Other·January 23, 2024

The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported Incident (FRI) #: CA00861613 and CA00862439 Event ID: E9OT11 Representing the Department, HFEN # 44708 State Citation written: Class A 42 C.F.R. 483.21, subdivision (b) - Comprehensive Care Plans. (b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25, or 483.40; and (ii) Any services that would otherwise be required under 483.24, 483.25, or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv) In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. 42 C.F.R. 483.25(d)(2) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR 72311(a)(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: ... (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 9/27/23 at 9:40 a.m., an unannounced visit was conducted at the facility to investigate a resident fall with an injury. Resident 1 fell from the bed and sustained a right ankle fracture (broken bone). Resident 1 was hospitalized and underwent surgery and experienced pain and discomfort, immobility, and diminished ability and opportunity to participate in activities of daily living and out-of-bed socialization with others. The facility failed to implement interventions, supervision, and assistance to prevent falls and injury when on 9/19/23, Resident 1 was repositioned in bed by one staff member instead of two staff members based on Resident 1's needs and care plan. Resident 1 was a 77-year-old female who was admitted to the facility on 9/20/18. Resident 1's "Admission Record (AR)" dated 10/17/23, indicated that on 9/19/23 Resident 1 sustained a fracture of the upper and lower end of right fibula (the outer and usually smaller of the two bones between the knee and the ankle ) and fracture of lower end right tibia (the inner and typically larger of the two bones between the knee and the ankle). The AR indicated Resident 1's diagnosis included lack of coordination, History of falling, chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus (a disease that occurs when blood glucose, also called blood sugar, is too high), and age-related osteoporosis (brittle bones). During a review of Resident 1's "Minimum Data Set" (MDS, a federally mandated process for clinical assessment of all residents of long term care nursing facilities) dated 6/29/23, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment of a resident's cognitive status (the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 8 on a scale of 0-15 (a score of 8 - 12 indicates moderate cognitive impairment, a score of 0 - 7 indicates severe cognitive impairment, and a score of 13 - 15 indicates the resident is cognitively intact). During a concurrent interview and observation on 9/27/23 at 10:14 a.m. with Resident 1 in Resident 1's room, Resident 1 was observed lying in bed with an ace wrap (a strip of stretchable cloth that is wrapped around an injured area to help reduce swelling) to her right leg and foot. Resident 1 stated she fell from the bed on 9/19/23 and broke her right ankle. She stated she had pain from her neck down to her feet. During a review of Resident 1's MDS for "Functional Status for Self-Performance (FSSP)" dated 6/29/23, the FSSP indicated Resident 1 required extensive to total assistance of one person with bed mobility (how resident moves - BIS-to and from lying position, turn side to side); and Resident 1 required one-person physical assistance with transfers (how residents move between surfaces including to or from: bed, chair, wheelchair, standing position. During a review of Resident 1's "Morse Fall Scale (MFS - a simple method of assessing a person's likelihood of falling)," dated 6/23/23, the MFS indicated Resident 1 had a fall risk score of "15" (a score 0 - 24 is low risk; a score 25 - 44 is moderate risk and a score 45 or higher is high risk). During a review of Resident 1's "Care Plan (CP)," dated 4/10/23, the CP indicated, Resident 1 had Activities of Daily Living (ADL) Self-Care Performance Deficit (lack or loss) related to Weakness, Congestive Heart Failure (CHF, a weakened heart condition that causes fluid to buildup in the feet, arms, lungs, and other organs), Asthma (a chronic condition that affects the airways in the lungs), Diabetes Mellitus, and was at risk for complications of Immobility (unable to move). The CP interventions indicated "BED MOBILITY: [Resident 1] requires extensive assistance by 2 staff to turn and reposition in bed as necessary ..." During a review of Resident 1's "Radiology (a branch of medicine that uses imaging technology to diagnose and treat disease) Report (RR)" dated 9/19/23, the RR indicated "(X-ray) Ankle 2 Views Right ... Findings: ...Displaced fracture of the distal tibia ... A possible nondisplaced subtle fracture through the adjacent fibula ... Impression: ... A displaced fracture of the distal tibia and possible nondisplaced fracture of the fibula (broken right ankle bones)." During an interview on 9/27/23 at 11:18 a.m. with the Director of Nursing (DON), the DON stated CNA 1 was rolling Resident 1 onto her left side when she fell. The DON stated Resident 1 was on a low air flow mattress (special bed with air to prevent skin from breaking down). The DON stated Resident 1 slid off the bed during the turn and fell to the floor. The DON stated Resident 1 injured her right ankle, hit her head on the Oxygen concentrator (OC, a medical device that takes regular air and purifies it to 90-95% oxygen), and complained of right leg and shoulder pain. The DON stated Resident 1 was transferred to the hospital for further evaluation and was treated with closed reduction of the right ankle (a procedure to set [reduce] a broken bone without cutting the skin open). The DON stated the expectation was for all staff to follow the resident's care plan. The DON stated CNA 1 did not follow Resident 1's care plan which required two staff members to assist when repositioning Resident 1 in bed. During an interview on 9/27/23 at 11:30 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated that on 9/19/23, she assisted Resident 1 with a bed bath. CNA 1 stated, after assisting Resident 1 with the bed bath, she instructed Resident 1 to turn onto her left side to change the bed sheet. CNA 1 stated she tucked in the new bed sheet under Resident 1 and Resident 1 started sliding off the bed and fell onto the floor. CNA 1 stated Resident 1 hit her head on the Oxygen concentrator, scraped her right knee, and injured her right ankle and was transferred to the hospital on 9/19/23. CNA 1 stated Resident 1's plan of care required two staff members to assist during repositioning. CNA 1 stated the fall could have been prevented if there were two staff members to assist Resident 1 during the repositioning. CNA 1 did not comment nor offer an explanation as to why she did not call for a second CNA to help her. During a review of a facility document titled, "POSITION DESCRIPTION: Nursing Assistant, Certified," dated 6/2012, the Position Description indicated, "The purpose of the position is to provide direct daily care to the residents at the skilled nursing level of care according to care plans, standard procedures and established State and Federal regulations ... This position assists in the safety, comfort, and wellbeing of the residents ...This position is entrusted with the following responsibilities ... Assist residents with basic personal care according to procedures ... This includes but is not limited to ... Assist residents with routine ... movement ... positioning." During a review of the "User Manual - Med-Aire 8" Alternating Pressure Mattress Replacement System with Low Air Loss," undated, the User Manual indicated: WARNING: When using a therapy mattress system, always ensure that the patient is repositioned properly within the confines of the bed. The patient's head should be in the center of the top section of the mattress. Do not let any extremities protrude over the side or between the bedrails when the therapy mattress is being used. General Repositioning: Patients should be turned or repositioned based on their individually planned treatment schedule or per facility policy ... Recommended Linen: Air Loss Bed support surfaces are designed to be used with appropriate linens. Multiple layering of linens or under pads beneath the patient should be avoided ..." During a review of the facility's Policy and Procedure (P&P) titled, "Repositioning the resident in bed," dated 5/2013, indicated " ...Check the care plan, assignment sheet, or the communication system to determine resident's specific positioning needs, level of participation, and the number of staff required to complete the procedure ..." During a review of the Policy and Procedure titled, "Falls and Fall Risk, Managing" dated 3/2022, indicated " ...The staff ... will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of fall for each resident at risk or with a history of falls." The facility failed to implement interventions, supervision, and assistance to prevent falls and injury, for Resident 1, when on 9/19/23 Resident 1 was repositioned in bed by one staff member instead of two staff members based on Resident 1's needs and care plan. Resident 1 fell from the bed and sustained a right ankle fracture. Resident 1 was hospitalized and underwent surgery and experienced pain and discomfort, immobility, and diminished ability and opportunity to participate in activities of daily living and out-of-bed socialization with others. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and constitutes as A Citation.