Health inspection·October 24, 2022

§483.21(b) Comprehensive Care Plans §483.21(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 — §483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents 22 CCR §72311(a) 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 7/12/2022 at 9:36 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident (FRI) regarding Resident 1’s unwitnessed fall with injury that occurred 6/28/2022. Resident 1 was assessed as a high risk for falls and the care plan interventions of 1) full-length floor mats to be placed on both sides of the bed and 2) ensure the low- air- loss (LAL- an air mattress with fluctuating air) mattress prescribed air pressure setting is set at 80 pounds were not in place for Resident 1. Resident 1 suffered skin tears, bleeding from her right hand, right forearm, pain, and right shoulder fracture (broken bone). Resident 1 was sent to the general acute care hospital (GACH) for treatment of her fall related injuries on 6/28/22. Resident 1 was given pain medication to treat the pain and placed on a right shoulder immobilizer for the shoulder fracture. The facility failed to implement Resident 1 's fall care plan when full length floor mats to be placed on both sides of the bed and to ensure the low- air- loss mattress prescribed air pressure setting was set at 80 pounds were not in place for Resident from 6/22/22- 6/28/22. The facility also failed to implement Resident 1’s fall care plan when the low air loss mattress was set to 150 pounds instead of 80 pounds upon Resident 1’s return to the facility. Resident 1 is an 86-year-old-female, admitted to the facility on 4/5/2016. Resident 1 had diagnoses that included contracture (shortening of muscle, preventing normal muscle movement of the body area), history of falling and Parkinson's disease (a brain disorder that causes unintended or uncontrollable body movements, such as shaking, stiffness, and difficulty with balance and body movement coordination). Resident 1 was assessed to have moderate cognitive deficit. During an observation on 7/12/22, at 11:26 a.m., in Resident 1 ' s room, Resident 1 was lying in bed on a low air loss (LAL- mattress filled with air) mattress. The LAL mattress air setting was on lock position and the LAL mattress air pressure was set at 150 pounds. Resident 1 had padded full length floor mats on both sides of the bed. Resident 1 was wearing a right sided shoulder brace immobilizer (sling device used to limit movement of the shoulder) to her right shoulder. Resident 1 was unable to speak when questions were asked, and only opened and tightly closed her eyes. During a review of Resident 1's "Admission Record" (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on 4/5/2016. Resident 1's diagnosis included contracture, history of falling and Parkinson's disease. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment dated 6/20/22, indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment scored was 10. The BIMS assessment indicated Resident 1 had moderate cognitive impairment, within the BIMS scale range of 0-15. During a review of Resident 1's "Progress Note" (PN), dated 6/28/22, the PN indicated, "The writer heard a yell and ran to the room [Resident 1's room], 2 staff members were with the resident [1] at the time of the writer's arrival. Staff stated the fall was unwitnessed. The resident [Resident 1] was found on the floor lying on Rt [right] side beside [Resident 1's] bed. [Resident 1] Observed to have a pool of blood underneath [Resident 1's] head with skin tear [skin wound] noted on Rt [right] top of hand as well as Rt forearm, abrasion [wound] to Rt shoulder, upon assessment ...MD [Medical Doctor] was called via phone [MD gave] ... orders to be [Resident 1] sent out [to the hospital emergency department]." During a concurrent interview and record review on 7/12/22, at 11:36 a.m., with Licensed Vocational Nurses (LVN) 2, Resident 1's physician "Order Summary" dated 3/7/2022. The "Order Summary" indicated, " ...Floor mat to both sides of the bed to minimize injury ...order date 3/07/2022 ..." LVN 2 stated Resident 1 was moved to the room where she had the fall on 6/22/22 from different room in another unit in the facility. LVN 2 stated at the time of the fall, the floor mats were not in place on either side of Resident 1's bed. LVN 2 stated during the room transfer Resident 1's floor mats were left in her prior room. LVN 2 stated the floor mats should have been moved to her new room and were not. LVN 2 stated it was the licensed nurse's responsibility to ensure Resident 1's physician orders for floor mats were followed. During a concurrent interview and record review on 7/12/22, at 11:45 a.m., with LVN 2, Resident 1 ' s "Care Plan" with revised date of 7/1/22 was reviewed. The "Care Plan" indicated, "High risk for injury/accident and falls related to: ...poor safety awareness Parkinson ' s Disease- has rocking motion at times. History of fall. High fall assessment score of 75. 3/07/2022-Care plan reviewed and revised ...[place] Floor mat to both sides of the bed to minimize injury. Date Initiated: 3/07/2022 ...Keep bed in the lowest position with floor mats on both side when resident is in bed ..." LVN 2 stated it was the licensed nurse's responsibility to ensure fall care planned interventions were in place During a concurrent interview and record review on 7/12/22, at 11:50 a.m., with LVN 2, Resident 1 ' s "MDS" dated 6/20/22 and 7/5/22 were reviewed. The "MDS" dated 6/20/22 indicated, " ...Section G Functional Status ...Activities of Daily Living (ADL) ..." Resident 1 required one-person physical assist with bed mobility, dressing, toilet use and person hygiene. Change of condition MDS dated 7/5/22, after the fall of 6/28/22, indicated Resident 1 ' s functional mobility status was assessed as Resident 1 requiring two-person physical assist for bed mobility, dressing, toilet use, and personal hygiene. LVN 2 stated after the fall, Resident 1 was assessed to need two-person physical assistance with all her ADL needs. LVN 2 stated the increase in assistance indicated a decline in Resident 1 ' s ADLs. LVN 2 stated Resident 2 (Residents 1 ' s roommate) was in the room when Resident 1 fell on 6/28/22. LVN 2 stated Resident 2 was alert and was able to tell the staff what she witnessed when Resident 1 fell. During an interview on 7/12/22, at 11:58 a.m., with Resident 2, Resident 2 (Resident 1 ' s roommate) stated she was in her bed with a curtain between her and Resident 1 ' s bed when she heard a loud thump on the concrete floor and saw Resident 1 had fallen out of her bed. Resident 2 stated she went out into the hallway and yelled for staff to come help Resident 1. Resident 2 stated at the time of Resident 1 ' s fall, the floor around Resident 1 ' s bed was "bare" and that the floor mats were placed after Resident 1 ' s fall on 6/28/22. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment dated 4/18/22, indicated Resident 2's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment scored was 9 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 2 had moderate cognitive impairment. During a telephone interview on 7/12/22, at 12:07 a.m., with LVN 1, LVN 1 stated she was caring for Resident 1 the day of her fall on 6/28/22. LVN 1 stated she was at the nurse ' s station when she heard yelling for help from Resident 2 and ran to Resident 1 ' s room. LVN 1 stated upon entering Resident 1 ' s room she found Resident 1 lying on the floor with blood underneath her head. LVN 1 stated Resident 1 ' s fall was unwitnessed. LVN 1 stated Resident 2 (Resident 1 ' s roommate) was in the room on 6/28/22 when Resident 1 fell but she did not witness how Resident fell. LVN 1 stated Resident 2 told her that she heard a loud thump on the concrete floor and saw Resident 1 on the floor. LVN 1 stated she was unsure how she had fallen since Resident 1 was unable to get in or out of bed on her own and was unable to walk. LVN 1 stated on the day of Resident 1 ' s fall 6/28/22, there were no floor mats on either side of Resident 1 ' s bed. LVN 1 stated on the day of the fall, Resident 1 was found on the vinyl concrete floor, bleeding next to her bed. LVN 1 stated Resident 1 was sent to the hospital on 6/28/22 for evaluation of her injuries. LVN 1 stated Resident 1 could not move, was bleeding from her head and had signs of pain to her right shoulder. LVN 1 stated Resident 1 had recently been moved from another unit in the facility, to the room where she experienced the fall. LVN 1 stated the reason Resident 1 did not have the floor mats on both side of her bed was because the floor mats were not moved to the room when Resident 1 was moved on 6/22/22. LVN 1 stated she had provided care to Resident 1 for a few days prior to the fall but she was unaware that Resident 1 was assessed as a high fall risk or that she needed floor mats on both sides of her bed because she had not reviewed Resident 1's fall care plan. LVN 1 stated she was unaware Resident 1's fall prevention interventions include to make sure Resident 1 had padded full length floor mats on both sides of her bed. LVN 1 stated after Resident 1's fall, she reviewed the fall care plan, indicating Resident 1 was supposed to have floor mats on both sides of her bed. LVN 1 stated she then asked a staff member to bring floor mats from Resident 1's previous room and place them in her new room to ensure Resident 1 had floor mats when she came back from the hospital. LVN 1 stated if the floor mats had been in place at the time of Resident 1's fall, the floor mats could have minimized Resident 1's injuries. LVN 1 stated it was the Licensed nurse ' s responsibility to ensure fall care plan interventions were in place and physician orders were followed. LVN 1 stated she typically reviewed care plans and physician orders during her weekly progress notes but had not reviewed Resident 1's care plans prior to the fall on 6/28/22. During a telephone interview on 7/12/22, at 1:32 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 6/28/22 she was in another room feeding a resident when she heard staff calling for help. CNA 1 stated when she entered Resident 1's room she saw Resident 1 on the floor with blood coming from her head. CNA 1 stated there were no fall mats on the floor, on either side of Resident 1's bed. CNA 1 stated if the floor mats had been in place when Resident 1 fell, it may have prevented the injury she received, because Resident 1 fell next to the bed where the floor mats would have been placed. CNA 1 stated Resident 1 was recently moved from her previous room, into the room where she had the fall. CNA 1 stated she was unaware that Resident 1 was a fall risk or that she had floor mats as her care plan interventions because she was not informed. CNA 1 stated there should have been communication between the unit staff to ensure fall care plan interventions were in place when Resident 1 was moved to the new room. CNA 1 stated if she would have had access to Resident 1's care plans, she could have reviewed the care plans prior to providing Resident 1's care and ensured the fall care plan interventions were in place to prevent fall injuries. During a review of the General Acute Care Hospital (GACH) medical record titled, "ED (Emergency Department) Notes," dated 6/28/22, was reviewed. The Emergency Department (ED) Notes indicated, " 6/28/22 ...Pt [patient] presents to ED for evaluation after fall out of bed. Unwitnessed. Pt suspected to have rolled out of bed. Pt is non ambulatory, and bed bound. Nonverbal [unable to speak] at bedside. Right shoulder pain ...Multiple abrasions to right arm, skin tear to scalp and left hand ...Diagnosis Fall ... Right shoulder fracture [broken bone] ... daughter updated on ...[facture]. Placed [Resident 1] in shoulder immobilizer. [daughter] would like [Resident 1] to start hospice ... Pt will be sent back to [facility 6/29/22] ..." During a concurrent observation and interview on 7/12/22, at 2:29 p.m., with LVN 2, in Resident 1 ' s room, Resident 1 was lying in bed on a low- air- loss mattress (LAL). The LAL mattress air pressure setting was on lock position and the air pressure was set at 150 pounds. The LAL mattress pump had eight weight settings; 50 lb. (pound), 100 lb., 150 lb., 200 lb., 250 lb., 300 lb., 350 lb., and 450 lbs. LVN 2 stated the mattress setting was set at 150 lbs. LVN 2 disarmed the lock button and changed the LAL mattress air pressure setting to 100 lbs. LVN 2 stated Resident 1 ' s weight was 84 pounds and that the air pressure setting had been set incorrectly too high. LVN 2 stated if the LAL mattress was not set at the correct air pressure weight setting and the shifting air in the mattress could cause Resident 1 to fall out of bed. LVN 2 stated Resident 1 had a physician ' s order for the LAL mattress and that the care plan indicated to keep the air pressure setting at 80 pounds not 150 pounds. LVN 2 stated it was the Licensed nurse responsibility to ensure that the air mattress air pressure setting was set at the correct weight and not too high. LVN 2 stated the high LAL mattress air pressure setting had been set at 150 lbs. since Resident 1 moved rooms and may have contributed to Resident 1 ' s fall. During a review of Resident 1 ' s "Order Summary" dated 7/12/22 was reviewed. The "Order Summary" indicated, " ...LAL Mattress for wound healing. Monitor [LAL Mattress] every shift for placement, functioning, and appropriate [air pressure] settings according to resident ' s weight ..." During a review of Resident 1 ' s Care Plan" dated 7/1/22, the "Care Plan" indicated, "High risk for injury/accident and falls related to ... poor safety awareness ... Parkinson ' s Disease- has rocking motion at times. History of fall. High fall assessment score of 75 [high]. 3/07/2022-Care plan reviewed and revised ...LAL [mattress] setting [to be] reset to 80 lbs. ..." During a concurrent interview and record review on 7/12/22, at 2:39 p.m. with LVN 3, LVN 3 reviewed Resident 1 ' s physician order dated 7/2022 and Resident weight record dated 7/2022 and stated the LAL mattress weight setting should have been set at 80 pounds, the closest weight set based on Resident 1's weight of 84 pounds. LVN 3 stated there was a potential for falls if the LAL mattress air pressure weight was not at the correct air pressure setting of 80 lbs. During a review or Resident 1 ' s "weight sheet" dated 7/7/22. The "weight sheet" indicated Resident 1 ' s weight was 84 pounds During a concurrent interview and record review on 7/12/22, at 3:04 p.m., with the Director of Staff Development (DSD), the facility policy and procedure titled "Physician