Health inspection·February 16, 2024

State Citation (B) was written. 483.25(c) Mobility (2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. (3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. Tit. 22, § 72315 - Nursing Service - Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures, and deformities. Such care shall include: (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. On 6/19/23 at 8:00 a.m., an unannounced visit was conducted at the facility for their annual recertification survey. The department determined the facility failed to provide the necessary care and services to ensure that one of 39 sampled residents (Resident 108's) functional abilities did not diminish when Resident 108 had a decline in his ability to transfer and walk, and services were not provided to determine the cause and/or to maintain his abilities. These failures resulted in Resident 108's decline in range of motion (ROM, the full movement potential of a joint) to his left leg, and a decline in his transfer and ambulation abilities. Resident 108 was admitted to the facility on 9/27/22 with diagnoses which included, displaced intertrochanteric fracture (fracture that occurs 3-4 inches from the hip bone) of left femur (thigh bone) and muscle weakness. During a concurrent observation and interview on 6/20/23, at 9:06 AM, in Resident 108's room, Resident 108 stated, "...I can't straighten my left leg..." Resident 108 attempted to straighten his leg. His left knee remained in a bent position. A review of Resident 108's MDS (minimum data set, a resident assessment and screening tool) Section G, dated March 28, 2023, indicated, "...Transfer...limited assistance, one-person physical assistance ... Walk in room...activity occurred only once or twice ...Functional Limitation in Range of Motion ... lower extremity ...no impairment ..." During an interview on 6/21/23, at 7:43 AM, certified nurse assistant (CNA) 6 stated, Resident 108 "...cannot straighten his left leg, I do not know how long it has been like that, I do range of motion with him..." During an interview on 6/21/23, at 10:11 AM, licensed nurse (LN) 11 stated, Resident 108 "...does not bear weight on his left leg. He cannot stand and pivot. He uses the Apex machine (mechanical lift used to transfer residents) to transfer." LN 11 further stated, "He has not walked since he has been on this wing." During an interview on 6/21/23, at 11:12 AM, the director of rehabilitation (DOR) stated Resident 108 received rehabilitation services in late 2022 for a left femur fracture. He was walking 25 feet when he was discharged to long term care. He was able to straighten his left leg at that time. A review of Resident 108's clinical document titled, "Physical Therapy PT Discharge Summary," dated 11/30/2022, indicated, "... Patient will safely ambulate on level surfaces 25 feet using Two -wheeled walker with CGA [care giver assist] 95% of the time to allow patient to get to bathroom with decreased assistance ...Prognosis to maintain CLOF [current level of function] = excellent with consistent staff support...Mobility...bed mobility = CGA, Transfers = Min (A) [minimum assist], Level surfaces = CGA." A review of Resident 108's clinical document titled, "Documentation Survey Report v2", dated March 2023, indicated, Resident 108 was "Independent/no set up or help" on March 24 and 25 for the care area "walk in room". All other dates in March indicated, "not applicable" or "activity did not occur" or there was no documentation. For the care area of "transferring", Resident 108 required "supervision only" on March 14, 25, and 26. The care area was documented as "did not occur" or "not applicable" on 24 shifts. It was documented as refused on March 19. A review of Resident 108's clinical document titled, "Documentation Survey Report v2", dated April 2023, indicated, Resident 108 was "independent" for the care area "walk in room "on April 1, 9, 10, 17 and 18. The care area "walk in room" was documented as "not applicable" on 47 shifts. For the care area "transferring" Resident 108 required "limited assistance" on April 1, 7, 8, 9, 17, 18, 26 and 29. Resident 108 was "totally dependent" for transfers on April 3, 6, 8, 9, 11, 15, 16, 19, 20, 21, 25 and 26. The care area "transferring" was documented as "not applicable" on 16 shifts and there were several omissions in documentation. A review of Resident 108's clinical document titled, "Documentation Survey Report v2", dated May 2023, indicated, Resident 108 was "totally dependent" on May 1, 6, 8, 9, 12, 13, 14, 15, 19, 21 and 31, for the care area "walk in room". Resident 108 required "limited assistance" on May 20th. All other dates and shifts were documented as "not-applicable" or there was no documentation. For the care area "transferring" Resident 108 required "limited assistance" on May 1, 4, 8, 9, 12, 13, 14, 15, 17, and 19. Resident 108 required "maximum assistance" or was "totally dependent" on May 2, 6, 7, 10, 17, 20, 21, 26, 29, 30 and 31. All other shifts and dates indicated "not applicable" or there was no documentation. During a concurrent interview and record review on 6/21/23, at 1:32 PM, the assistant director of nurses (ADON) reviewed Resident 108's clinical records for March, April, and May 2023. The ADON stated, Resident 108 "is ...showing a steady decline ... There is no documentation about his left leg being unable to straighten. There should have been some intervention. Staff should inform us so we can intervene as soon possible...the documentation is lacking so we do not have an accurate picture of what the resident is doing ..." The director of nurses (DON) stated, "...for any change of condition that is significant, the staff need to tell the unit manager...They should inform the interdisciplinary team (IDT-a team of professional staff from different disciplines) so we can discuss interventions and update the plan of care for that change in condition. Without intervention there is the risk of continued decline, weakness, and contractures [a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff]." During an interview on 6/22/23, at 8:24 AM, the Medical Doctor (MD) stated, "...I rely on physical therapy to make decisions about physical declines and changes in mobility. I depend on the nurses to make me aware of any changes. If [Resident 108] has lost mobility, restorative nursing aide services could help slow the progression..." During a concurrent observation and interview on 6/23/22, at 10:20 AM, in Resident 108's room, the MD asked Resident 108 to straighten his left leg. Resident 108 raised his left leg, his knee remained bent, and he was unable to straighten the leg. The MD stated, he would "...order rehabilitation services for the contracture to the left lower extremity..." The MD further stated, he should be informed when there were changes in a resident's function and mobility. A review of a facility policy and procedure (P&P) titled, "QUALITY OF LIFE Activities of Daily Living (ADLs)/Maintain abilities", dated, 11/2017, indicated, "...the facility will provide the necessary care and services to support the resident's abilities in activities of daily living do not diminish unless circumstances of the individuals clinical condition demonstrate that such a decline in function is unavoidable...a resident is given appropriate treatment and services to maintain or improve his/her ability to carry out the activities of daily living including...Mobility-transfer and ambulation..." A review of a facility P&P titled, "QUALITY OF CARE Restorative Nursing Program", dated 6/2018, indicated, "...Purpose: The facility provides services, care and equipment to assure that a resident maintains and/or improves his/her level of range of motion and mobility unless a reduction is clinically unavoidable ....Policy: To assist our residents in obtaining and maintaining their highest practicable functional levels, prevent unnecessary declines, and provide an active and healthy living environment...Guidelines: Residents will be routinely assessed for the need for a formalized Restorative Nursing program..." In violation of the above cited standards, the facility failed to provide the necessary care and services to ensure that Resident 108's functional abilities did not diminish when Resident 108 had a decline in his ability to transfer and walk, and services were not provided to determine the cause and/or to maintain his abilities. These failures resulted in Resident 108's decline in range of motion to his left leg, and a decline in his transfer and ambulation abilities. These violations jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents. Avalon Sonora Recertification Survey 06/22/2023 Representing the Department 47369