Other·February 29, 2024

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. 42 CFR 483.21(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. Findings: On 11/29/23 at 9 a.m., an unannounced visit was conducted at the facility to investigate an FRI regarding a fall of Resident 1 which resulted in a Fractured Occipital Condyle (break at the base where skull meets spine), laceration (cut) to her nose, bruising, swelling to her left eye and pain. Resident 1 fell out of bed assisted by Certified Nurse Assistant (CNA) 1 without assistance from another staff member in accordance with the Comprehensive Assessment, care plan and needs of the resident. Resident 1, an 87-year-old, admitted on 04/20/19 with diagnoses that included, Dementia (loss of cognitive functioning, thinking, remembering, and reasoning), Muscle Weakness, Difficulty in Walking and Other Specified Disorders of Bone Density and Structure (disease of the bone). During a review of Resident 1's "Minimum Data Set" (MDS) assessment (assessment of functional and cognitive abilities), dated 11/09/23, the "MDS" Section C indicated, Resident 1 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score) score of 4 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 cognitively intact).The "MDS" Section GG (Functional Abilities and Goals) indicated, Resident 1 was dependent (requiring assistance from staff) to roll from left and right, for a Tub/shower, Transfer, completion of Oral Hygiene, upper and lower body dressing, personal hygiene and eating. During a concurrent interview and record review on 11/29/23 at 12:10 p.m. with the Assistant Director of Nursing (ADON), Resident 1's "Care Plan" (CP) dated 6/22/23 was reviewed. The CP indicated, "...provide assistance and care to resident with two staff members..." The ADON stated CNA 1 was changing Resident 1's brief on 11/6/23 when Resident 1 was rolled out of bed and unto the floor. The ADON stated Resident 1 sustained injuries from the fall. The ADON stated he spoke with CNA 1 after the fall and CNA 1 was aware Resident 1 required the assistance of two staff members to assist when care was being provided. During a concurrent observation and interview on 11/29/23 at 9:45 a.m. in Resident 1's room, Resident 1 was lying in bed awake. Resident 1 had an [brand name] Collar (device used to prevent movement of head and neck) around her neck. Resident 1 stated she was having difficulty speaking due to the presence of the device. Resident 1 stated she was having pain. During an interview on 11/29/23 at 11:20 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 1 always required extensive assistance by two staff members. CNA 2 stated prior to Resident 1's fall on 11/6/23 Resident 1 was able to feed herself and brush her teeth. During a record review on 11/29/23 of "untitled" undated document, signed by CNA 1, the document indicated, at 5:44 a.m., "When doing my last round, I knocked on resident door and asked to come into complete my last round, as I was changing resident I pulled the draw [half] sheet toward me so I can turn resident on side to change her brief, but she continued to roll and fell off bed." During a concurrent observation and interview on 11/29/23 at 12:55 p.m. with CNA 2, outside of Resident 1's room, CNA 2 stated there was a picture of a handshake by Resident 1's name outside the doorway of her room. CNA 2 stated the picture indicated Resident 1 required two persons to assist with Resident 1's care to meet any of her needs. During an interview on 11/29/23 at 1:00 p.m. with CNA 4, CNA 4 stated she was aware Resident 1 required the assistance of two staff members when providing care. CNA 4 stated the picture of the handshake was there for staff to always provide two-person care. CNA 4 stated when staff provided care without following the two-person assistance rule it placed Resident 1 at risk for falls and injuries. During an interview on 11/29/23 at 1:10 p.m. with CNA 3, CNA 3 stated Resident 1 was unable to feed herself or brush her teeth due to the supportive device around her neck. CNA 3 stated Resident1's care and needs had changed because of the injuries from the fall. During an interview on 11/29/23 at 1:30 p.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated Resident 1 required the assistance of two staff members when care was provided. LVN 2 stated Resident 1 was at risk for falls, injuries, or death when care was not provided according to the care plan interventions in place. LVN 2 stated prior to the fall, Resident 1 was able to feed herself, and was currently unable to feed herself because of the injuries. LVN 2 stated Resident 1 fell off her bed and sustained injuries that were life threatening. During an interview on 11/29/23 at 1:45 p.m. with the Director of Nursing (DON), the DON stated Resident 1 needed assistance and care for brief changes, showers and repositioning. The DON stated CNA 1 did not follow the protocol for a two person assist when care was provided. The DON stated the outcome from the fall resulted in Resident 1 falling out of bed and sustaining major injuries. The DON stated the fall and injuries could have been prevented if there had been two staff members assisting with Resident 1's care. The DON stated the interventions were put in place to keep Resident 1 from harm. The DON stated there was actual harm to Resident 1 as a result of the fall. During an interview on 11/29/23 at 2:10 p.m. with the facility Administrator (ADM), the ADM stated Resident 1's fall was avoidable. The facility Administrator (ADM) stated CNA 1 did not follow the facility policy and care plan that was in place for Resident 1. The ADM stated during the investigation, CNA 1 admitted she provided care to Resident 1 by herself. The ADM stated CNA 1 admitted it was wrong to provide care for Resident 1 without assistance from a second staff member. During a telephone interview on 11/30/23 at 12:15 p.m. with LVN 3, LVN 3 stated he was assigned to Resident 1 during his shift on 11/06/23. LVN 3 stated he noticed the door to Resident1's room was closed and thought staff were providing care to the resident. LVN 3 stated CNA 1 came out of Resident 1's room and alerted him that Resident 1 had fallen out of bed. LVN 3 stated when he then went into Resident 1's room CNA 1 was alone in the room with Resident 1. LVN 3 stated he saw Resident 1 lying on the floor next to her bed face down. LVN 3 stated there was blood on the floor around Resided 1's face and she was moaning in pain. LVN 3 stated he then assisted Resident 1 back into bed and performed an assessment. LVN 3 stated Resident 1 was bleeding from her nose and there was a laceration across her nose and swelling to her left eye. LVN 3 stated Resident 1 was moaning in pain during the physical assessment. LVN 3 stated prior to the fall Resident 1 was able to feed herself and brush her teeth. LVN 3 stated Resident 1 was now unable to feed herself and required assistance. LVN 3 stated Resident 1 was now unable to brush her teeth and had limited movement of her head and neck. LVN 3 stated Resident 1's fall could have been prevented if CNA 1 had provided care assisted by with another staff person. During a review of Resident 1's general acute hospital record, titled, "AFTER VISIT SUMMARY, "dated 11/6/2023, the "AFTER VISIT SUMMARY" indicated Resident 1 received an x-ray of the cervical spine (neck region of your spinal column or backbone) due to a fall. The X-Ray indicated Resident 1 was found to have an occipital condyle fracture. During a review of the facility's policy and procedure (P&P) titled, "Fall Management Program" undated, the P&P indicated, "...To prevent residents a safe environment that minimizes complications associated with fall...the facility will implement a Fall Management Program that supports providing an environment free from fall hazards... staff will develop a care plan according to the identified risk factors and root causes..." During a review of the facility's P&P titled, "Resident Safety," undated, the P&P indicated, "...To provide a safe and hazard free environment ...Residents will be evaluated to identify circumstances that pose a risk for the safety and wellbeing of the Resident...After a risk evaluation is completed, a Resident-centered care plan will be developed to mitigate safety risk factors..." During a review of the facility's P&P titled, "Comprehensive Person-Centered Care Planning" undated, the P&P indicated, "...It is the policy of this facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain their highest physical, mental and psychosocial well-being..." The facility failed to implement Resident 1's nursing care plan according to the Comprehensive Assessment and Resident 1's needs to ensure Resident 1 was assisted with care needs by two staff members when CNA 1 assisted Resident 1 in bed without the aid of a second person's assistance. This failure resulted in a Fractured Occipital Condyle (break at the base where skull meets spine), laceration (cut) to her nose, bruising, swelling to her left eye and pain. In violation of the above cited standards, the facility failed to implement Resident 1's care plan according to the established standards. 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 constitute a Class A violation.