Health inspection·October 12, 2023

F689 Free of Accident Hazards/Supervision/Devices 483.25 The facility must ensure that - (d)(1) The resident environment remains as free of accident hazards as is possible; and (d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Title 22, Section 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. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 4/3/23 at 3:15 p.m., the California Department of Public Health made an unannounced visit to the facility to investigate one complaint regarding a patient (Resident 1) who fell at the facility and expired from an intracranial (brain) head bleed from a fall. Resident 1 was admitted 7/28/22 to the facility for rehabilitative care after sustaining a fall at home. Resident 1 was readmitted to the facility on 8/2/22, after sustaining one fall at home and one fall at the facility. Both falls required Resident 1 to receive corrective surgeries. Resident 1 was dependent on staff for care and had a known history of getting up without staff assistance. The facility failed to provide appropriate interventions and supervision regarding Resident 1's lack of following directions, which resulted in Resident 1 sustaining a second fall in the facility. The second fall led to the death of Resident 1 due to an irreparable brain bleed. Based on interview and record review, the facility failed to establish a safe environment for one of four sampled residents (Resident 1) at risk for falls when Resident 1 experienced two consecutive falls and hospitalizations; the first on 7/28/22, and second on 8/26/22. The facility failed to: 1. Ensure Resident 1's care plan was updated after readmission to the facility on 8/2/22; 2. Prevent Resident 1 from falling, by placing new interventions; and, 3. Ensure the facility followed up regarding Resident 1's inability to follow directions. As a result, Resident 1 was found on 8/26/22 on the bedroom floor and sustained two broken ribs, an eyebrow laceration (cut), bleeding in the functional part of the brain, and subsequent death on 9/8/22 due to the irreparable brain bleeding. Findings: A review of Resident 1's, "Minimum Data Set [MDS - a standardized assessment tool that measures health status in nursing home residents]," dated 7/22/22, indicated Resident 1 had a "Brief Interview for Mental Status - BIMS," score of 3 (The BIMS test determines how well a resident is functioning cognitively (thinking, or conscious mental processes) and ranges from 0 - 15. A score of 3 indicates a severe cognitive impairment). The MDS indicated the following: 1. Resident 1 required extensive assistance of two persons for bed mobility, transferring, and toilet use; 2. Resident 1 was dependent on staff for bathing; 3. Resident 1 was not steady while walking or using the toilet and needed staff assistance to stabilize; and, 4. Resident 1 had impairment to one side of his lower extremity and needed the assistance of a wheelchair and a walker. A review of a facility document titled, "Care Plan History," dated 7/15/22, indicated "potential for falls and injury due to: impaired balance, left hip fx [fracture]..." The approach for this problem related to the care plan included: "call light within reach and answered promptly [and] ensure resident understands how to use call light." A review of a facility document titled, "Progress Note," dated 7/17/22, indicated Resident 1 needed a psychiatric evaluation and could not stay in one place. The note further indicated Resident 1 verbalized he wanted to go home. A review of a facility document titled, "Progress Note," dated 7/28/22, indicated Resident 1 was found on the floor of the facility around 7 a.m. laying on his left side reporting he was in pain. The note indicated Resident 1 was transported to the General Acute Care Hospital (GACH) by medical transport. A review of a facility document titled, "Progress Note," dated 7/28/22, indicated Resident 1 was "... observed on the floor in the bathroom after unassisted transfer using walker... PT [patient; sic] unsure of what happened but thinks that he slipped." A review of Resident 1's "History and Physical [H&P]," from the GACH, dated 7/28/22, indicated Resident 1 had a fall at the Skilled Nursing Facility (SNF) the morning of 7/28/22 and noticed left hip pain. The H&P further stated Resident 1's "x-ray showed periprosthetic fracture of the femur involving the distal stem of the left hip prosthesis area [broken bone that occurs around the bottom part of the implant of a total hip replacement]." A review of Resident 1's "Discharge Summary," from the GACH, dated 8/2/22, indicated Resident 1 had an operation to include: arthroplasty (a surgical procedure to restore the function of a joint) hip revision, ORIF (Open reduction and internal fixation; a type of surgery used to stabilize and heal a broken bone) of the left periprosthetic fracture revision hemiarthroplasty (surgical repair of a broken bone that occurs around the implants of a total hip replacement). Resident 1 was discharged back to the facility. A review of Resident 1's "Care Conference Information," dated 7/28/22 and last updated 8/16/22, indicated a meeting was held the same day of the resident's fall on 7/28/22. The note indicated a Certified Nursing Assistant (CNA) found Resident 1 on the floor in the bathroom. The note indicated Resident 1 was sent to the ER (Emergency Room) for further evaluation. The note further indicated the interdisciplinary team (IDT) recommended "education about using the call light when getting up." A review of Resident 1's "Minimum Data Set," dated 8/9/22, indicated Resident 1, had a "Brief Interview for Mental Status - BIMS," score of 5 (severe cognitive impairment). The MDS indicated the following: 1. Resident 1 required extensive assistance of one person for bed mobility, transferring, and toilet use; 2. Resident 1 was dependent on staff for bathing; 3. Resident 1 only performed surface to surface transfer; and, 4. Resident 1 had impairment to one side of his lower extremity and needed the assistance of a wheelchair and a walker. A review of Resident 1's "Progress Notes," dated 8/26/22, indicated Resident 1 was, "seen and evaluated on the floor halfway [from the] bedroom lying down per staff pt [patient; sic] was walking and slip..." Resident 1 was found to have a "...head injury bleeding on the left forehead." The progress note indicated Resident 1 was transported to the GACH. A review of Resident 1's "ED [Emergency Department] Physician Notes," from the GACH, dated 8/26/22, note indicated EMS (Emergency Medical Staff) stated Resident 1 fell off his bed to the ground which was about three feet off the ground. The progress note further indicated Resident 1 had a 3 cm (centimeter, a unit of measure) laceration (open cut) just inferior (below) to left eyebrow and 3 cm ulceration to left cheek. A review of Resident 1's "XR [X-ray, imaging that shows internal structures such as tissues, bones, and organs] Chest 1 View Portable," from the GACH, dated 8/26/22, indicated Resident 1 sustained two rib fractures of the left lateral eighth and ninth rib. The XR report also indicated Resident 1 did not have the rib fractures on a previous XR on 7/20/22. A review of Resident 1's "CT [computerized tomography - provides more-detailed images compared to x-rays] Head wo [without] Con [contrast- dye injected into the vein to see body parts better]," from the GACH, dated 8/26/22, the CT indicated Resident 1 had an acute intraparenchymal hemorrhage (ruptured blood vessel in the brain that causes bleeding into the functional tissue of the brain, disrupts normal blood flow and leads to loss of oxygen to the brain) in the right temporal lobe (right side of the brain that contains areas that manage or contribute to several abilities such as: language, memory and senses) measuring 5.6 by 3.1 by 3 cm. A review of Resident 1's "Assessment/Plan," from the GACH, dated 8/27/22, indicated the following recommendations from the GACH Medical Doctor (MD): hospice placement if Resident 1 survived GACH hospitalization, his condition was critical. The note indicated, Resident 1's overall prognosis (likely outcome) was poor. During an interview on 4/4/23 at 1:25 p.m., Director of Nursing (DON) stated an IDT meeting was held on 7/28/22 to address Resident 1's first fall at the facility. The DON stated after Resident 1's return from the GACH on 8/2/22, the intervention in place to prevent Resident 1 from falling was for Resident 1 to use the call light, which was the same intervention Resident 1 had upon admission to the facility on 7/15/22. The DON denied any other interventions in place for Resident 1. During a telephone interview on 4/13/23 at 3:58 p.m., Licensed Nurse (LN) 4 stated, standard interventions to prevent residents from falling include: beds in the lowest position, call light in reach and a yellow arm band so other staff are aware resident was a fall risk. LN 4 further stated interventions for confused residents can include finding out why the resident was confused or assigning a staff member as a sitter. LN 4 stated fall mats, and PT (physical therapy) consults are beneficial in preventing falls with residents. LN 4 stated the process for a psychiatric consult was to notify the MD of the request for the consult. LN 4 confirmed there was no follow up for the request of a psychiatric consult. LN stated "yes," the psychiatric consult might have prevented Resident 1's falls at the facility. A review of the facility's policy and procedure (P&P) titled, "Fall Prevention Program," revised 5/25/21, indicated, "Fall risk care plans will be updated by nursing to reflect the potential problem... individualized interventions." A review of Resident 1's "Certificate of Death," dated 9/15/22, indicated, "Immediate Cause (final disease or condition resulting in death) ... (A) Intracranial Hemorrhage," as Resident 1's sole cause of death, with "none" listed under "other significant conditions contributing to death..." Based on interview and record review, the facility failed to establish a safe environment for one of four sampled residents (Resident 1) at risk for falls when Resident 1 experienced two consecutive falls and hospitalizations; the first on 7/28/22, and second on 8/26/22. The facility failed to: 1. Ensure Resident 1's care plan was updated after readmission to the facility; 2. Prevent Resident 1 from falling, by placing new interventions; and, 3. Ensure the facility followed up regarding Resident 1,'s inability to follow directions. As a result, Resident 1 was found on the bedroom floor on 8/26/22 and sustained two broken ribs, an eyebrow laceration, bleeding in the functional part of the brain, and subsequent death on 9/8/22 due to the irreparable brain bleeding. These violations presented imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result, and was a substantial factor in the death of Patient 1.