Other·November 30, 2021

F 600 G §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; 22 CCR § 72315 (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 22 CCR § 72527 (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: (10) To be free from mental and physical abuse. 22 CCR § 72311 (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. The facility failed to follow the aforementioned regulations by failing to keep Resident 1 free from abuse when Resident 1 was not monitored or assessed for a change in condition after an unwitnessed fall. Resident 1 had increased difficulty speaking for five days after the fall, before transfer to the acute care hospital where Resident 1 received treatment for severe sepsis (overwhelming infection), dehydration (insufficient body fluids), and acute kidney injury (sudden onset of kidneys not functioning properly). A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 2/19/21, indicated Resident 1 had a diagnosis of dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities). The MDS indicated Resident 1 had minimal hearing impairment, clear speech, was understood by others, and usually understood what others said. The MDS indicated Resident 1 needed only set-up and supervision for eating but required extensive physical assistance from one person for bed mobility, transfer between surfaces, and walking in the room; Resident 1 used a walker for locomotion and required assistance to maintain balance when walking. The MDS indicated Resident 1 had fallen within the previous two to six months before entering the facility. A review of Resident 1's facility form, "Situation, Background, Assessment, Recommendation (SBAR)," by Licensed Vocational Nurse 1 (LVN 1) dated 4/28/21, at 7:30 a.m., in Situation section, indicated, "Suspected, Change of Condition," and "Describe the situation: CNA [certified nursing assistant name] called nurses attention to an unwitnessed fall in Room [number]. It happened to be [Resident 1]. He was found lying on his right side facing his bed. He was claimed to be coming from the bathroom when he fell, according to his room mate [resident name] of bed B. Resident was asked how he fell. He was aphasic [unable to speak] ..." The SBAR indicated at 7:32 a.m., LVN 1 completed vital signs (temperature, pulse, respiratory rate, blood pressure), and oxygen saturation. (Oxygen saturation is a measurement of oxygen in the blood, expressed as a percentage, with 100 percent the maximum amount of oxygen possible. Normal range is 95-100 %.) The section for "Assessed, Categories of Change," indicated Resident 1 showed pain, with a pain site of "face," at an intensity of "two-mild pain." The SBAR indicated Resident 1 was "unable to answer" the questions of when the pain occurred, and if the resident was satisfied with the pain management plan. The SBAR Recommendations included notification of the physician and Family Member 1 (FM 1). The SBAR indicated FM 1 asked how Resident 1 was doing, and LVN 1 told FM 1 that Resident 1 "was doing fine." During an interview on 6/15/21 at 10:30 a.m., with the Director of Nursing (DON), the DON stated LVN 1 no longer worked at the facility and provided a contact number for LVN 1. Telephone calls made on 6/15/21 at 10:30 a.m. and 6/29/21 at 12 p.m. went unanswered, and the voicemail message box was unable to take messages. During an interview on 6/14/21 at 10:05 a.m., with FM 1, FM 1 stated she had received a call from a facility nurse on 4/28/21 around 7 a.m., the nurse told her Resident 1 had fallen that morning but was doing fine. FM 1 stated she had a video call with Resident 1 in the evening of 4/28/21 and noticed a change in his behavior: normally Resident 1 was excited to talk with her on a video call, but on this occasion Resident 1 had not wanted to talk with her. FM 1 stated she had a video call with Resident 1 on 4/30/21, and FM 1 noticed more changes in Resident 1's behavior: Resident 1 tried to talk but was not able to speak. FM 1 stated she asked facility staff to send Resident 1 to the hospital for further evaluation but was told staff would monitor Resident 1 in the facility. MD stated it was his expectation that after an unwitnessed fall, Resident 1 would have had routine neurological checks (Neurological checks, an assessment of the functional status of the brain and spinal cord, which minimally include assessment of level of awareness and arousal to stimuli, size and reaction of pupils to light, pulse, respiratory rate, blood pressure, temperature, hand grip equality and strength, speech quality, and ability to move extremities.) to identify changes in condition. During an interview and clinical record review, including the 4/28/21 SBAR and nursing progress notes on 7/20/21 at 12:15 p.m., with the Director of Nursing (DON), the DON was unable to provide any documentation that indicated nursing staff had completed neurological checks for Resident 1 between 4/29/21 and 5/3/21. The DON confirmed Resident 1's nursing progress notes showed no entries after 4/26/21 at 3:47 p.m., until 5/3/21 at 1:11 p.m. A review of Resident 1's nursing progress notes dated 5/3/21 at 1:11 p.m., indicated, " ...Found resident in the bed. Appeared SOB [short of breath] ..." The nursing progress note indicated Resident 1 had a heart rate of 188 (normal range of 72-80), and an oxygen saturation of 70%. The nursing progress note also indicated Resident 1 was sent to acute care hospital via 9-1-1 transport at 1 p.m. A review of Resident 1's acute care hospital record, "Internal Medicine History and Physical," date of service 5/3/21 at 3:10 p.m., indicated upon arrival in the emergency department, Resident 1 was in an altered mental state, and had respiratory distress (difficulty breathing) with oxygen saturation in the low 80's, severe sepsis (infection), severe dehydration, and an acute kidney injury. A review of Resident 1's acute care hospital, head CT without IV contrast (CT, computed tomography, a radiology exam of the head, done without injection of a contrasting dye into a blood vessel), exam time 5/3/21 at 4:57 p.m., signed by the physician on 5/3/21 at 5:39 p.m., indicated Resident 1 had a left parietal bone fracture (a broken bone in the upper side of the skull above the ear) with a left extra-axial hematoma (a collection of blood from broken blood vessels in an area between the skull and the membranes covering the brain). A review of Resident 1's acute care hospital record, "Discharge Summary," dated 5/13/21 at 10:33 a.m., indicated Resident 1 was hospitalized from 5/3/21 to 5/13/21, with multiple diagnoses which included severe sepsis, acute respiratory failure, acute kidney injury, parietal skull fracture with two subdural hematomas (a specific type of extra-axial hematoma). During a telephone interview on 10/14/21 at 10:55 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she had frequently been assigned to Resident 1 and was very familiar with his care needs. CNA 1 stated Resident 1 had been able to walk on his own and talk before his fall. CNA 1 stated after Resident 1 returned to the facility from the acute care hospital, he was barely able to walk or talk. A review of the facility policy and procedure titled, "Abuse - Prevention Program," revised 11/2015, indicated, "The Facility does not condone any form of resident abuse, neglect and/or mistreatment, and develops Facility policies, procedures, training programs, and systems in order to promote an environment free from abuse and mistreatment ... 'Neglect' is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." Therefore, the facility failed to keep Resident 1 free from abuse when Resident 1 was not monitored or assessed for a change in condition after an unwitnessed fall. Resident 1 had increased difficulty speaking for five days after the fall, before transfer to the acute care hospital where Resident 1 received treatment for severe sepsis (overwhelming infection), dehydration (insufficient body fluids), and acute kidney injury (sudden onset of kidneys not functioning properly).