Other·June 2, 2023

The following reflects the findings of the California Department of Public Health during investigation of an Entity Reported Incident. Representing the Department, 41119 RN, HFEN. 42 C.F.R. 483.21, subdivision (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. 42 C.F.R. 483.25(d) Accidents. The facility must ensure that: (d)(1) - The resident environment remains as free of accident hazards as is possible; and (d)(2) - Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR 72311Nursing 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 1/11/2023 at 8:59 a.m., an unannounced visit was conducted at the facility to investigate an entity reported incident regarding Resident 1s unwitnessed fall with injury that occurred on 12/23/22. The facility failed to ensure residents' environment remained free of accident hazards (environmental factors with a potential to cause injury or illness) when Resident 1 was assessed as high risk for falls requiring extensive assistance during toileting and had known behavior of self-ambulating to the restroom. The care plan interventions did not reflect the one-person physical assist required by Resident 1 when toileting and the facility did not implement effective interventions to prevent future falls after Resident 1 had two falls on 7/19/22 and 12/23/22. This failure resulted in Resident 1 experiencing an unwitnessed fall in the restroom on 12/23/22, resulting in Resident 1 suffering pain, bruises, fracture (partial or complete break in the bone) of the left shoulder and immobilization of the left hand, and placed Resident 1 at risk of continued falls. Resident 1's Admission Record (document containing resident demographic information and medical diagnosis) indicated, Resident 1 was admitted to the facility on 8/17/2021. Resident 1's diagnoses included dementia (impaired ability to remember, think, or make decisions). Resident 1's Minimum Data Set Assessment (MDS, resident assessment tool used to identify resident cognitive and physical function), dated 11/14/22, indicated, Resident 1's Brief Interview for Mental Status (BIMS) (assessment of cognitive status for memory and judgment) assessment score was 6 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 1 had severe cognitive impairment. Resident 1's Fall Risk Assessment (FRA), dated 11/14/22, indicated, a score of 65 which placed Resident 1 at high risk for falls. A score of 45 and higher indicates high risk, 25-44 moderate risk and 0-24 low risk. The factors that contributed to the assessed fall risk score were "history of falling, difficulty rising from chair, keeps head down when walking, watches the ground, grasps furniture, person or aid when ambulating. " Resident 1's "Progress Note" (PN), dated 7/19/22, indicated, " ...writer [Licensed Vocational Nurse, LVN 2] informed by CNA [Certified Nursing Assistant] Resident is sitting on the floor, with head against the wall, w/c [wheelchair] was behind the resident wheels not locked, no footwear on, Resident known to self-ambulate when going to the bathroom ...found small red induration (localized hardening of soft tissue of the body) to back of head ... " During an observation on 1/11/23, at 9:22 a.m., in Resident 1's room, Resident 1 was seated was seated in her wheelchair near her bed (bed A). Resident 1 was wearing a shoulder brace immobilizer (sling device used to limit movement of the shoulder) to her left shoulder. Resident 1 was unable to respond to questions regarding her fall. Resident 1 had padded floor mats on the right side of the bed. A sign labeled "Stop Call Don't Fall” was posted underneath the television next to the closet which faced the residents in bed B and bed C. During a review of Resident 1's "Care Plan", dated 12/23/22, the CP indicated, "The resident had fall on 12/23/22 with injury ...Place Stop and Call don't fall sign ..." During a concurrent observation and interview on 1/11/23, at 9:53 a.m., with Certified Nursing Assistant (CNA) 1, in Resident 1's room, CNA 1 stated the "Stop Call Don't Fall "was not posted near Resident 1's bed. CNA 1 stated, the sign was posted between bed B and C. CNA 1 stated, Resident 1 "never" used the call light, was known to self-ambulate with the walker to the restroom and was at risk for falls because she was confused. During a concurrent interview and record review, on 1/11/23, at 10:34 a.m., with Minimum Data Set Coordinator (MDSC), Resident 1's MDS assessment dated 11/14/22 was reviewed. The MDS section "G” titled "functional status assessment”, indicated, Resident 1 required extensive assistance and one staff member physical assistance with toilet use and extensive assistance and one staff member physical assistance with transfers to and from bed, chair and wheelchair. MDSC stated an extensive assist meant that staff would have to assist hands on and physically help Resident 1 with toilet use. During a telephone interview with CNA 2 on 1/11/23, at 11:46 a.m., CNA 2 stated she was the assigned CNA to care for Resident 1 on 12/23/22. CNA 2 stated, she witnessed Resident 1 ambulate to the restroom located in Resident 1's room with her walker. CNA 2 stated she did not assist Resident 1 to the restroom and proceeded to sit down to feed another resident in the room for breakfast. CNA 2 stated as she was going to sit down to feed another resident when she heard a "loud "sound from Resident 1's restroom. CNA 2 stated she went to the restroom and found Resident 1 lying on her left side on the ground in-between the toilet and the wall. CNA 2 stated Resident 1 "never” used the call light for assistance, and she would observe her at times ambulating herself to the restroom. CNA 2 stated Resident 1 did not need supervision during toileting and that after the fall on 12/23/22, Resident 1 became “more tired” not wanting to participate in activities as she did before. Resident 1's "Progress Note (PN)," dated 12/23/22, the PN indicated, " ...CNA reported to LN [Licensed Nurse] at approximately 0745 [7:45 a.m.] stated heard a fall in restroom, LN went into restroom found resident was on the floor left side leaning against wall in a sitting position with slippers on ...pain in left shoulder radiating down arm to elbow ...pain level ...6 out of 10 [pain assessment zero means no pain and ten means worst pain] ...administered Acetaminophen [pain medication] tab [tablet] ...Notified MD [Medical Doctor] gave order for X-ray (an imaging study that takes pictures of bones) of left shoulder…" During a telephone interview on 1/11/23, at 12:04 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, during her medication pass on 12/23/22 CNA 1 informed her that Resident 1 had fallen. LVN 1 stated, she went to Resident's 1 room and found her on the ground in the restroom on her left side facing the toilet. LVN 1 stated, Resident 1 was completely dressed and complained of pain when her left arm was touched. LVN 1 stated, she called the physician and obtained an order for an X-ray which revealed a shoulder fracture. LVN 1, stated Resident 1's fall also resulted in pain and the need to immobilize her left hand. LVN 1 stated, Resident 1 had dementia and would overestimate her abilities. LVN 1 stated Resident 1 should not have been left unattended when she was observed ambulating to the restroom by CNA 1. LVN 1 stated staff should have assisted Resident 1 by removing her clothes and assisting her to sit on the toilet to prevent a fall. Resident 1's "Radiology Report" (RR), dated 12/23/22, the "RR" indicated, "Shoulder ...Left ...Fracture of the surgical neck [area of the bone] … " Resident 1's "Progress Note" (PN), dated 12/25/22, the PN indicated, " ...having pain r/t [related to] fracture. [medication name (acetaminophen)] is ineffective. Telephone call to MD [medical doctor] and received order for Tramadol [narcotic pain medication used for moderate to severe pain] ..." Resident 1's "Progress Note" (PN), dated 12/27/22, the PN indicated, " ...bruising noted to L [left] side of jaw line, dark in color, delayed injury to fall ...scattered bruising throughout L [left] hand to L [left] forearm, dark in color, delayed injury r/t fall ... " Resident 1's "Progress Note" (PN), dated 12/27/22, the PN indicated, " ...Resident has c/o [complain of] pain and after given tramadol, had an increase of pain from 5 to 10. MD notified ...Gave order to begin fentanyl patch [narcotic pain medication] ... " Resident 1's "Progress Note" (PN), dated 12/28/22, the PN indicated, " ...L [left] arm appeared discolored and extensively swollen ...fingers swollen ..." During a concurrent interview and record review on 1/11/23, at 12:59 p.m., with the Director of Nursing (DON), Resident 1's Care Plan (CP)dated 8/17/21 was reviewed. The CP indicated, "The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] Mobility, Advancing age, weakness, dementia, heart problem ...Interventions ...Toilet Use: The resident requires limited by 1 staff for toileting ..." The DON stated Resident 1's current ADL care plan had not been updated since 2021 to reflect her current assessed need which required extensive assistance with toileting. The DON stated the purpose of Resident 1's care plan was to guide Resident 1's care and implement interventions for staff to follow. The DON stated the CNA's have access to the care plan and should review it when caring for residents. The DON stated according to the MDS dated 11/14/22, Resident 1 required extensive physical assist with toileting. The DON stated if staff see Resident 1 self-ambulating to the restroom they should, "help her if they see her and assist her to the toilet". The DON stated the MDSC should have ensured that the care plan was updated and current with Resident 1's assessed needs but was not. During a concurrent interview and record review on 1/11/23, at 1:20 p.m., with the DON, Resident 1's "Care Plan (CP)”, dated 12/23/22 was reviewed. The CP indicated, "The resident had fall on 12/23/22 with injury ...Place Stop and Call don't fall sign ... " The DON stated on 12/23/22 the only new intervention that had not been implemented previously that the interdisciplinary team (IDT) (group of professionals from the facility that meet to address the residents' needs) recommended was placing the sign "Stop and Call don't fall" as an intervention to prevent future falls. The DON stated there was no assessment done to verify if Resident 1 was able to read the sign. The DON stated the sign was not posted near resident 1 and instead it was placed between bed B and bed C. The DON stated the intervention was not effective since there was no determination if Resident 1 could read the sign and was not placed in her view. The DON stated that there were no new interventions in place to prevent another fall. During a concurrent interview and record review on 1/11/23, at 1:30 p.m., with the DON, the facility policy titled "Fall Management Program" dated 6/2022 was reviewed. The policy indicated," ...To prevent resident falls and minimize complications associated with falls through the development of a Fall Management Program ...The Facility has developed a Fall Management Program that strives to prevent resident falls through meaningful assessments, interventions, education, and reevaluation ...The Nursing Staff will develop a plan of care to the resident's needs with interventions to reduce the risk of falls. Interventions will be implemented or changed based on the resident's condition and response ... " The DON stated the care plan should have been revised and new interventions implemented to reduce the risk of falls for Resident 1 after the falls on 7/19/22 and 12/23/22. During a review of the facility's policy and procedure (P&P) titled, "Care Planning," dated 12/2015, the P&P indicated," ...To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs ... The IDT will revise the Care Plan as needed at the following intervals: ...As dictated by changes in the resident's condition ...Other times as appropriate or necessary ..." In violation of the above cited standards, the facility failed to ensure Resident 1's environment remained free of accident hazards when care plan interventions did not reflect the one-person physical assist required by Resident 1 when toileting and the facility did not implement effective interventions to prevent future falls after Resident 1 had two falls on 7/19/22 and 12/23/22. This failure resulted in Resident 1 experiencing an unwitnessed fall in the restroom on 12/23/22, resulting in Resident 1 suffering pain, bruises, fracture (partial or complete break in the bone) of the left shoulder and immobilization of the left hand, and placed Resident 1 at risk of continued falls. These violations presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result and constitutes an A Citation.