanitizers and alcoholic beverages. No hand sanitizers with alcohol were allowed on the Corcoran Unit. tf alcohol-based sanitizers were found on the unit, they were to be removed from the area, secured and the supervisor was to be notified. A General Events Report (GER), dated 5t14/13, was reviewed. The GER revealed that on 5t14/13 staff was alerted to Client 1exiting his room when his door alarm sounded. Staff was not able to locate Client 1 in the immediate area but followed the noises coming from a peer’s room. When staff entered the peer’s room, Client 1 was observed to be standing there. Upon seeing staff, Client I then jumped over an approximate seven foot wail which separated the living quarters from each peer. Staff immediately entered the next room and observed Client 1 holding a bottle of alcohol-based hand sanitizer. On 5/16/13 during interview, Staff A stated, "Even though we have put an alarm on the client’s door frame to alert staff if he leaves his room, and the assigned staff to supervise NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000765 ~[ate of Uallfornla - Heatl~ and Human ~Servlces Agency uepanment or ~uo~c Hea~m SECTION 1424 NOTICE Page 3 of 3 CITATION NUMBER: SECTIONS VIOLATED 15-2021-0009937-S Date: 04t02/2014 Time: CLASS AND NATURE OF VIOLATIONS him wears a door alarm pager on his/her belt, and we do every five minute checks according to his behavior plan, he was still able to get away from us. Somehow our system for providing adequate supervision for him broke. This should not have happened." The facility failed to protect Client 1 from, harm and neglect when staff failed to provide close supervision (staff must be in the immediate area and must make visual contact every five minutes) which resulted in Client 1 leaving his room, climbing over a peer’s bedroom wall and obtaining a bottle of alcohol-based hand sanitizer. These violations had a direct or immediate relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000766 State 5f California - Heafth and Human Services Agency Depadment of Public Health SECT,!~QN 1424 NOTICE Page 1 of 4 CITATION NUMBER: 15-202%0009861-S Date: 04t02/2014 Time: Type of Visit ¯ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number.: Facility Name: Address: Telephone: Facility Type: Facility tD: SECTIONS VIOLATED IncidenliComplaint No.(s) " CA00351241 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: Slate Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000 Arnold Dr Eldridge, CA 95431 intermediate Care Facility/Developmentally Disabled Capacity: 581 150000230 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT $10,000.00 trebled to $30,000.00 76315(b) 76525(a)(20) DEADLINE FOR COMPLIANCE 4/16/14 12:00 a,m. CLASS A CITATION -- PATIENT RIGHTS T-22 DIV 5 CH 8 ART 3 76315 (b) Developmental Program Services - Individual Program Plan (b) The individual program plan shall be implemented aswritten. T22 DIV 5 CH 8 ART 4 76525 (a) (20) Clients’ Rights (a) Each client has the rights listed in (a) of the section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to protect Client 1 from harm and neglect when staff failed to. provide constant supervision (staff must be able to see andlor hear him and be in close enough proximity to intervene when necessary) when Client 1 was off of the unit which resulted in Client 1 ingesting a bottle of hand sanitizer and a bottle of rubbing alcohol and the facility failed to implement Client l’s IPP (Individual Program Plan) as the IPP identified alcohol poisoning as a risk due to Client l’s behavior which was addressed in Client l’s Behavior Plan. Name of Evaluator: Christina Mangum HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000767 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 4 CITATION NUMBER: SECTIONS 15-202t-0009861-S Date: 04t0212014 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED Client l’s medical record was reviewed and indicated that Client 1 had multiple diagnoses that included profound intellectual disability and autism (failure to relate in the ordinary way to people and situations and by repetitive activities, developmental language disorders and inability to adjust socially). The facility document titled, "IPP" (Individual Program Plan) dated 12t12/12, revealed under Section P5-2 Alcohol Dependency that Client 1 had a history of abusing alcohol and that he was at risk for alcohol poisoning and that Client 1 could be very cunning at his attempts at procuring alcohol. His persistent interest in alcohol was a serious risk. The facility document titled, "Psychological Evaluation," dated 12/17t12, revealed that Client 1 drank a potentially fatal amount of alcohol in 2002 which resulted in a coma for more than one day. The facility document titled, "Behavior Support Plan," (BSP) dated 3t28/13, revealed that Client 1 had an open plan for PICA (attempts to ingest inedibte items including alcohol-based products) and was at risk for ingestion of life-threatening amounts of alcohol which heightened the risk of injury during an elopement. The primary sources of alcohol had been hand sanitizers and alcoh01ic bevel:ages. The BSP indicated that Client 1 required constant supervision when off of the unit. Facility policy number NC227 PICA, dated December 2011, was reviewed. The policy indicated... "When a client has a PICA condition, LOC (level of care) staff will monitor client per level of supervision." Facility policy number 460 Supervision of Clients, dated January 2012, was reviewed. The policy indicated..."Constant Supervision: Staff must be able to see andlor hear each client and be in close enough proximity to intervene as necessary." Facility document titled "General Events Report," dated 4116/13, was reviewed. The document indicated that Client 1 was working with his mobile crew on 4/16/13 loading the trailer with paper from different buildings, on their daily scheduled route. The clients’ van was parked outside of the lab, The lab staff documented that a client was in the lab and was going from one room over to another room. The client.was holding a bottle of hand sanitizer. The lab staff observed the client throw the bottle of hand sanitizer into the trash. The client picked up a bottle of rubbing alcohol and appeared to be drinking from it. The lab staff intervened and took the bottle of alcohol from him, at which time the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000768 State of California - Health and Human Services Agency Department of Public Health SECTION ’1424 NOTICE Page 3 of 4 C~ATION NUI~IBER: SECTIONS VIOLATED 15~202!-0009861-S Date: 0410212014 Time: CLASS AND NATURE OF VIOLATIONS client ran off. On 4/17/13, at 1:05 p.m., Staff A was interviewed. Staff A stated, "1 was walking down the hall in the lab around 10:45 a.m. and saw a client going from one room to another room. He was holding a bottle of hand sanitizer in his hand. When he saw me, he threw the bottle in the garbage. When I checked the bottle, it was empty. The hand sanitizer bottle is an eight ounce bottle. It was half full prior to him taking it. He drank at least four ounces of hand sanitizer." During a concurrent interview with Staff B, Staff B stated, "About the same time after my staff saw the client with the hand sanitizer, I heard a noise down the hall near the lab draw area. I went down to see what was going on. I observed the same client with a bottle of rubbing alcohol in his hand and it appeared that he was drinking it. I immediately intervened and took the bottle from him. At that point, the client ran out the back door. The client was alone. I did not see any other staff with him. The 16 ounce bottle of rubbing alcohol was half to three quarters full before the client took it. I looked at the bottle after I had removed it from his hand, and there were only about one to two ounces of alcohol left in the bottle. I started to took for the client outside and noticed that he was sitting in a van with other clients parked behind a building not far from the lab. I told the van staff what had happened. The van staff opened the van door and I identified the client that had been in the lab," staff Bc0ntinued to state that the rubbing alcohol was kept on a cart in a separate room for staffto use for blood draws and the hand sanitizer was kept on a tray in another room for staff to take on the units to do blood draws. Staff B stated, "The doors to these two rooms are not locked, as staff go in and out of them frequently for lab procedures." Review of the facility "Emergent/Non-Emergent Community Hospital Transfer," record . dated 4/16/13, showed that Client 1 had "ETOH (alcohol) on breath" and decreased level of consciousness. A "(Community) Fire & Rescue Authority Prehospital Patient Field Notes" form dated 4t1.6/13 described Client 1 as "very diaphoretic (perspiring greatly) on scene. Opens eyes to voice only...New abrasion/hematoma above (left) eye and abrasions to both knees. Some blood in nares (nostrils) as well." Review of the "Emergency Provider Record" from the local community hospital emergency room (ER), dated 4t16/13, described the client’s decreased mental status upon admission.to the ER at t2:51 p.m. as "obtunded" (decreased alertness, slow responses and sleepiness) with a "roving gaze." The client was held for observation prior to discharge at approximately 3:35 p.m., the documentation showed an alcohol level of 0.022. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000769 b[ale or L, allfOrlhla - Heal[n and Human Services Agency Department of Public Health SECTION 1424 N(~TICE Page 4 of 4 , CIT.~TION NUMBER: SECTIONS 15-2021-0009861-S Date: 04f02!2014 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED On 4t17/13, at 2 p,m., Staff C was interviewed. Staff C stated that Client 1 had a history of alcohol seeking behavior. StaffC stated, "The client is an opportunist and a deep thinker. If he notices an opportunity to take any substance which is alcohol based, he will wait until the right time to take the item. He should never be left alone when he is off of the unit. His supervision level is constant (staff must be able to see and/or hear him and be in close enough proximity to intervene when necessary)." On 4/19/13, at 1:30 p.m., Staff D was interviewed. Staff D stated, "1 admit,, f am guilty. I was not watching the client. I was too busy helping other clients and he was out of my line of sight. His level of supervision is constant supervision and i did not provide this for him." The facility failed to protect Client 1 from harm and neglect when staff failed to provide constant supervision (staff must be able to see andlor hear him and be in close enough proximity to intervene when necessary) when Client 1 was off of the unit which resulted in Client 1 ingesting a bottle of hand sanitizer arid a bottle of rubbing alcohol and the facility failed to implement Client l’s IPP (Individual Program Plan) as the IPP identified alcohol poisoning as a risk due to Client 1 ’s behavior which was addressed in Client 1 ’s Behavior Plan. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000770 State of California - Health and Numan Services Agency Department of Public Heailh SECTION~ 1424 NOTICE Page 1 of 6 CITATION NUMBER: 15-1594-0009749-S Date: 04/08/2014 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS Incident/Complaint No.(s) ¯ CA00335329 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA Type of Ownership: 95814 State Agency SONOMA DEVELOPMENTAL CENTER DIP ICFDD Eldridge, CA 95431 15000 Arnold Dr Intermediate Care FacititytDevebpmentally Disabled 150000230 Capacity: 581 PENALTY ASSESSMENT $10,000,00 CLASS AND NATURE OF VIOLATIONS VIOLATED 76316(b) CLASS A CITATION’-- PATIENT RIGHTS 76525(a)(20) T22-DIV5CH8ART3 - 76316(b) Developmental Program Services-Grouping Criteria DEADLINE FOR COMPLIANCE 4/22/14 12:00 a.m. (b) Clientsshall be integrated with peers of comparable socialand intellectual development and shall not be segregated on the basis of their handicaps unless such segregation is planned to promote the growth and development of all those grouped together. T 22 - DIV 5 CH8 ART 4 - 76525 (a)(20) Clients’ Rights (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to ensure that clients were integrated with peers of comparable social and intellectual development so as not to endanger the health and safety of the clients. Name of Evaluator: Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE CAROL D£VITA HFEN Signature: Name : Evaluator Signature ¯ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000771 State of California - Health and Human Services Agency Department of Public Health SECTIO~ 1424 NOTICE Page 2 of 6 CITATION NUMBER: SECTIONS VIOLATED 15-1594-00Q9749-S Date: 04f08/2014 Time: ~ CLASS AND NATURE OF VIOLATIONS When a residence (Unit B) closed on 10t16/12, twelve (12) male clients, (seven of which had severe intellectual disabilities) were moved to another residence, Unit A, with thirteen (13) higher functioning male and female clients. The facility also failed to ensure a client’s right to be free from the harm/potential harm of abuse when clients, with a histories of aggression/intrusiveness towards peers and staff, did not receive effective interventions to ameliorate the immediacy or serious threat to clients/staff, when a pattern where individuals openly expressed being fearful of their living environment was not addressed so that the ongoing threats of harm was removed. Review of the ICF (intermediate Care Facility) roster, dated 9/12, indicated that Clients 1,3, 4, 5, & 9 had mild developmental disabilities. Clients 2, 6, & 8 had moderate developmental disabilities. Client 7 had severe developmental disabilities. On 11/30/12 at 3 p.m. and on 12/3112 at 8:50 a.m. to 10:30 a.m., there were multiple observations of a loud and chaotic environment on Unit A and through interview and review of records, multiple clients and staff voiced fear and concerns about their safety on the unit as follows: 1. During record review on.1..2/-~/12, an I.DN (Interdiscipliaary Note), dated 1.0/11/12 at 10:30 p.m., indicated that Client 5 heard somebne banging on her door and she came out of her room screaming. The note indicated that Client 5 stated it was a peer (Clieht 6). The IDN also indicated that while the client was talking to staff, the same peer came out of his room staring at her. Documentation indicated that the client was visibly upset crying, "keep him away from me." "1 don’t want to be here no more," with tears in her eyes. Record review on 12/3/12, of a facility provided document, showed that Client 6 had recently moved from Unit B to Unit A. 2..During record review, an IDN, dated 10t18t12 at 9:45 a.m. indicated, "[Client 5] told me she is afraid to live on [Unit A] because one of the new residents keeps chasing her." 3. During an interview with Client 5 on 11f30112 at 11:30 a.m., Client 5 stated that she was frightened, as she heard her door being rattled during the night. 4. On 11130/12 at 3 p.m., loud banging was heard outside of the dining room. During concurren-t interview, a staff member stated the clients were tipping the weighted chairs. At 3:10 p.m., observations revealed there were no chairs remaining in the hallway and NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT WOLAT~ONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000772 State of California ~ Health and Human Services Agency Department of Public Health SECTION, 1424 NOTICE Page 3 of 6 ~ITATION NUMBER: SECTIONS VIOLATED 15-1594-0009749-S Date: 04f08/2014 Time: CLASS AND NATURE OF VIOLATIONS the floor of the hallway was streaked with markings from furniture movement. 5. During an interview with StaffA, on 12t3t12 at 9:30 a.m., StaffA stated that a male client (Client 7) checks other clients’ bedroom doors in search of magazines. Record review on 12/3/12, of a facility provided document, showed that Client 7 had recently moved from Unit B to Unit A. 6. On 12/3/12 commencing at 8:50 a.m., the following observations were made on Unit A: a. Upon entering Unit A at 8:50 a.m. there were ongoing loud verbalizations and repetitive intrusive behaviors observed being made by a client (Client 7). Client 7 was approaching the surveyor and staff with loud vocalization which when redirected immediately resumed. b. At 8:50 a.m. staff were observed continually attempting to redirect multiple clients throughout the unit who were roaming, yelling, and displaying disruptive behavior. During a concurrent observation a client (Client 9) was observed walking with a fast pace down a hallway, repeatedly PoUnding the walls with his fists while staff attempted to redirect and calm him. Record review on 12t3/12, of a facility provided document, showed that Client 9 had recently moved from Unit B to Unit A. c. On 12/3/t2 at approximately 9:15 a.m., there were observations of boarded up windows and walls noted in an activity room and in the Family 1 hallway. Windows in the hallway and windows on the hallway door were shattered, d. At 9:30 a.m., a female client, Client 8, was observed standing naked in the hallway, visible to male clients in the immediate area. She verbalized, in a distressed type tone that she wanted to, "take a bath." Staff intervened and provided a towel for privacy, at which time she removed the towel and sat down naked on the floor in the corner of the hallway. During an interview with Staff A on 12/3t12 at 9 a.m., the staff stated that there had been an incident of extreme property destruction by Client 1. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000773 ~sta~e oi ual~torma - Health and Human Services Agency Page 4 of 6 SECTION, 1424 NOTICE ~ITATION NUMBER: SECTIONS VIOLATED ¯ Deparlment of PubIic Health 15-1594-0009749-S Dale: 0410812014 Time: CLASS AND NATURE OF VIOLATIONS Work orders included requests to repair/replace 10 broken windows in-the north wing hallway, to replacetrepair double door windows, and to replace a broken window in the family room, 131. Forms entitled, "Completed Work Order," indicated the following: 1. On 12/1/12, there were expo.sed wires in the alarm box. 2. On 12tlf12, repairs were made to the wall that was associated with the damaged wires. Review of Client l’s IPP (Individual Program Plan), dated 9/13112, indicated that Client 1 had diagnoses that included Impulse Control Disorder. The tPP indicated that Client 1 was on general supervision (visual and/or verbal contact no less than every 15 minutes) at home and at his worksite and constant supervision (where staff must be able to see andtor hear each client and be in close enough proximity to intervene as necessary) around female peers. During the incident of property destruction by Client 1, the client was on individual supervision (1 "1) which had been implemented following an 11/29112 incident, per interview with Staff D on 12/6/12 at 3:20 p.m. Individual supervision is definedas, staff must be able to see their assigned client at all times and be in close enough proximity to protect them and others from injury. Review of Client l’s Behavior Plans on 12/4/t2 included, but were not limited to, the following: 1. Aggression: Hits, punches, kicks, spits, throws objects or scratches others. 2. Bites or attempts to bite peers or staff. 3. Property Destruction-destroys valuable property (e.g. beds, windows, TVs), throws chairs and furniture, can use items he has destroyed to harm self, kicks window in bedroom, sets fires. 4. Elopement - Bolts from supervision. On 12t4/12, review of Physician’s Progress Notes, dated 10/11t12, indicated that Client 1 successfully had Clonazepam (antianxiety medication) and Quetiapine (antipsychotic medication) weaned. Further documentation indicated, "He¯ is doing well, but is stressed by 12 clients just transferred from [Unit B]. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT WOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000774 :51ale o1 L;al~torn~a Health and Human Services Agency SECTION t424 NOTICE ’CITATION NUNBER: SECTIONS VIOLATED Department of Public Health Page 5 of 6 15-1594-0009749-S Dale: 04t08/2014 Time: CLASS AND NATURE OF VIOLATIONS : On 12/4/12, review of Interdisciplinary Notes, dated 1211/12 at 6:30 p.m:, indicated that Client 1 became upset at the beginning of the p.m. shift because he wanted and was demanding a specific staff to provide his individual supervision. The client stormed down to Family 1 hallway into the activity room and started to engage in property destruction. Further documentation indicated that, ’!Client broke a table leg and started to use it like a sledgehammer and busted several window [sic], broke a plexy mirror and made holes on the walls pulling the fire alarm until wires were exposed, when staff attempted to intervene client became violent towards staff startedto swing table leg at staff and was throwing broken objects to staff." The campus police were called to assist and when the police and fire department arrived, the client was able to calm down. He was given an immediate dose of Lorazepam (an anti-anxiety medication) 2 milligrams orally to help his aggression. During his escalation, he used broken plexy mirror and cut his chest, abdomen and arms, requiring first aid. On 12/4/12, review of the HSS (Health Services Specialist) note, dated 1211112 at 5 p.m., indicated that Client 1 sustained the following self-inflicted injuries: 1. Contusion to the middle of the forehead, 4 centimeter (cm.) x 3 cm. 2. Laceration, 7 cml long, On the ieftchest above nipple line. 3. Laceration, 11 cm. long, on the left abdomen. 4. Laceration, 2 cm. long, on the left middle finger. 5. Laceration, 2 cm. long, on the left wrist. 6. Also noted was an "old" deeper laceration on the left forearm from an incident on 11 t28/12. During an interview with licensed staff, Staff A, on 12/3/12 at 9 a.m., Staff A stated that she was "scared" for the first time. During an interview with licensed staff, Staff B, on 12/3/12 at 10 a.m., Staff B stated that the mixing of Unit A and Unit B was not working. On 12/3/12 at 10:30 a.m., Staff A further stated that the clients from Unit B have their routines and the clients from Unit A are not use to it, it happens, "every day." During an interview with offsite staff, Staff C, on 12/3/12 at t 1 a.m., Staff C stated that since the units combined, the clients from Unit A have had increase in anxiety and the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000775 State of California ~ Health and Human Services Agency Department of PubI[c Health SECTI,O ..N Page 6 of 6 "1424 NOTICE CITATION NUMBER: SECTIONS VIOLATED 15-1594-0009749-S Date: 04/08/2014 Time: CLASS AND NATURE OF VIOLATIONS clients from Unit B do not understand boundaries. During an interview with Client 2 on 12t3/12 at 3:15 p.m., Client 2 stated that he wanted to move, "because it is dangerous here." This client asked the surveyor, three times, to be sure that the surveyor wrote his statement down. During an interview with Client 3 on 12t3t12 at 3:18 p.m., Client 3 stated that he did not feel safe on this unit. During an interview with Client 4 on 12/3t12 at 3:25 p.m., Client 4 stated that she was, "scared." Client 4 further stated that she, "did not like living here with people getting hurt," On 12/4/12, review of thefacility document entitled, "General Event Report," the event summary indicated that Client 1 also broke off several table legs, broke the water fountain and chipped the tile floors when he threw the table leg to the floor. The policy for Abuse/MistreatmentlNeglect Prevention and Reporting, #-413- effective 7t2012, included the following: "Abuse, mistreatment, or neglect of any person living at [the facility] is strictly prohibited." The policy further contained the definition of psychological abuse, as follows: "Any act that causes or may cause emotional distress (fear, humiliation, agitation, anxiety, confusion, depression or other negative emotional state) to a child or dependent adult; including, but not limited to threats, intimidation, or harassment." By failing to ensure that program structure met clients’ individual needs and by failing to ensure a client’s right to be free from the harm of abuse/potential abuse, 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. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000776 ~tate ot L;a~torn~a - Health and Human Services Agency Department of Public Health SECTION ’~424 NOTICE Page 1 of 3 CITATION NUMBER: 15-0786-0010982-S Date: 10t3012014 Time: Type of Visit ’ YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76315(b) Incident/Complaint No.(s) ’ CA00396967 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD 15000 Arnold Dr Eldridge, CA 95431 Intermediate Care FacilitylDevelopmentally Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B Capacity: 581 PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 1t/9/14 12:00 a,m. CITATION-- PATIENT CARE T22 DIV5 CH8 ART3 76315(b) Developmental Program Services-Individual Program Plan (b) The individual program plan shall be implemented as written. The facility failed to ensure implementation of the program plan when Client 1 ingested two keys subsequently found in her gastrointestinal tract. This had the potential to cause harm to Client 1 and was the second incident of ingestion of a foreign body in five weeks. The record, reviewed on 5/1/14, indicated that Client 1 had a behavior support plan for parasuicidal/self-injurious behavior/pica (ingestion of non-eatable items). A prior ingestion incident had occurred on 3/21t14 when the client ingested part of a safety scissor which had to be surgically removed. Review of the facility reported incident, dated 4t29/14, indicated that Client I reported ingesting two keys. The client was transferred to an outside community hospital for tests an x-ray conf rmed the presence of two keys one in her esophagus and one in her stomach. Name of Evaluator: Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Ann Fitzgerald HFEN Signature: Name : Evaluator Signature ’ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000777 ,State of Ualitornia - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS 15-0786-0010982-S Date: 10/30/2014 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED Review of the record of Client 1 on 5/1t14 contained a behavior plan which included the need for individual supervision and direct line of sight at all times, last updated 4/21t14, the purpose of which was to avoid ingestion behavior. "Staff must provide Individualized Supervision (i.e. direct line of sight, within arm’s reach) at all times, including worksite, sleep and hygiene (female staff should assist during bathingltoileting) with no exceptions." Review of a client protection plan and Individual Program Plan (IPP) special meeting, dated 4/30/14, indicated that on 4t28114 at 4:30 p.m., Client l’s individual supervision was replaced by a male staff (Staff A). During this time the client wanted to take a sho.wer. Staff A allowed the client to shower in private behind a closed curtain. During an interview on 5/1/14 at 1 p.m., StaffA stated at the time there was no female staff available and the client just got her things and went into the shower room, and could not be redirected. A special meeting document, dated 4/30f14, indicated that on 4t29f14 Client I had been agitated commencing that morning when the nurse noted a superficialop6ning of the 3/21/14 wound and recommended the use of an abdominal binder. The client left the off-site upset about this and was subsequently followed by hospita{..police, and returned home. The client c0ntinued to refusethe binder and was placed in a pica safe room and became combative. At 4:25 p.m., Client 1 reported that she wanted to hurt herself. The client’s supervision level was increased to two staff. Dur!ng this time, the client reached down pulled a key from her sock and placed it in her mouth while-staff attempted to redirect. The client then reported that she had swallowed another key the night before. The client’s keys had been accounted for in her fanny pack by the evening shift staff. Review of the record on 9/9/14 included the IPP special meeting document dated 5t6/14, that indicated that the client returned from the hospital on 5/3t14 and the client had passed one key but net the other. A physician’s progress note, dated 5/5f14, indicated that the surgeon managing the ingestion felt it was appropriate to resume a regular diet and wait to pass the second key at home. The plan was to monitor bowel movements closely until the passing of the second key. Review of the record on 9/9/14 indicated in the Interdisciplinary Notes, dated 6/1114 at 1:50 p.m,, that .two keys were found in the client’s stool measuring 4.5 centimeters in length and no trauma and no complaints as noted per the nursing assessment. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAF’rEY CODE, FAILURE TO CORRECT VIOLATIONS 1S GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000778 ~ia[e o~ ual~torn~a - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 3 of 3 dlTATION NUMBER: SECTIONS VIOLATED 15~0786-0010982-S Date: 10t30/2014 Time: CLASS AND NATURE OF VIOLATIONS In summary Client 1 swallowed two keys and her individual supervision/behavior plan was not followed. This failure had a direct or immediate relationship to resident health, safety and security. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCA’rlON OF YOUR LICENSE DPH POD 000779 State of California - Health and Human Services Agency Department of Public Health SECTI’~)N 1424 NOTICE CITATION NUMBER: Page 1 of 2 15-2021-0010924-S Date: 10/31/2014 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID; SECTIONS VIOLATED 76525((a))(20) Incident/Complaint No.(s) ¯ CA00404525 State of CA Dept of Devebpmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA Type of Ownership: 95814 State Agency SONOMA DEVELOPMENTAL CENTER DIP ICFDD Eldridge, CA 95431 15000Arnold Dr intermediate Care FacilitytDevelopmentally Disabled Capacity: 581 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000,00 DEADLINE FOR COMPLIANCE 11/10/14 12:00 a.m. CITATION -- PATIENT RIGHTS . T22 DIV5 CH8 ART4-76525(a)(20) CLIENT’S RIGHTS Each client has the rights listed in (a) of this section which shall not be denied or withheld except.as provided in (c) of this section:Each facility shall establish and ¯ implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20)To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to comply with the above regulation by failing to ensure that Client 1 was adequately protected from sexual abuse when her designated 1:1 (constant supervision) Staff A sexually abused her while on duty. A report received from the facility on 7/7t14, revealed on 7t4/14 at 11 p.m., Client 1 had informed on-duty staff that her individual supervision staff (1:1) from the A.M. shift had sex with her. The facility report indicated, "The client stated to staff that she had placed her soiled undergarments and sheets on top of her dresser and that she was scared to go back into her room and preferred to sleep outside in the hall that evening. She was transported to a local hospital at 3:30 a.m., on 7t5t14 for a SART (rape test) exam and further assessment. The alleged perpetrator was met on-site at 6:30 a.m., on 715t14. He was placed on administrative reassignment and detained by the Sonoma County Name of Evaluator: Christina Mangum HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature " Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000780 ~[ate or ua[~lorn~a - Healti~ and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 2 CITATION NUMBER: SECTIONS VIOLATED 15-2021-0010924-S Date: 10/31/2014 Time: CLASS AND NATURE OF VIOLATIONS Sheriffs’ Office." Review of Client l’s record on 7/7/14, revealed that Client 1 had diagnoses of Post-Traumatic Stress Disorder (disorder characterized by recurrent episodes in which the patient relives a trauma - symptoms include nightmares, sleep disturbances, psychic numbness, flashbacks and aggressive behavior), chronic Mild Intellectual Disability and Borderline Personality Disorder (how the patient sees and acts in life - this is not an illness but rather how the patient relates to the world, can manifest in problems with low self-esteem, relating and trusting). Further review revealed that Client 1 had a history of sexual abuse by a family member as a child. During interview of a supervisory staff (Staff B) on 718/14, at 10 a.m., Staff B stated, "On 7f4t14, at approximately 11 p.m., the client reported to a night shift staff that a mate staff had sexually abused her on the day shift. The client did not tell anyone about the incident until the night shift staff came on. The evening shift reported that the client had been scared and teary eyed most of the shift. The incident was immediately reported to the Sheriffs’ Department by the facility’s administrative staff. The client was taken to a hospital for further assessment and a SART exam was done. I do not have the exact test results, however t was informed that evidence was collected at the time of the exam. The accused staff member was removed from duty and arrested the next morning .on 7/5/’14.’" During interview with staff psychologist (Staff C) on 7/8t14 at 10:30 a.m., Staff C stated, "This client struggles with her compulsion to deal with emotional distress through extreme acts of self-injurious behaviors such as cutting herself and swallowing dangerous objects. She is stable at this time however maybe in six months she could become emotionally unstable as a result of this sexual assault. We need to monitor her closely." The facility failed to comply with the above regulation by failing to ensure that Client 1 was adequately protected from sexual abuse when her designated 1:1 (constant supervision) staff sexually abused her while on duty. These failures had a direct or immediate relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE. DPH POD 000781 State ot Calitornia - Health and Human Services Agency Department of Public Health SEO’ClON 1424 NOTICE Page 1 of 2 CITATION NUMBER: 15-1727-0010888-S Date: 10t31/20t4 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE Incident/Complaint No.(s) : CA00406612 CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76345((c)) State of CA bept of Developmental Servi&es 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P ICFDD 15000Arnold Dr Efdridge, CA 95431 Intermediate Care FacilitylDevelopmentally Disabled Capacity: 581 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1,000.00 DEADLINE FOR COMPLIANCE 11/10/14 t2:00 a.m. CITATION --PATIENT CARE T22- DIV 5 CH 8 ART 3 - 76345 Health Support Services - Nursing Services (c) The attending physician shall be notified immediately of any signs of illness or marked change in condition. The Department determined the facility failed to ensure prompt medical care and treatment and assessment of the client (Client 43) by a physician for three days despite complaints of pain, edema, and bruising following an accident which resulted in a right foot fracture. Record review showed Client 43 was approximately 63 years old. Client 43 was ambulatory, diagnosed with abnormal movement disorders, impulse control disorder, attention deficit disorder of childhood with hyperactivity, and the client’s medical history included a prior foot fracture and a history of contusions. An interdisciplinary note (IDN) signed by the Health Services Specialist (HSS), dated 4t5tt4 at 10:30 a.m., indicated Client 43 fell and had scraped her left knee. The client sustained a superficial abrasion 2 centimeters (approximately 3/4 inch) on her left knee. No swelling or drainage were noted and ambulation was at baseline. HSS I stated during an interview, on 5/14t14 at 4:45 p,m., that she had looked at the Name of Evaluator: Mark West HFEN Withoul admitting guilt, I hereby acknowCedge receipt of this SECTION 1424 NOTICE Signature: Name: Evaluator Signature Title: .NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000782 ~51ate of UallfOrnla - blealtl~ and Human ~erv~ces Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 2 C]TArlON NUMBER: SECTIONS VIOLATED 15-1727-0010888-S Date: 10131/2014 Time: CLASS AND NATURE OF VIOLATIONS patient on 4/5/14, Saturday, because the patient stepped in a pothole, fell to the ground and injured her knee. The HSS said she knew it happened in the morning, so the morning HSS also had looked at the injury. HSS 1 stated Client 43 had no pain or fever so the injury did not need further ~ittention. The HSS also stated the incident was in the MD log book, and he (the physician) would check the log when he came in on Monday. HSS 1 stated Client 43 had osteoarthritis (a disease of the entire joint involving the cartilage, joint lining, ligaments, and underlying bone). The HSS indicated she was not aware if the client received pain medication but thought she received pain medication after the x-ray. An IDN, dated 415/14 at 8:15 p.m., revealed, the client had fallen on the a.m. shift and had complaints regarding her right foot. The noted showed, "Noted a large bruise w/ (with) edema (swelling) forming on trip of R (right) foot below the ankle. Approx. (approximate) size t0 cm (centimeters) by 5 cm with red bruise, but perimeter is light purple. Wearing her shoes, but easily removes them..." Documented by the HSS on the IDN note, dated 416/14 at 8:55 p.m., was that the top of the right foot was red and swollen, and Client 43 was complaining of pain. There was no indication of notification to MOD (Medical Officer on Duty) / physician for further evaluation. The clinical record confirmed Client 43 did not have a physician evaluation until Tuesday, 4/8/14 at 9:40 a.m.. Documented in the "Physicians’ Progress Notes," was, "Right foot w/(with) mild swelling and diffuse bruising over foot. Patient refusing to allow palpation or further exam.., bruising and injury is consistent with ankle sprain. Pt. (patient) is not limping or displaying signs of pain. In light of pt’s (patient’s) history of osteoporosis, will obtain x-ray today." The "Physicians’ Progress Notes," dated 4t8/14 at 3:10 p.m., showed, "X-ray reveals fx (fracture) at base of 5th metatarsal (bone in th.e toe) - non-displaced. Fx (fracture) is clw (consistent with) mechanism of injury Sat. (Saturday)..." The facility failed to ensure a medical assessment by the physician and provide prompt care for a patient with developmental disabilities after a witnessed fall, which resulted in a fracture, pain and swelling. These violations had a direct relationship to the health, safety or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000783 State of California - Health .and Human Services Agency Department of Public Health Page 1 of 3 ¯ SECT]ON 1424 NOTICE CITATION NUMBER: 15-2021-0010923-S Date: 11/19/2(~14 Time: Type of Visit : YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 76525((a))(20) Incident/Complaint No.(s) : CA00408451, CA00403600 State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DiP ICFDD Eldridge, CA 95431 15000 Arnold Dr Intermediate Care FacilitytDeve!opmenta]ly Disabled 150000230 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT $1 ,ooo.oo Capacity: 581 DEADLINE FOR COM PLIANCE 12/1/14 12:00 a.m. CITATION -- PATIENT RIGHTS ¯ T22, DIV5 CH 8 ART 4 - 76525 (a) (20) Clients’ Rights. (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld exceptas provided in (c) of this section. Each faciiity shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to comply with the above regulation by failing to ensure Client 1 was adequately protected from harm when staff failed to identify the potential risk to Client 1 of being harmed by peers and failed to monitor peers with identified behavioral issues of biting other peers. These failures resulted in inflicted multiple bites to Client 1 with increasing seriousness of infection and tissue damage. A report received from the facility on 6/26t14, revealed on 6/26t14 at 7:05 a.m., staff discovered multiple human bites on Client 1. Bites were observed on Client 1 ’s arms and lower leg. The bites had teeth impressions, opened skin areas, slight bleeding, swelling and bruising. A report received from the facility on 8/6t14, revealed on 8/2/14 at 7:20 a.m., staff Name of Evaluator: Christina Mangum HFEN Without admitting guilt, ! hereby acknowledge receipt of this SECTION 1424 NOTICE Signature: Name: Evaluator Signature ’ Title: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000784 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 3 CITATION NUMBER: SECTIONS VIOLATED "15-2021-0010923-S Date: 11/19/2014 Time: CLASS AND NATURE OF VIOLATIONS observed a human bite mark on Client l’s upper arm. The facility ~eport indicated that Client 1 was bitten - perpetrator unknown. Clinical record review starting on 7/17/14, indicated: Client 1 was a male, 35 years of age admitted to the facility on 4/2t1979. Client 1 had multiple diagnoses that included Profound Intellectual Disability, Autism and SIB (self-injurious behavior). Further review revealed that Client 1 had good receptive language skills and was able to make his needs known to staff verbally and through gestures. Client 1 received general supervision (staff must make visual andtor verbal contact with client no less than every 15 minutes) when on the unit and close supervision (staff must in the immediate area and must make visual contact every five minutes) at worksite. On 7tl 7/14, at 10 a.m., supervisory staff (Staff A) was interviewed. Staff A stated that a direct care staff had obseived four bite wounds on Client l’s arms and leg during Client l’s shower. Staff A stated, "There were areas of broken skin, some dried blood, swelling and bruising. There were visible teeth marks on the skin. This client has a history of biting himself, however he will usually bite the back of his hand and he is a very large framed, overweight man with a.]arge trunk girth and lacks the flexibility to be able to bite himself in the areas of his bite wounds. He is on general supervision during the day and night time hours and is checked every 15 minutes when awake and every 30 minutes when he is sleeping. This client enjoys his private time in his bedroom looking through his belongings and is usually in bed by 9 p.m. and asleep." Observation on 7t17t14 at 10:45 a.m., revealed that Client 1 had a private room. In addition to his bedroom door, his bedroom was accessible through a connecting restroom to an activity room. During a concurrent interview with Staff A, Staff A stated, "All the clients who use this activity room can also use the connecting restroom and they can go into this client’s bedroom, too. This is why the staff is to monitor the clients using the activity room closely to prevent this from happening. Many of our clients like to use the activity room until very late in the evening. The staff will be training this client to use a press lock when he goes to bed to lock his side of the restroom for his security and staff must continue to monitor him for his safety from the other clients entering his bedroom." On 8/12/14 at 12 p.m., supervisory staff (Staff A) was interviewed. Staff A stated, "This is the second bite injury for this client. The direct care staff was starting his shower on 8/2114 around 7:30 a.m., and noticed a red bite mark on his upper, arm. Staff observed NOTE: iN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000785 State of California - Health and Human Services Agency Page 3 of 3 ,. SEGTI~ON t424 NOTICE CITATION NUMBER: SECTIONS VIOLATED Department of Public Health 15-2021-.0010923-S Date: 11/19/2014 Time: CLASS AND NATURE OF VIOLATIONS small skin openings in the bite area. We have eleven clients with behavior support plans in place for biting. This is a unit that can have.biting issues. This client being bitten twice in a very short time is not the fault of the other clients on this unit. This is the fault of the staff on all three shifts. The staff failed to monitor and supervise our clients as they should have." The facility failed to comply with the above regulation by failing to ensure Client 1 was adequately protected from harm when staff failed to identify the potential risk to Client 1 of being harmed by peers and failed to monitor peers with identified behavioral issues of biting other peers. These failures resulted in inflicted multiple bites to Client 1 with increasing seriousness of infection and tissue damage. These failures had a direct or immediate relationship to the health, safety, or security of patients. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FA1LURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000786 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 1 of 5 CITATION NUI~IBER: 15-0786-0010016-F Date: 04/10/2014 Time: Type of Visit" Complaint Investig. Incident]Complaint No.(s) " CA00358901 YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: T~lephone: Facility Type: Facility ID: SECTIONS VIOLATED State of CA Dept of Developmental Services 1600 9TH.STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P SNF Eldridge, CA 95431 15000Arnold Dr (707) 938-6000 Skilled Nursing Facility 150000229 Capacity: 427 CLASS AND NATURE OF VIOLATIONS PENALTY ASSESSMENT .$10,000.00 DEADLINE FOR COMPLIANCE 4/24/14 12:00 a.m. CLASS A CITATION-- MEDICATION F333 F425 F333 - CFR 483.25(m)(2) Residents are free of any significant medication errors. F425 - CFR 483.60(a)(b)(1) Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.75(h) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provi.de pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs. and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who(1) Provides consultation on all aspects of the provision of pharmacy services in the facility;. The above regulations were violated when the facility failed to ensure that: (1) the facility pharmacy filled the.physician’sprescription for oral morphine correctly; (2) licensed staff identified wrong medication dispensed to the unit; (3) failed to ensure that Resident 1 wasadministered the correct medication (morphine a short-acting narcotic) as Name of Evaluator: Ann Fitzgerald HFEN Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Signature : Name : Evaluator Signature : Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000787 State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-0786-0010016-F Date: 04/10/2014 Time: CLASSAND NATURE OF VIOLATIONS prescribed and instead administered methadone, (a long acting narcotic). These failures resulted in the r~esident’s emergent transfer and admission to a community hospital for respiratory failure. Resident 1 was a 59 year old, dependent on staff.for all activities Of daily living. The resident had a history of chronic obstructive pulmonary disease (chronic lung disease that restricts airflow), with recurrent aspiration (the taking of foreign matter into the lungs with the respiratory current) and received all medication and nutrition ~/ia a stomach feeding tube~R~sident~ w~S prescrib#cl medications and routine breathing~reatments for this chronic respiratory condition, as well as periodic morphine 10 milligrams oral solution Ordered for pain. Resident 1 died on 6/8/13. On 6/12/13 the resident’s medications were returned to the pharmacy by the facility Office of Police Services (OPS), at which time the discovery was made by the receiving pharmacist, that the package had two labels: one label for morphine 5 mg. per 0.25 milliliters, and the other label for methadone 2.5 mg. per 0.25 milliliters. The syringes for oral dosing, inside the package were all labeled "methadone 2.5 mg, per 0.25 milliliter" and not morphine as prescribed by the physician. The pharmacy document titled, ."Control Sheet," for the prescribed morphine (which accompanied dispensed medication) had the tracking number 1353. The tracking number on each of the two labels on the package was also 1353. However one label identified the medication as morphine and the other label as methadone. Nursing Progress notes dated 6/1/13 at 9:40 p.m., indicated that Licensed Staff called the Health Services Specialist (HSS) at 8:10 p.m., because Resident 1 had "poor vital signs and was not looking well." The HSS noted the resident was cool with raspy respirations and suctioned a large amount of thick, brown phlegm. The resident continued to receive respiratory treatment and oxygen and the physician was notified and came to assess the resident. The nursing note and the Medication Treatment Record (MTR: the nursing document used to indicate administration of the dose and time a medication was given), indicated that at t 0:30 p.m., Staff A, administered morphine 10 mg. via the resident’s gastrostomy (stomach feeding tube). However, the syringes of oral solution administered, actually contained and were labeled methadone 2.5 mg per 0.25 ml’s each. The resident received 10 rag. of methadone instead of morphine. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000788 State of California - Health and Human Services Agency Department of Public Health SEC!I’ION 1424 NOTICE Page 4 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-0786-0010016-F Date: 04/10/2014 Time: CLASS AND NATURE OF VIOLATIONS Technician both checked the dosage and double checked the orders. Staff was at a loss to explain how the conflicting labels on the package and on the syringe was missed by. so many staff. The resident had Physician’s orders for 10 mg of oral morphine every two hours as needed for pain. Review of the resident’s monthly Medication Treatment Record, indicated that the resident’s usual dose when needed was 10 mg: of morphine in a 24 hour period. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain Sixth_Edition (2008) p~ublished_by _the American Pain Soci~ety,~docum~nted on page 27 Table 4 titled: "Guidelines for Methadone Administration" that: "If the total morphine or equivalent dose per day is less than 90 mg (oral),. a methadone dose ratio of 1:4 (methadone to morphine) is used..." Therefore a 2.5 rag. dose of methadone Would be considered to be equivalent to 10 mg. of morphine for Resident 1. The resident received 10 mg. methadone four times the recommended dose, in error. Review of the package insert for methadone (which is the Food and Drug Administration approved product labeling for a medication), obtained from "Daily Med!’ ’ at the National Library of Medicine, National Institute of Health website, contained the. following risk under Section 5 subsection 5.2 titled Warnings and Precautions: "5.2 Life-Threatening .Respiratory Depression: Respiratory depression is the primary risk of mel~hadone. Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest and death. Respiratory depression from opioids is manifested by a reduced urge to.breathe and a decreased rate of respiration,, often associated with a "sighing" pattern of breathing (deep breaths separated by abnormally long pauses)." And the same package insert under subsection 5.6: "Use in Patients with Chronic Pulmonary Disease. Monitor patients with significant chronic obstructive pulmonary disease.., particularly wheninitiating therapy and titrating (see below) with methadone, as in these patients, even usual therapeutic doses of methadone may decrease respiratory drive to the point of apnea [see Warnings and Precautions (5.2)]. Consider the use of alternative non-opioid analgesics in these patients if possible." Titration means the smallest amount of a reagent of known concentration required to bring about a given effect. In summary, failure of the facility to dispense and administer the correct medication (morphine) as ordered by the physician, and to instead dispense and administer methadone, to Resident 1, who had a history of respiratory compromise, resulted in the hospitalization of the resident, in respiratory distress. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000789 State of California - Health and Human Services Agency Department of Public Health SEC’~’ION 1424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-0786-0010016-F Date: .04/10/2014 Time: CI~ASS AND NATURE OF VIOLATIONS Nursing progress notes indicated that at 1:30 a.m., on 6/2/13 staff notified emergency personnel upon observing the resident’s color change and need for respiratory assistance. The resident was transferred via ambulance to the local community hospital. Review of the Emergency Room Report dated 6/2/13, documented: "Per paramedic report, the patient was found to be with significantly depressed respirations at 3 to 4 per minute... She was given Narcan at 2mg IV (intravenous) in the field with immediate. improvement. The pupils became equal, round and reactive. Respiratory status improved," Theresident was admitted with "apparentnarcotic overdose, accidental with secondary aspiration..." The community hospital discharge summary dated 6/5/13 indicatedthe resident’s discharge diagnoses as aspiration pneumonia, respiratory failure, acute and chronic and. urinary tract infection. " The resident was discharged back to the facility’s acute hospital on 6/5/13 and died on 6/8/13. During an interview on 6/28/13 at 11 a.m., the Unit Supervisor (U.S.) stated that when she picked up the medication from the pharmacy on 5/28/13 she counted the syringes and checked the control number but overlooked the drug name on the label. The. U.S. further stated that the licensedstaff and she had discussed the dosage on the labels and thought it was confusing. During .an interview on 6/28/13 at 2 p.m., Pharmacist A verified that the error was not picked up until the medication was returned to the pharmacy on.6/12/13. He stated "it definitely got missed by a lot of eyes." The system of distributing narcotic oral solution via pre-filled syringes had just been initiated 5/3/13. Packages of pre-filled methadone and morphine had been stored right next to each other at that time. The packages were labeled by the pharmacy technician and verified by the pharmacist on duty. During an interview on 7/11/13 at 3 p.m., Pharmacist B stated that a pharmacist ~re-filled and labeled the syringes. The technician would have obtained the control " document and placed that label on the bag. The pharmacist always verifies the order before it goes out. Pharmacist B stated that it was his responsibility to catch a mistake and he didn’t catch it. The pharmacist stated that he felt very badly. During an interview on 6/28/13 Licensed Staff A stated that the R.N. and the Psychiatric NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000790 ~ State of California - Health and Human Services Agency Department of Public Health SEO’I"I(~N 1424 NOTICE Page 5 of 5 CITATION NUMBER: SECTIONS VIOLATED Date: 04/10/2014 Time: 15-0786-0010016-’F CLASS AND NATURE OF VIOLATIONS ¯ 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 for Resident 1. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE . DPH POD 000791 Depar~rnent of Public Health State of California - Health and Human Services Agency Page 1 of 2 ¯ SEC:I’iON 1424 NOTICE CITATION NUI~IBER: 15-1116-0009935-S Date: 03/14/2014 Time: Type of Visit : Incident/Gomplaint No.(s) : CA00349050 YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone: Facility Type: Facility ID: SECTIONS VIOLATED 1418.91 State of CA Dept of Developmental Services ¯ 1600 9TH STREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP SNF Eldridge, CA 95431 15000 Arnold Dr (707) 938-6000 ...... Skilled Nursing Facility .Capacity: 427 150000229 CLASS AND NATURE OF VIOLATIONS CLASS B PENALTY ASSESSMENT DEADLINE FOR $800.00 COMPLIANCE 3/28/14 12:00 a.m. CITATION -- FAILURE TO REPORT TII~IELY Health and Safety Code Div. 2. Licensing Provisions Chapter 2.4 - Quality of Long-Term Health Facilities 1418.91. (a) A long-term health care facility shall report all incidents of alleged abuseor 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 3/29/13 at 10:52 a.m., the Department received written notification that on 2/15/13 two residents (Resident 1, Resident 2) were found in urine soaked bed linens and that neither resident had been repositioned all night. The notification reported that the Unit Supervisor had found both residents in this condition after the night shift - a.m. shift rounds, "suggesting that the two clients [residents] had not been repositioned or had their incontinent briefs changed on the NOC [night] shift as required." The facility’s failure to notify the Department impeded the ability of the Department to investigate this. allegation in a timely manner, potentially exposing the residents to risk of repeated neglect. According to the facility’s notification, the nurse responsible for caring for the two Name of Evaluator: Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE Gregory Hannan HFEN Signature : Name : Evaluator Signature " Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000792 State of,California - Health and Human Services Agency Department of Public Health ~ECTION 1424 NOTICE Page 2 of 2 CITATION NUN1BER: SECTIONS 15-1116-0009935-S Date: 03/14/2014 Time: CLASS AND NATURE OF VIOLATIONS VIOLATED residents continued to work in the facility after the 2/15/13 incident, until 3/15/13, when that nurse took a leave of absence due to illness, potentially placing those and other residents at.risk of neglect during that period of time. It was not until 3/28/13, .forty-two days after the incident, that the facility contacted and advised the nurse that she was placed on administrative reassignment with no resident contact. It was one day later, on 3/29/13 that the facility notified the Department. Review of Resident l’s record on 3/29/13, included an "Individual Plan Treatment Rrofile,~’dated 12/19/12, which showed that the resident was diagnosed with quadriplegia (paralysis of both arms and legs). Resident l’s "Service/Health Care Objectives and Plans," (undated) showed that the resident relied on staff to be positioned and turned when in bed. _ _ Review of Resident 2’s record on 3/29/13, which included a "Nursing Evaluation Assessment," (undated) showed that the resident was totally dependent on stafffor all activities of daily living." A "Service/Health Care Objectives and Plans,’~ (undated), for the resident, showed that Resident 2 was diagnosed with quadrip!egia. During interview of a unit supervisor (US A) on 3/29/13 at 2 p.m., the unit supervisor stated that the reason for not reporting immediately was that US A was gathering more information about the nurse responsible for the care of Residents, 1 and 2 at the time of the incident, as that particular nurse was still in a probationary period.. US A stated, "1 know now that I should have reported right away and not waited until the 28th." Failing to report the incident of suspected neglect of the two residents, Resident 1 and Resident 2, to the Department immediately or within 24 hours had a direct or immediate. relationship to patient health, safety, or security. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000793 . State of California - Health and Human Services Agency Department of Public Health SECTION !~t424 NOTICE Page 1 of 5 CITATION NUMBER: 15-1594-0009750-F Date: 03/06/2014 Time: Type of Visit ¯ Complaint Investig. Incident/Complaint No.(s),: CA00318376 YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: Telephone:. Facility Type: Facility ID: SECTIONS VIOLATED State of CA Dept of Developmental Services 1600 9TH STREET, RM 340 150000089 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER D/P SNF Eldridge, CA 95431 15000 Arnold Dr ~7D7) 938-6000 Skilled Nursing Facility - ~ : - Capacity: 427 150000229 PENALTY ASSESSMENT $10,000.00 CLASS AND NATURE OF VIOLATIONS CLASS A F 309 SACRAMENTO, CA 95814 DEADLINE FOR COMPLIANCE 3/20/14.., 12:00 a.m. CITATION-- PATIENT CARE F 309 - 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. The facilit_y failed to provide necessary care and services to attain or maintain the highest practicable physical and psychosocial well-being in accordance with a comprehensive assessment and plan of care when the facility: 1. Failed to recognize and assess factors which placed a resident (Resident 1) at risk for altered wound healing by.not ensuring that ongoing assessments of a wound, undergoing current treatment, were conducted; 2. Failed to ensure consistent implementation of interventions in a health care plan when observations of the wound were not documented on a daily basis, as specified; 3. Failed to consistentlymonitor and evaluate the resident’s response to the initial treatment. Documentation referencing the wound/dressing was initiated on 7/2/12 through 7/7/12. The record lacked evidence of any further wound assessments for the next 7 days. On 7/14/12, Resident l’s right 4th finger, distal phalange, showed severe erosion down to the bone. Name of Evaluator: CAROL DEVITA HFEN W~thout admitting guilt, I hereby acknowledge receipt ofth.is.SECTION 1424 NOTICE Signature : Name : Evaluator Signature ¯ Title : NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000794 " State of California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1594-0009750-F Date: 03/06/2014 Time: CLASS AND NATURE OF VIOLATIONS These failures resulted in Resident l’s wound not being evaluated for seven days, .a hospital admission for treatment, and subsequent surgical intervention. Record review on 7/30/12 indicated that Resident 1 had diagnoses that included cerebral palsy (a disorder of movement and muscle tone) and was at risk for skin breakdown and cellulitis (bacterial skin infection). Resident 1 had a behavior plan for self-injurious behaviors (SlB) that included hitting his head against hard surfaces, s_cratching himself, p_iqking and r~l:)b!£g~!s s_kin; and p~!ling_ or biting his lips, causing tissue damage. Resident 1 had a current health care plan for "Abrasions" (P-17), which included the following objective: "Will be free of skin abrasions/lesions as evidenced by the absence of redness, swelling, pain, drainage, and streaking (red lines)." Plans to meet the objectives included ..."daily... Document observations and report them as clin.ically indicated, daily... Observe for signs of infection: swelling, redness, drainage, presence of pain or heat. Report findings to MD/HSS (Physician/Health ServicesSpecialist)" and, "Notify MD/HSS if not responding to tx (treatment)." Physician’s monthly orders, dated 6/16/12, included an order for Bacitracin (antibiotic) ointment to be applied to self-injurious behavior lesions/abrasions prn (as needed) each shift, and Povidone Iodine 10% (percent) ointment (antiseptic) to be administered twice per day to abrasions with appropriate dressings, if needed. On 7/30/12, review of "Interdisciplinary Notes" (IDNs), dated 7/2/12 at 12 noon., indicated that Resident 1 received APAP/Hydrocodone (pain medication) for outward signs of pain/discomfort by proxy, 4/10 (pain scale with 10 being the worst pain), at 9:45 a.m. The notes showed that Resident 1 "displays grimacing, SIB evidence [sic] by hitting self in the head, face, forehead, and ears. [Resident 1] was picking and rubbing hands/fingers..." The HSS had been notified. Interdisciplinary Notes, dated 7/2/12 at 12!50 p.m., indicated, "HSS.notified an abrasion on r (right) ring finger approx. (approximately) 1 .cm (centimeter) x 0.5 cm circular abrasion due to witnessed SlB. Povidone-lodine and bacitracin applied and covered with Kerlix [gauze dressing]. Will continue to observe." Daily entries in the Interdisciplinary Notes from 7/2/12 through 7/7/12, that related to the NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAI~TEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000795 State of California - Health and Human Services Agency Department of Public Health SECTION~1424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1594-0009750-F Date: 03/06/2014 Time: CLASS AND NATURE OF VIOLATIONS wound, were as follows: 7/2/12 at 4 p.m. - "(R) [right] ring finger abrasion tx (treatment) applied." 7/3/12 at 6 a.m., !’R finger covered." 7/3/12 at 2 p.m. -"R ring finger abrasion dry, no bleeding, remains open. Povidone-lodine applied and bacitracin dressing changed." 7/3/12 at 10 p.m. - "R ring finger tx (treatment) applied drsg (dressing) intact." 7/4/12 at 5 a.m. "R ring finger dressing intact. No sign of pain. Will continue to monitor." 7/5/12 at 6 a.m. - "R ring finger dressing dry and intact." 7/5/12 at 2:30 p.m. -"R ring finger abrasion still noted, dry, witl~out bleeding noted." 7/5/12 7:20 p.m. - "R ring finger abrasion healing slowly." 7/6/12 at 6 a.m. - "R ring finger no bleeding noted.". 7/6112 at 2:30 p.m.- "R ring finger abrasion healing." 7/6/12 at 9:30 p.m. -"L [sic] ring finger is healing, sm. (small) dry scab in place." 7/7/12 at 6:10 a.m. -"R ring finger covered and kept dry." 7/7/12 at 9:30 p.m.- "R ring finger healing slowly." After the above entry on 7/7/12,.the record lacked evidence of any further documentation of a wound assessment, description of the wound, or response to treatment until seven days later when the wound was observed by an HSS on 7114/12 at 7:30 a.m., at which time a TC (Temporary Condition) was initiated. The TC indicated, "During my nursing assessment for pressure wound on the coccyx, I became more involved addressing other skin issues. As I was evaluating and treating those, a NOC (night) shift staff asked me to check dressing on the client’s right 4th finger. When 1 opened the gauze dressing, I noticed severe erosion on the distal joint of NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000796 -- 7~tat~olC~llf~rnia _ Health and Human Services Agency ¯ Page 4 of 5 SECTION~1424 NOTICE CITATION NUMBER: SECTIONS Department of Public Health 15-1594-0009750-F Date: 03/06/2014 Time: CLASS AND NATURE OF VIOLATIONS VI O LATED the finger and asked MOD [Dr. A] to exam [sic] the client. IDN recorded on the 7/2/12 about 1.5x 0.5 cm (centimeter) skin abrasion on the right 4th finger. Staff observed SIB at that morning and treated the abrasion with iodine and bacitracin ointment. Dressing was changed one more time on the next day but no follow ups since then." Objective findings included: "Severe erosion on the distal joint of the Right 4th finger. The distal finger joint is almost gone and only flappy fingernail bed remains." The client was seen by the MOD. Physician’s Progress Notes, dated 7/14/12 at 7:30 a.m., indicated the following: "Just brought to my attention this a.m. Tip of 4th finger distal phalange shows severe erosion down to the bone without any purulence around [unable to read] of fingertip. This will require surgical consultation. Imp: (Impression) - [unable to read] R. 4th finger probable osteomyelitis. Plan: To ER [name of outside hospital] for surgical consultation." Review of the Emergency Room Report,.dated 7/14/12, indicated, "Impression... Mangled right ring finger, self-injurious behavior." The x-ray report of the right ring finger, dated 7/14/12, indicated, "Soft tissue avulsion [a forcible tearing away or separation of a bodily structure or part] with probable underlying bony injury, distal phalanx (finger bone) of the fourth digit." The Admitting History and Physical decumentation, dated 7/15/12, indicated: "1 saw him the morning of 7114/12 where he was noted to have a large avulsion fracture with bone exposed and high risk of infection... Cultures were taken. He was started on Vancomycin (an antibiotic) as a precaution and also as a preoperative antibiotic... Assessment: Somewhat of a degloving (section of skin is torn off underlying tissue, severing the blood supply) type injury to the tip of the finger with bone exposed." The Operative Report, datec} 7/15/12, indicated the procedure performed was Osteotomy (bone .cutting) of distal phalanx, removal of bone, debridement and V-Y plasty (surgical method for lengthening tissue), skin coverage to the right ring finger. Physician’s Progress Notes,. dated 7/15/12 at 4:30 p.m., indicated that Resident 1 NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000797 State of California - Health and Human Services Agency Department of Public Health SECTIQN4424 NOTICE Page 5 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1594-0009750-F Date: 03/06/2014 Time: CLASS AND NATURE OF VIOLATIONS returned to the facility’s GAC (general acute care) on intra-venous Vancomycin and Cipro (antibiotics). Resident 1 returned to his unit on 7/20/12. The facility IR (Incident Report)Level 111, signed on 7/20/12, indicated on 7/2/12 there was no IDN from an HSS noting that they had examined the resident’s finger. Further documentation indicated that Resident 1 was seen eight times by an HSS.but none of their notes indicated that they had examined/checked the status of the client’s right 4th finger until 7/14/12 when the HSS reported the severe erosion to his finger. On 7/30/12 at 11:45 a.m., when asked about the lack of continuity with assessment, the Unit Supervisor, Staff B, stated., "It didn’t get followed." During an interview:with Staff C on 11/27/12 at 12:15 p.m., Staff C stated that she had noticed the abrasion on Resident l’s finger and that he had a standing order for treatment. She stated that four staff were present, including an HSS, as the client..was highly agitated while applying the dressing .to his finger. During an interview with administrative staff, Staff D, on 11/27/12 at 1:30 p.m., Staff D was asked about the protocol for utilizing the HSS log and opening a Temporary Condition. Staff D stated that, "Every little abrasion isn’t logged, not something tiny. It’s not expected to be on the log.;’ Staff D further stated that a Temporary Condition would not have had to been opened because the Resident had a standing order and a health care plan. Therefore, the facility’s failure to provide an ongoing assessment for a wound with a "high risk of infection," along with lack of implementation of the health care plan resulted in a delay in .treatment necessitating hospitalization and surgical intervention. 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. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000798 State ,~f California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page ! Of 5 CITATION NUMBER" Date: 02/11/2014 Time: 15-1594-0009318-S Type of Visit" Incident/Complaint No.(s) ’ CA00296690 YOU ARE HEREBY FOUND IN VIOLATION OF APPLICABLE CALIFORNIA STATUTES AND REGULATIONS OR APPLICABLE FEDERAL STATUTES AND REGULATIONS Licensee Name: Address: License Number: Facility Name: Address: T~lePh-on~i Faciiity Type: Facility ID: SECTIONS VIOLATED 72311(a)(1)(A) 72523(a) State of CA.Dept of Developmental Services 1600 9THSTREET, RM 340 150000089 SACRAMENTO, CA 95814 Type of Ownership: State Agency SONOMA DEVELOPMENTAL CENTER DIP SNF Eldridge, CA 95431 15000 Arnold Dr ~707) 938~6000 Skilled Nursing Facility Capacity: 427 150000229 CLASS AND NATURE OF VIOLATIONS. CLASS B PENALTY ASSESSMENT DEADLINE FOR $800.00 COMPLIANCE 2/25/14.12:00 aom. CITATION-- PATIENT CARE T22 DIV5 CH3 ART 3 - 72311 (a) (1) (A) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following:. (A) Identification of Care needs based upon an initial written and continuing, assessment of the patient’s needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. . T22 DIV5 CH3 ART5 - 72523(.a) Patient Care Policies and Procedures Written. patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to ensure facility protocols and Administrative Directives were implemented. A resident with a prior elopement history independently exited the unit in his wheelchair without staff supervision. The resident was found face down outside on the grass while still strapped into his wheelchair and had sustained a nose bleed and a scratch to his forehead. Staff moved the resident indoors before he was assessed as safe to be moved by appropriate medical staff. The facility also failed to ensure that the Name of Evaluator: Without admitting guilt, I hereby acknowledge receipt of this SECTION 1424 NOTICE CAROL DEVITA HFEN Signature : Name : Title : Evaluator Signature ¯ ¯ NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000799 Sta!e ef California - Health and Human Services Agency Department of Public Health SECTION 1424 NOTICE Page 2 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1594-0009318-S Date: 02/11/2014 Time: CLASS AND NATURE OF VIOLATIONS assessment of the resident’s supervision level was consistently d6cumented in the record. Review of the facility’s Unusual Occurrence Report, signed on 1/16/12, indicated that on 1/16/12 at 9:15 a.m., kitchen staff reported to unit staffthat they observed a resident’s wheelchair had tipped over with the seatbelt and lap tray intact. The resident was positioned face forward. As indicated in the Offi_ce of Protective Service’s re_port the lap tray was still attached. _ Furtherodocumentation in the Unusual Occurrence Report indicated that it appeared upon finishingbreakfast, Resident 1 propelled himself toward the front door,.out of the unit, and out of the. front door of the building where his wheelchair’s front wheels rolled off of the sidewalk and onto the grass propelling him forward. Staff assisted the resident and the wheelchair was put in the upright position..Resident 1 was assisted back to the unit where first aid was administered for a bloody nose and a scratch on his forehead. The Unusual Occurrence Report indicated that this was the second incident where the resident had eloped frog the residence without staff assistance during the past year. The .prior incident occurred on 1/3/11.. Review of the IPP (Individual Program Plan), dated 9/28/11 ,. indicated that Resident 1 ’ was non-ambulatory and used a customized wheelchair for mobility, which he self-propelled with his feet. Physician’s Progress Notes, dated 1/16/12 at 9:30 a.m., indicated the resident was possibly out of the unit for 15-20 minutes. Subsequent to the 1/3/11 elopement, a review of the IPP, dated 2/7/11, indicated the following: Team determined for Resident l’s safety and protection, his supervision level should be modified to "cor~stant" (staff must be able to see and/or hear each client and be in close enough proximity to intervene as necessary) when he isin the living room in his wheelchair and "general" (visual and/or verbal contact no less than every 15 minutes) while he is in the living room in the lounge chair. He will continue to receive general supervision while in other areas of the residence, including the backyard. The Administrative Directive for "Supervision of C!ients," (#,460, effective 1/12), included the following definitions: NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000800 State of California - Health and Human Services Agency Department of Publiq~ Health SECTION 1424 NOTICE Page 3 of 5 CITATION NUMBER: SECTIONS VIOLATED 15-1594-0009318-S Date: 02/11/2014 Time: CLASS AND NATURE OF VIOLATIONS General Supervision Staff must make visual and / or verbal contact with each assigned client no less than every 15 minutes. Constant supervision- Staff must be able to see and/or hear each client and be in close enough proximity to intervene as necessary. Close Supervision- Staff must be in the immediate area andmustmake visual contact at least every 5 minutes. Despite having one staff present in the living room at the time of the current incident, as indicated in the Unusual Occurrence Report, Resident 1 was able to exit the unit unsupervised through the front door. A subsequent IPP, dated 9/28/11, indicated Resident l’s level of supervision was "general" supervision in familiar indoor environments and "close" supervision in unfamiliar environments and on outings, as he did not have hazard awareness: There. was no reference made to the enhanced supervision that was put in place during the above mentioned 2/7/11 IPP that indicated "constant" supervision when Resident 1 was in his wheelchair in the living room nor was there any documentation that the resident was reassessed to reduce / downgrade his supervision as indicated in the 9/28/11 IPP. Additionally, the "wind0ws/cue card"document (a document given to staff listing a variety of aspects of care i.e., diet, behaviors, risks, supervision levels, etc.) indicated that Resident 1 was on "close" observation. Documentation of supervision levels in the 2/7111 IPP, 9/28/11 IPP, and the "windows" document was inconsistent. Clarification regarding Resident l’s level of supervision, at the time of the incident, was requested by the surveyor. The Unit Supervisor, Staff A, stated that Resident~ 1 .was on "close"supervision and the entry in the 2/7/11 IPP for "constant".superv sion was a "typo." On 2/7/12 at 2 p.m., during an interview with the MDS/IPC (Minimum Data Set/ Individual Program Coordinator), the Coordinator stated that the supervision levels were probably not updated with the 9/28/11 IPP. The MDS/IPC acknowledged that ther# were inconsistencies in the documentation Of Resident l’s supervision levels. NOTE: IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFTEY CODE, FAILURE TO CORRECT VIOLATIONS IS GROUNDS FOR SUSPENSION OR REVOCATION OF YOUR LICENSE DPH POD 000801 State ,of California - Health and Human Services Agency Depa~ment of Public Health SECTION 1424 NOTICE Page 4 of 5 CITATION NUI~IBER: SECTIONS VIOLATED 15-1594-000£318-S Date: 02/11/2014 Time: CLASS AND NATURE OF VIOLATIONS During an interview with Staff B on 2/10/12 at 11"15 a.m., Staff B state.d that she was the Group Leader in charge of 4 to 5 residents, including Resident 1. Staff B stated that she lad finished feeding another resident in Dining Room 1, brought the food cart to the kitchen, and then helped to feed a resident in Dining Room 2, as they were behind with feedings. Staff B further stated that another staff, Staff C, Was feeding. Resident 1 in Dining Room 1. , Staff B state_d that she was unaware that Resident 1 had finishe_d eatin_g in Din!ng Room 1 as there was no communication from Staff C that he had completed his meal. During an interview with Staff C on 2/28/12 at 1:45 p.m., Staff C stated that she could mot recall if she fed Resident 1 but did remember seeing him in the hallway at 9 a.m. Staff C siated, "We had to watch him." The policy for "Falls Prevention, Assessment and Care Cervical Spine Precautions" (P 901, reviewed 9/11) included the following: "Unless the client is. in immediate danger, do not move the client and summon medical/nursing assistance immediately by calling MD/FNP. (physician / family nurse 3ractitioner) and HSS/ACNS (Health Services Specialist/Assistant Coordinator of Nursing Services). In an emergencyl dial "3" for Medical Emergency team response." During an interview with StaffA on 2/7/12 at 1:30 p.m., staff acknowledged that the resident was moved before he was assessed. During a telephone interview with Staff D on 2/7/12 at 1:45 p.m. Staff D stated that four staff went to assist the resident. Resident 1 was face forward with the side of his face leaning to the right side. Staff D stated, we were slowly getting him upright, "1 was trying to get him air." He stated he was awake and alert and was brought back to the unit where he was assessed. The facility failed to ensure assessment of supervision levels wasconsistently documented to ensure staff implemented supervision as intended for a resident with a