Other·December 1, 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 — 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 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 1/5/22, at 1: 35 p.m., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Resident 1’s unwitnessed fall with injury on 12/27/21. Resident 1 was assessed as being at risk for falls, with a history of multiple falls in the facility, and the facility created a comprehensive care plan intervention for the bed to be placed in the low position. [BA1]On 12/27/21, Resident 1’s bed was not in the low position. This resulted in Resident 1 sustaining injuries after falling from the bed onto the floor. After the fall, Resident 1 experienced left side pain and was sent to the general acute care hospital (GACH) for evaluation. Resident 1 was diagnosed with a left femur fracture (broken thighbone) and required surgical repair and was hospitalized from 12/27/21 to 1/4/22 (eight days). After the fall, Resident 1 experienced a decline in mobility and pain due to the fall and injury. Resident 1 was an 85-year-old male, admitted to the facility on 10/14/20. Resident 1’s diagnoses included Alzheimer’s (progressive disease that destroys memory and other important mental functions), pulmonary embolism (condition in which one or more arteries in the lungs become blocked by a blood clot), acute embolism and thrombosis and thrombosis of unspecified deep veins of lower extremity bilateral (blood clot forms in one or more of the deep veins in the body), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), morbid (severe) obesity (commonly defined as being 100 pounds over ideal body weight), muscle weakness, and difficulty walking. During a review of Resident 1's "Admission Record" (document containing resident demographic information and medical diagnosis), dated 1/5/22, the admission record indicated Resident 1 was admitted to the facility on 10/14/20. Resident 1's diagnosis included " ...ALZHEIMER'S...PULMONARY EMBOLISM...ACUTE EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VEINS OF LOWER EXTREMITY BILATERAL ...DEMENTIA ...MAJOR DEPRESSIVE DISORDER...MORBID OBESITY...MUSCLE WEAKNESS ...DIFFICULTY WALKING ..."[BA2] During a review of Resident 1's "Care Plan" (CP) dated 10/26/21, the CP indicated, " ...At risk for falls related[BA3] [disease] of Alzheimer's Dementia, Major Depressive Disorder, Obesity, Pulmonary Embolism, DVT (deep vein thrombosis), LE (lower extremity) muscle weakness; not steady and requiring assistance by staff with walking, toileting, and sit to stand, and poor safety awareness ...[BA4]Resident slid from bed while sitting at the edge of bed on 12/12/2020; [status post] unwitnessed on 12/22/2020 in room; on 1/21/21 CNA (Certified Nursing Assistant) was assisting resident with the walker to the bathroom and he just stopped walking and kneeled down by the doorway to the bathroom-CNA helped lower him to the floor. 2/8/2021, resident as noted laying on the floor. On 5/25/2021 resident rollover from bed. Unwitnessed fall on 8/29/2021 with a redden area to left side of thigh. Unwitnessed fall on 12/04/2021 self-transfer from bed to wheelchair. Unwitnessed fall on 12/11/21 self-transfer from wheelchair to bed. Date initiated: 10/14/2020 ...Goal Minimize risk for falls and fall related injuries. Date Initiated: 10/14/2020 ...Target Date: 1/24/2022 ...Interventions ...Assess for pain and medicate as needed ...Bed in low position ..." 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 10/21/21, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation and memory recall) score of 4 (four) (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had severe cognitive impairment. During a review of Resident 1's "Progress Note" (PN), dated 12/27/21, the PN indicated, " ...[status post] Unwitnessed fall Date of Event: 12/27/21 Time of Event: [8:15 p.m.] ... Writer heard resident verbally yelling for help upon entering residents room writer noticed resident laying on his left side next to his bed. Resident [1] [complained of] pain to [left] hip. Writer administered [as needed] Medication. Resident [1] was lifted with lyft [sic] and placed in bed. No delayed injuries noted except [complaints of left] hip ...Resident verbally stated [h]e just fell down ...Patients description of event: Resident verbally stated He just fell down ...If Fall note-injury how patient was found, environment footwear, last toileted, [Fasting Blood Sugar-amount of sugar in the blood overnight] if diabetic (a person who's body cannot turn sugar into energy): Resident was found in a side laying position to [left] side, resident was wearing non-skid socks, last time toileted was one hour ago...Author [Licensed Vocational Nurse1] ..." During a review of Resident 1's "Neuro Check (an evaluation of person's nervous system)", dated 12/27/21, the Neuro Check indicated, " ...Was there any injury sustained ...Yes ...If yes, explain ...Resident [complains of] [left] hip pain ...Change in range of motion ...Yes ...If yes, explain ...unable to move [left lower] Body extremity ...Is resident experiencing any pain ...Yes ...If yes, explain in detail ...[blank] ..." During a review of Resident 1's "Fall Assessment-Post Incident", dated 12/27/21, the "Fall Assessment-Post Incident" indicated, " ...History of falls within last six months ...1-2 times ..." During a review of Resident 1's "Pain Assessment-Post Incident", dated 12/27/21, "Pain Assessment-Post Incident" indicated, " ...Pain location and characteristics ...Based on appropriate pain scale for Resident, what is the current level of pain?...0 ...If able to verbalize what is the Residents acceptable level of pain?...0 ...What appears to increase the resident's pain?... Moving resident [left] hip ...What is most likely cause of pain?...Resident fell on [left]side and hurts to [left] hip ..." During an observation in 1/5/22, at 2:05 p.m., in Resident 1's room, Resident 1 was asleep in bed, snore-like sounds were heard. Resident 1 was unable to be interviewed. During a concurrent observation and interview on 1/5/22, at 2:45 p.m., with Registered Nurse (RN) 1, at the nurse's station, Resident 1 was observed calling out for assistance in the room. RN 1 stated, Resident 1 had returned to the facility from a GACH today (1/5/22) and Resident 1 was non weight bearing (when an area of the body cannot withstand pressure from body weight) on his left side. RN 1 stated, Physical Therapy (PT) needed to assess him in order to determine the assistance Resident 1 needed. RN 1 stated, prior to Resident 1's fall on 12/27/21, Resident 1 was able to get up and use the bathroom with assistance. RN 1 stated post fall (1/5/22) Resident 1 could not get up and needed to use a urinal (a vessel into which a bedridden person urinates) at his bedside. During an interview on 1/5/22, a 2:57 p.m., with RN 2, RN 2 stated Resident 1 did not complain of pain prior to his fall on 12/27/21. RN 2 stated after the fall Resident 1 complained of left sided pain. RN 2 stated Certified Nursing Assistant (CNA) 3 found Resident 1 on the floor on 12/27/21. During an interview on 1/5/22, at 3:10 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he entered Resident 1's room on 12/27/21 when Resident 1 was on the floor. LVN 1 stated CNA 3 called out for assistance with Resident 1. LVN 1 stated Resident 1 was on the floor next to his bed. LVN 1 stated, Resident 1 wanted to be placed back into bed after the initial fall assessment was completed and that Resident 1 had no visible injuries and Resident 1 said he was ok. LVN 1 stated after placing Resident 1 back into bed Resident 1 complained of pain to the left side of his body. LVN 1 stated he called an ambulance to transfer Resident 1 to a GACH. During a review of Resident 1's "Care Conference Summary v2.0 (Care Conference)", dated 1/14/22, the Care Conference indicated, " ...Nursing ...Summary of Nursing Services/Concerns ...[Resident 1] does [complain of] pain to the left leg due to recent fracture of the femur that was a result of a fall. [Status post open reduction and internal fixation (ORIF- a type of surgery that is used to repair broken bones that need to be put back together) to [his] left femur ...At this time requires extensive to total assist with [Activities of Daily Living-ADLs] such as bed mobility, toileting, personal hygiene and bathing. Resident [1] does not transfer at this time per [Doctors] orders due to being toe touch weight bearing (resident can place their toe on the ground for very subtle balance) on the left leg only but unable to tolerate ...Medication Changes/Concerns ...none ...Falls/Accidents ...Briefly describe any falls/accidents. If none, Enter "none" ...none ...Signed By ...MDS Coordinator ...Signed Date ...01/27/2022 ...Therapy/Restorative ...Summary of Therapy/Restorative Services or Concerns ...[Resident 1] presents with [left] hip [fracture with] new ORIF from acute ...and has been currently on therapy services to address pain, functional mobility, [lower extremity strength, activity tolerance ...Signed By ...[Physical Therapy] ...Date ...01/14/22 ..." During a review of Resident 1's "Care Plan", dated 4/22/22, Resident 1's Care Plan indicated, " ...Resident [1] has physical functioning deficit related to: Total dependency with Mobility impairment, [status post Open Reduction Internal Fixation for Broken [BA5](surgery to fix a severely broken bone)] to left femur ... Date Initiated: 01/06/2022 ..." During a review of Resident 1's "Section G Functional Status (Section G)" (prior to fall on 12/27/21), dated 12/27/21, Section G indicated, " ...Activities of Daily Living (ADL) Assistance (term used in healthcare to refer to person daily self-care activities ability) ...ADL Self Performance ...Coding ...2. Limited assistance-resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance ...C. Walk in room-how resident walks between locations in his/her room ...2 ...D. Walk in corridor-how resident walks in corridor on unit ...2 ...F. Locomotion off unit-how resident moves to and returns from off-unit locations ...2 ..." During a review of Resident 1's "Section G Functional Status (Section G)" (post fall 12/27/21) dated 7/14/22, the Section G indicated, " ...Activities of Daily Living (ADL) Assistance ...ADL Self Performance ...Coding ...8. Activity did not occur ...C. Walk in room-how resident walks between locations in his/her room ...8 ...D. Walk in corridor-how resident walks in corridor on unit ...8 ... F. Locomotion off unit-how resident moves to and returns from off-unit locations ...8 ..." During an interview on 7/28/22, at 3 p.m., with CNA 3, CNA 3 stated, on 12/27/21, he had placed Resident 1 in his wheelchair at approximately 6 p.m. CNA 3 stated, he was not Resident 1's assigned CNA for the shift. CNA 3 stated, when he walked by Resident 1's room at approximately 7:45 p.m., Resident 1 was in his bed. CNA 3 stated he had not placed Resident 1 in his bed and the bed was not in the lowest position from the floor. CNA 3 stated, after he passed Resident 1's room and turned the corner, he heard Resident 1 yell out for help and when CNA 3 returned to Resident 1's room, Resident 1 was on the floor. CNA 3 stated, it was important that Resident 1's bed be placed in the "lowest position" because he was considered a fall risk. During a concurrent observation and interview on 8/4/22, at 3:52 p.m., with CNA 3, in Resident 1's room, Resident 1 was observed in his bed at a height that was not in the lowest position. CNA 3 stated, when Resident 1 had fallen out of bed on 12/27/21, Resident 1's bed was raised slightly higher. CNA 3 was observed as he raised the height of Resident 1's bed to demonstrate the difference in height. CNA 3 used a measuring tape to measure the height of Resident 1's bed. The height of Resident 1’s bed was 22 inches (unit of measurement) from the bottom of the mattress to the floor. CNA 3 stated, Resident 1 was a fall risk, and the bed should always be at the "lowest height." CNA 3 lowered Resident 1's bed to the lowest position and measured the height from the bottom of the mattress to the floor, the height measurement was 14 inches (a difference of 8 inches). CNA 3 stated, before Resident 1's fall on 12/27/21, Resident 1 was able to assist with transfers, however Resident 1 is now a two- person transfer (post fall). During an interview on 8/4/22, at 4:05 p.m., with LVN 1, LVN 1 stated, Resident 1 was more mobile prior to his fall on 12/27/21 than he was on 1/5/22[BA6]. LVN 1 stated, prior to Resident 1's fall on 12/27/21 fall, Resident 1 could assist with moving himself in his bed. LVN 1 stated, Resident 1 post fall on 12/27/21 was a two-person transfer. During an interview on 8/5/22, at 10:03 a.m., with the Director of Physical Therapy (DPT), the DPT stated, prior to 12/27/21, Resident 1 was a sit to stand mid assist (when a resident needs minimal assistance to move from sitting to standing) and had a higher level of function. The DPT stated, Resident 1 post fall on 12/27/21 is a two-person transfer with a mechanical lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone). During a review of Resident 1's "[X-Ray] (picture through the body to see bones) Femur Left Final Result (XR femur)", dated 12/28/21, the XR femur indicated, " ...REASON FOR EXAM ...Fall ...Pain ...FINDINGS/IMPRESSION ...Comminuted (bone that is broken in at least two places), mildly displaced fracture of the subtrochanteric (below the femur) left femur with 1.4 [centimeter-cm unit of measurement] displacement ..." During a review of Resident 1's "[X-Ray] Hip Left Complete (XR hip)", dated 12/28/21, the XR hip indicated, " ...REASON FOR EXAM ...Fall ...Pain ...FINDINGS/IMPRESSION ...Comminuted oblique (incline) fracture of the proximal (near center) femur just below the intertrochanteric (area of femur where angle changes) region. There is a 9 [millimeter-mm unit of measurement] displacement ..." During a review of Resident 1's, "Patient Care Timeline 12/27/21 to 12/30/21 (PCT)", the PCT indicated, " ...12/27/2021 ...[10:26 p.m.] ... Patient arrived in the [Emergency Department (ED)] ...[10:33 p.m.] ....Pain Assessment Pain Scale Used: Faces Wong-Baker Faces Scale (patients are not able to understand the standard 0-10 pain scale): 2-Hurts a little bit ...[10:35 p.m.] ED Fall Risk ...Fall Risk: High Risk ...12/28/2021 ...[1:05 a.m.] fentanyl (powerful drug used in the treatment of severe pain) ...injectio