Other·January 22, 2024

Event ID: MX3U11 State Citation A was written. 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. 42 CFR 483.25(d) 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. FINDINGS: On 9/8/2023 at 12:45 p.m., an unannounced visit was conducted at the facility to investigate Facility Reported Incident CA00858937 regarding a fall with injury which resulted in a cervical fracture, bruises, and contusions. On 8/31/2023, Resident 7 fell from her wheelchair after the Certified Nursing Assistant (CNA) left Resident alone, unsupervised, while attending to another resident across the hall which resulted in a cervical fracture. The facility failed to provide Resident 7 with supervision and to prevent an accidental fall as well as follow Resident 7's care plan requiring care team to minimize risk of falls which resulted in injury. Resident 7 was an elderly female admitted to the facility on 8/4/2015 with diagnoses including Alzheimer's Disease (a progressive disease with memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. The disease involves parts of the brain that control thought, memory and language), bilateral (both ears) hearing loss, age-related osteoporosis (bones become weak and brittle) without current fracture (broken bones). During Resident 7's stay at the facility, she had been diagnosed with cerebral vascular accident disease (CVA- an interruption of blood flow to the brain-stroke), generalized muscle weakness, and cognitive communication deficit (ability to think, reason and remember). During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated 8/13/23, Resident 7's MDS assessment indicated Resident 7's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 99. BIMS scoring typically ranges between 0 to 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment); however, a BIMS summary score of 99 indicated Resident 7 was unable to complete the interview. The BIMS assessment indicated Resident 7 had a severe cognitive impairment (a person that has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). During an interview on 9/8/23 at 12:50 p.m., with the Director of Nursing (DON), the DON stated on 8/31/23 Resident 7 was "tired and sleepy" in her wheelchair located at the nurse's station. The DON stated CNA 2 took the resident back to her room. The DON stated when CNA 2 got back to Resident 7's room, she heard another resident yell from across the hall and went to that room to check on that resident, leaving Resident 7 alone in the wheelchair. The DON stated CNA 2 left Resident 7 by herself for a "minute or two" and when she came back to Resident 7, she was lying face down on the floor. The DON stated Resident 7's safety was put at risk when CNA 2 left Resident 7 up in the wheelchair and left Resident 7's room. The DON stated the fall was avoidable and CNA 2 should not have left Resident 7 unattended when Resident 7 was sleepy sitting in the wheelchair. The DON stated Resident 7's fall resulted in an injury and hospital admission. The DON stated Resident 7 had a history of falls at the facility including a prior fall on 4/16/23 where she fell forward in her wheelchair. The DON stated Resident 7 had a fall-risk score that resulted in being a "high-risk for falls" resident. The DON stated Resident 7 required extensive assistance (individual cannot perform any Activities of Daily Living or weight bearing without another person providing assistance) with all transfers. During an interview on 9/8/23 at 2:30 p.m., CNA 2 stated she was the CNA responsible for Resident 7's care when Resident 7 fell. CNA 2 stated she knew Resident 7 was a high fall-risk and had cared for her many times before. CNA 2 stated Resident 7 needed staff for "basically everything" and required extensive assistance. CNA 2 stated on 8/31/23 Resident 7 was "leaning forward" in her wheelchair and looked tired and uncomfortable at the nurse's station. CNA 2 stated she wheeled Resident 7 back to her room with the intention of putting her into bed. CNA 2 stated she parked Resident 7 in her room in front of the dresser facing her bed. CNA 2 stated Resident 7's feet were flat on the floor, and she did not lock the wheelchair. CNA 2 stated she left Resident 7's room to get the lift to put her in bed when she heard a resident across the hall yell something. CNA 2 stated she left Resident 7 for around a minute. CNA 2 stated when she came back into Resident 7's room, she was face down on the floor and her face appeared to have hit the floor. CNA 2 stated she should have never left Resident 7 up in the wheelchair by herself in the condition she was in. CNA 2 stated she did not meet the expectation of the facility which was to stay with Resident 7 and not leave her alone. CNA 2 stated Resident 7 fell because she left her unattended. During an interview on 9/8/23 at 4:45 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the nurse responsible for Resident 7 at the time of the fall. LVN 1 stated Resident 7 had fallen before and was a high fall-risk resident. LVN 1 stated CNA 2 took Resident 7 to her room because she was tired. LVN 1 stated CNA 2 left Resident 7 by herself in her room, and she fell forward out of her wheelchair hitting the ground. LVN 1 stated when she came to the room Resident 7 had a "big bump" on her forehead with facial grimacing and appeared to be in pain. During a review of Resident 7's "Fall- Nurses Note (NN),"dated 8/31/23, the NN indicated, "...CNA (Certified Nursing Assistant) writer, "Resident is on floor in room, she fell from her wheelchair...I was going to put her in bed because she was sleepy, I walked out from the room to get the lift that was outside the resident's door and I hear a patient screaming from room [number], I went to look really quick at her and when I came back, patient was on the floor." "Upon writer entering resident's room, resident was noted leaning forward with top of head on the floor mat that was placed by the wall (floor mat was placed by the wall in order to have space for the lift) patient was noted with more inclination towards left upper extremities, knees were down on floor. Upon assessment, writer noted [Resident 7] with facial grimaces and raised bump to left side of head, abrasion to 3rd left finger, bruise to 2nd left finger and left metacarpal. Writer asked patient is she ok, pt (patient) stated, "I don't know"... Writer and fellow nurse noted increased in facial grimaces, episodes of moaning and an increase in blood pressure... per Medical Doctor to transfer resident to hospital for further evaluation..." During a review of Resident 7's "Hospital Admission (HA) record," dated 8/31/23, the HA record indicated, "...Chief Complaint: ...Patient presents with Fall...Ground level fall unwitnessed at skilled nursing facility (SNF)...Mechanism of injury: ...unable to provide history. Per Emergency Medical Systems deformity to wrist and hematoma to face...Per son SNF called says she fell from her chair was down for at most 15 minutes...Past medical history: ...does not want any surgeries...Objective: Physical Exam- ...Mental status: mumbling incoherent speech...Head: ...hematoma (swelling) to face...Face: hematoma to left forehead...Extremities: Left upper extremity: Chronic deformity to left wrist, ecchymosis (type of bruise) to 2nd and 3rd finger and tender to palpation (a method of feeling with the fingers or hands during a physical examination)... Assessment/Plan: ...Odontoid fracture (a broken bone in the neck)...Hematoma of scalp...large, to left forehead...Ground-level fall...Plan: Admit medicine and surgery to follow..." During a review of Resident 7's "Progress Notes (PN)," dated 9/6/23, the PN indicated, "...Event being reviewed: ...unwitnessed fall at resident's room on 8/31/23 at 3:15 p.m., ... Root Cause Analysis for event: ...Resident possibly fell asleep while sitting up in a wheelchair, then fell forward to the floor in the resident's room. Prior to the fall, resident was wheeled by the Certified Nursing Assistant to the resident's room to put her back to bed when CNA and licensed nurses noted resident sleepy while sitting up in a wheelchair in front of the nurse's station. Assigned CNA just stepped out outside the room by the resident's door to get the [brand name] lift (equipment to lift a resident who cannot support their own body weight), when CNA came back to the room resident was on the floor. Resident was noted in prone [lying face down] left side lying position with top of head touching the floor mat (floor mat was against the wall)...Interventions initiated and residents response/compliance with intervention: ...Resident was on the floor- noted a raised bump to left side of head, abrasion (skin scrape) to third left finger, purplish discoloration to second left finger and left metacarpal (finger)...resident remains awake, conversant and with confusion...noted increased in facial grimaces, episodes of moaning when touching left hand and increased blood pressure of 166/85 when resident was in bed... Ambulance was called immediately...Medical Doctor (MD) notified with new order to send out resident to Emergency Room for further evaluation...update was given at the facility that resident has a neck fracture...Resident was admitted due to ground level fall with odontoid fracture (break of the second bone in the neck)." During a review of Resident 7's "Discharge Summary (DS)," dated 9/8/23, the DS indicated, "Admit date: 8/31/23, Discharge Date: 9/8/23...Chief complaint: Fall...Admission diagnosis: Odontoid fracture...Discharge Diagnoses: ...(Principal) Odontoid Fracture, hematoma of scalp, confusion, Ground-level fall...Alzheimer's dementia with anxiety...Resolved Hospital Problems: No resolved problems to display... Images: ...XR (X-Ray) Spine Cervical (neck)...Result date: 9/6/23...stable transverse odontoid process fracture...Computed Tomography (CT- diagnostic imaging procedure) Cervical (spine) with Contrast (a substance injected into an intravenous (in the vein) line that causes the particular organ/tissue/bone under study to be seen more clearly) result date: 8/31/23...Impression: 1. There is a nondisplaced transverse (bone not moved far enough to be out of alignment) odontoid fracture...3. The bones are osteopenic (bone loss) ...CT Head without Contrast, Result Date 8/31/23... Impression: 1. Large area of soft tissue contusion with hematoma of the left forehead and frontal area extending cephalad (toward the head) ...". During a review of Resident 7's "Care Plan (CP)," dated 9/12/22, the CP indicated, "Focus...At risk for falls and fall related injuries due to history of falls, impaired safety awareness due to cognitive deficit (impairment of an individual's mental process which affects how an individual understands and acts in the world), diagnosis of Alzheimer's Disease...CVA, generalized weakness, osteoporosis, history of fracture...hearing loss...Resident requires extensive assist with Activities of Daily Living (Activities such as toileting, brushing teeth, putting on clothes, feeding oneself), bed mobility and transfers. Resident observed with episode of bending forward when up in wheelchair...on 4/16/23 resident was noted lying on the floor in between the wheelchair and bed...on 6/4/23, residents' half of the body was laying on the floor mat with bed at the lowest position...on 8/31/23, resident fell forward from wheelchair...Goal: Minimize risk for falls and fall related injuries through next 90 day review...Interventions: ...Continue with PT [Physical Therapy] focus on safe transfers and wheelchair positioning/posture, date initiated 4/19/23...". During an observation on 9/15/23 at 11:30 a.m. by CDPH, Resident 7 was sitting in her wheelchair, asleep, in front of the nurse's station. Resident 7 had black and purple under each eye and on both eye lids. Resident 7 had a grey neck brace on and a 1-inch circular bump on her forehead above her left eye. During a review of the facility's policy and procedure (P&P) titled, "Falls and Fall Risk, Managing," dated July 2023, the P&P indicated, "...Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling... A fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force... when a resident is found on the floor, a fall is considered to have occurred...Fall Risk Factors: ... 2. Resident conditions that may contribute to the risk of falls include: ... e. lower extremity weakness... i. functional impairments... 3. Medical factors that contribute to the risk of falls include: ... d. neurological disorders; and e. balance and gait disorders... Resident-Centered Approaches to Managing Falls and Fall Risk...The staff...will implement resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident or with a history of falls... If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant...Monitoring Subsequent Falls and Fall Risk...The staff will monitor and document each resident's response to interventions intended to reduce falling or risk of falling...If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions..." These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result and constitute an A Citation.