San Fernando Post-Acute Hospital
Currently, the San Fernando Post-Acute Hospital has been designated a Special Focus Facility (SFF), meaning it has a history of serious healthcare quality problems. The CMS gives the facility the opportunity to correct these issues and establish a better foundation for providing the basic minimums of care for every resident. Before the facility’s designation can be removed, the Home must pass multiple surveys and investigations over the course of months or years. These issues involve problems that could cause minor to severe harm, injury or death of one or more residents.San Fernando Post-Acute Hospital
The San Fernando Post-Acute Hospital is a 204-certified bed Medicare/Medicaid-participating nursing facility providing care and services to the residents of Sylmar and Los Angeles County, California. The facility is located at:
12260 Foothill Blvd.
Sylmar, CA 91342
This for-profit round-the-clock nursing facility provides rehabilitation services, nursing care, long-term care, extensive care, respite and hospital care, and social services. The facility is Medicaid/Medicare-certified.Current Nursing Home Patient Safety Concerns
The information provided on the government Medicare.gov website reveals that the San Fernando Post-Acute Hospital currently maintains an overall one out of five stars compared to other nursing homes, assisted living centers and rehabilitation facilities nationwide. This ‘much below average’ ranking has triggered an SFF designation, requiring immediate corrections to ensure the safety, health, and well-being of every patient residing in the facility. Current safety concerns involving the nursing home include:
Failure to Develop Policies to Prevent Mistreatment, Neglect or Abuse of Residents eight
In a summary statement of deficiencies dated March a 2017, the state investigator noted the facility’s failure “to implement written policies and procedures to ensure residents were free from physical, physical, and mental abuse. The incident involved three residents considered “at risk for verbal, physical and mental abuse.”
The state investigator noted that the deficiencies involved a failure to “properly investigate [a resident’s] family’s complaints and concerns regarding staff members [who were] not attending to her needs, and conduct a thorough investigation of all allegations of abuse.” Additionally, there was a failure to “report immediately to the Administrator …and to the Department (Licensing and Certification Program) as soon as possible, but not to exceed 24 hours after the discovery of the incident, or within 24 hours of the knowledge of all alleged violations involving abuse and neglect.”
Surveyors also noted that the facility failed “promptly investigate alleged verbal abuse by Certified Nursing Assistant toward the resident such as speaking in a condescending manner, using foul language and making demeaning statements about the resident… and ensure residents were free from following language from staff members.” Investigators also said that the facility failed to “properly investigate alleged physical abuse by [a certain Certified Nursing Assistant when that assistant] rough-handled the resident by pressing hard on the lower part of her arm where” the resident underwent a surgical procedure to create a “passageway between an artery and vein.”
The San Fernando Post-Acute Hospital also failed to “properly investigate the allegation of placing the resident’s cellular (mobile) phone out of reach so she could not call her daughter when she needed assistance.” The resident calls her daughter to notify staff members when she “needs help and has not been attended to.” Investigators also claim that the facility failed to “prevent further potential abused while an investigation of abuse is in progress [and] ensure that residents were free from fear of reprisal and retaliation from staff members [and] ensure residents were free from alleged rough handling.”
The investigator stated that the facility “failed to protect residents from staff who allegedly rough handled the residents and who swore at the residents.” And that the Director of Nursing and Director of Staff Development “did not immediately report the allegations to the Abuse Coordinator and initiated an investigation of allegations of foul language and of rough handling as indicated in the facility’s abuse prevention prohibition policy. The facility also failed to protect the resident from psychological harm from staff members who demean the resident’s.”
Failure to Ensure Services Provided by the Facility Meet Professional Standards of Quality
In a summary statement of deficiencies dated February 15, 2017, the state investigator noted the facility’s failure to “ensure services provided meet professional standards of quality.” The deficiencies involved the observation of the Certified Nursing Assistant “eating and drinking in [a resident’s room] while redirecting providing frequent visual checks is considered, per the care plan. This deficient practice caused an increased risk and meeting [the resident’s] needs and had the potential to spread infections among residents and employees.”
A review of hospital records revealed that the Certified Nursing Assistant had received two 10-minute breaks and a lunch break, but was found eating in the resident’s room. The surveyor noted that the actions of the nursing staff failed to follow the facility’s Undated Meal Breaks policy and Procedure that reads in part:
“All employees were required to clock in at the start of the shift, clock out when leaving duty for their schedule meal breaks, clock back in when they return to duty from their meal break, clock out at the end of the shift.”The facility’s Control of Infection Policy reads:
“Ongoing education to in-services regarding handwashing and prevention of controlled infections should be given regularly to all personnel. The policy indicates good examples and ongoing teaching of all personnel, residents, and visitors, good practices, and procedures would be observed and thus promote an environment which can reduce the risk of infection.”
Failure to Tell the Resident Completely about Their Health Status, Treatment, and Care
In a summary statement of deficiencies dated March a 2017, the state investigator noted the facility’s failure “to ensure that licensed nursing staff are familiar with written informed consent facility policies and procedures and were able to explain the process of verifying antipsychotic [medications].” These antipsychotics are used “to treat mental disorders involving hallucinations, delusions, a and disorder thought paranoia.”
The investigator noted that three license vocational nurses “claimed that they and the registered nurses regularly obtain consent from the residents or the residents’ responsible party. The outcome was the failure of the facility staff to implement the proper informed consent procedures [which] placed the health and safety of the residents at risk for a potential decrease in their physical well-being.
The State surveyor interviewed a licensed vocational nurse on March 2, 2017, regarding “her knowledge of the written informed consent facility policy and procedure and her ability to explain the process of verifying psychotherapeutic informed consent, specifically antipsychotic medications. The nurse stated that the residents first get a psych assessment evaluation, then the resident’s physician or psychiatrist writes the antipsychotic order.” The nurse then stated that “we have to get consent from the self-responsible resident or responsible party.”
The investigator noted that the facility failed to follow their own March 1999 (revised) Informed Consent policy and procedure that reads in part:
“Procedures: Indicated. When the resident’s condition results in the use of a psychotherapeutic drug, physical restraint, or prolonged device: the licensed nurse shall request the physician to obtain informed consent from the resident if the resident has decision-making [capacities]. If the resident does not have the decision-making capacity, provide the name of the surrogate decision maker and the telephone number to the physician, and request that informed consent be obtained from the surrogate decision maker.”
Failure to Provide Necessary Care and Services to Ensure That the Resident Maintains Their Highest Level of Well-Being
In a summary statement of deficiencies dated March 8, 2017, the state investigator noted that the facility had failed to “continuously assess, monitor and re-evaluate the effectiveness of [a resident’s] pain management to prevent suffering from pain. These deficient practices have the potential to result in unrelieved pain and negatively affect the resident’s quality of life.” The resident’s Plan of Care shows extensive information on dealing with the resident’s pain that is relieved by effective medication.
The State surveyor observed the resident in the presence of a Licensed Vocational Nurse on the afternoon of February 27, 2017. At that time, the resident “was lying in bed, grimacing, [but was] able to nod or shake his head in response yes or no questions.” During the observation, the resident was asked “if he was in pain. The resident touched the right side of his face when asked for the location of the pain [and] nod if when asked if in pain, [indicated it] was related to his teeth.”
The following morning on February 28, 2017, at 7:25 PM, the resident was observed in the presence of the Certified Nursing Assistant while the resident “was awake, grimacing, moaning, and touching the right side of the face. The resident nodded and shook his head in response to yes or no questions” and was “asked if he was in a lot of pain.”
The Certified Nursing Assistant who provided the resident care said that the resident “had been complaining of a toothache every time she was assigned to the resident” which has been “going on for about a month.” The CNA stated that the “resident would withdraw when she attempted to clean his teeth [, and] sometimes refused daily oral hygiene because of pain.”
Failure to Provide Residents Proper Treatment to Prevent the Development of New Bedsores or Heel Existing Pressure Ulcers
In a summary statement of deficiencies dated March 8, 2017, the state investigator noted that the facility failed to “provide appropriate care for residents with pressure ulcers (lesions caused by unrelieved pressure that results in damage to the underlying tissues) and to implement the facility’s policy” involving two residents at the facility.
It was noted that the facility had failed to “avoid the use of multilayered bedsheets over a low air loss mattress” that alleviates pressure on the skin “that compromised the full effect of the pressure relieving device.” The surveyor also noted that the staff failed to “provide necessary treatment and services to promote healing as ordered by the physician. These deficient practices had the potential for delaying wound healing, the potential to result in a recurrence of a pressure ulcer and the potential for the development of new pressure ulcers.”
The investigator reviewed the facility’s November 2016 Low Air Loss Therapy policy and procedure that “indicated bed linens between resident and a low air loss mattress should be limited to one or two sheets/pads.”
Failure to Ensure That Every Resident Entering the Nursing Facility without a Catheter Is Not Given Catheter
In a summary statement of deficiencies dated March 8, 2017, the state investigator noted the facility’s failure “to provide care and services to prevent urinary tract infections” for three residents with a “history of UTI.” The staff failed “to ensure [one resident] who had a suprapubic catheter used to drain urine from the bladder… [and failed to monitor] for sediments, cloudiness, [and] other signs and symptoms of infection as indicated in [the resident policy’s] Plan of Care, in order to timely detect developments of a UTI.”
Are you or your loved one a victim of abuse or neglect while residing in a nursing home, assisted living center or rehabilitation facility? If so, hiring a California nursing home negligence attorney who specializes in neglect, abuse and mistreatment can help. A competent injured victim attorney can ensure that all parties responsible for the resident’s harm will be held financially accountable for the family’s damages.
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