Other·November 23, 2021

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 1/12/2021 at 11:25 a.m., an unannounced visit was conducted at the facility to investigate an entity reported incident regarding Resident 1's unwitnessed fall with injury that occurred 12/22/2020. Resident 1 was assessed as being a high fall risk, had a history of falls in the facility, a known behavior of getting up unassisted from the bed and the facility created a comprehensive care plan intervention of a pressure pad alarm (a device applied to the bed surface that beeps when the resident tries to get up) to alert staff of Resident 1's attempt to get out of bed unassisted. On 12/22/2020, the pressure pad alarm was not turned on and was not connected to the alarm pad box. This resulted in Resident 1 getting out of bed unassisted. Resident 1 sustained a fall, resulting in a left upper leg posterior and left hip femoral neck (bone that connects the hip and the upper thigh bone) impaction fracture (broken bone in the hip) and experienced pain. Resident 1 required a six-day hospitalization, from 12/22/2020 to 12/28/2020. The facility failed to implement its fall risk care plan for Resident 1 when the pressure pad alarm was not turned on and was not connected to the alarm pad box on 12/22/2020. Resident 1 was a 79-year-old female, admitted to the facility on 4/6/2020. Resident 1 had diagnoses that included Parkinson's disease (a progressive nervous system order that affects movement and causes tremors, slow movements, rigid muscles, impaired posture and balance), difficulty walking, muscle weakness, dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), anxiety (intense, excessive and persistent worry and fear about everyday situations) and osteoarthritis (is a joint disease which causes joint pain, stiffness and swelling). Resident 1 had moderate cognitive impairment in decision making during activities of daily living and required cues and supervision. During a telephone interview, on 1/20/2021, at 1:34 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was a CNA employed through a registry/agency (a company that refers employees to employers for temporary or long-term work) utilized by the facility as needed for staffing needs. CNA 1 stated she was assigned to work the night shift (11 p.m. to 7 a.m.) on 12/22/2020 and was the CNA assigned to Resident 1. CNA 1 stated on 12/22/2020, Resident 1 was very confused, kept getting up from her bed, had weakness and her gait was unsteady. CNA 1 stated the p.m. shift CNA (2:30 p.m. to 10:30 p.m.) informed her during the change of shift report that Resident 1 was very confused and kept getting up from her bed. CNA 1 stated she was not aware Resident 1 had a history of falls or was a high risk for falls or used a pressure pad alarm in the bed. CNA 1 stated the night shift Licensed Nurse (LVN 1) did not inform her that Resident 1 was a high fall risk and had a pressure pad alarm. CNA 1 stated she did her first rounds (observe the physical and mental condition of the resident) after getting report from the p.m. shift nurse but did not check for pressure pad alarm placement. CNA 1 stated she could not recall the exact time she saw Resident 1, but it was during her first rounds around 12 a.m. when she checked Resident 1's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). CNA 1 stated, " ... [Resident 1] gets up all the time that night (12/22/2020).... I did not check at the beginning of my shift if she had a bed alarm because I did not know she used a bed alarm. At around [1 a.m. to 1:15 a.m.], I heard somebody screaming in the hallway and I saw her [Resident 1] on the floor. She complained of leg pain, but she always had leg pain before. I saw the [pressure pad alarm] and it was not properly connected. It was connected and plugged to the phone line ... [the facility] is always short staffed so it's very scary. They should be giving reports about the resident if they are high risk for falls especially, we are from the registry and we are not familiar with the residents in the facility..." CNA 1 stated if she knew Resident 1 had a pressure pad alarm, she would have checked if it was working and plugged in the alarm box. CNA 1 stated Resident 1 does not walk fast and if the pressure pad alarm was connected properly and not in the telephone line, it would have made a loud sound when Resident 1 attempted to get up on her own unassisted and could have prevented her fall. CNA 1 stated the pressure pad alarm makes a loud sound when residents attempt to move or get up and would prompt her to respond and check on Resident 1. CNA 1 stated she had worked in different skilled nursing facilities as a CNA for registry/agency staffing, and she was familiar with pressure pad alarms being used as fall intervention for residents at high risk for falls. During a review of the facility document titled, "Certified Nursing Assistant Job Description" dated October 2012, the Job Description indicated, "... The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors ... Ensure that residents who are unable to call for help are checked frequently. Answer resident calls promptly ... Meet with your shift's nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or the improvement of services ..." During a telephone interview, on 1/22/2021, at 10:55 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he started working in the facility in November 2020. LVN 1 stated Resident 1 was alert, forgetful and had confusion. LVN 1 stated Resident 1 required one to two people assist with ADL's (activities of daily living - a term used in healthcare to refer to patients' daily self-care activities) and "she would try to get up on her own a lot without using the call light." LVN 1 stated Resident 1 had a history of falls in the facility and was a very high risk for falls because of her behavior of trying to get up unassisted. LVN 1 stated Resident 1 had a pressure pad alarm. LVN 1 stated it was very important for the nurses and the CNAs to check the pressure pad alarm if it was properly working especially if a resident is high risk for falls. LVN 1 stated he was not aware if CNA 1 knew Resident 1 used a pressure pad alarm while in bed. LVN 1 stated it was the responsibility of the Licensed Nurses to inform CNAs if a resident was high risk for falls, to check for placement of pressure pad alarms and to ensure the pressure pad alarm was properly working. LVN 1 stated the facility started to utilize staff from registry/agency to meet staffing needs. LVN 1 stated CNAs employed through the registry/agency were not that familiar with the residents in the facility so it was very important to inform registry/agency staff if a resident was a high risk for falls and the interventions to prevent falls. LVN 1 stated he saw Resident 1 on the floor and stated Resident 1's pressure pad alarm was a very important fall prevention intervention to prevent her falling because it would usually make a very loud sound whenever Resident 1 would attempt to move or get up from the bed unassisted. LVN 1 stated the pressure pad alarm was supposed to be plugged in the alarm pad box and not in the telephone line and it was not done. LVN 1 stated if Resident 1's pressure pad alarm was plugged in the alarm pad box, the staff could have heard when Resident 1 tried to get up and walked unassisted from her bed and could have potentially prevented her from fall and injuries. During a review of the facility document titled, "Licensed Vocational Nurse Job Description" dated November 2018, the Job Description indicated, "The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants.... Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility ...... Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards ...Make periodic checks to ensure that prescribed treatments are being properly administered by certified nursing assistants and to evaluate the resident's physical and emotional status ... Ensure that residents who are unable to call for help are checked frequently ... Monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies ... Review care plans daily to ensure that appropriate care is being rendered .... Ensure that your assigned certified nursing assistants (CNAs) are aware of the resident care plans. Ensure that the CNAs refer to the resident's care plan prior to administering daily care to the resident ..." During a telephone interview, on 1/25/2021, at 10:28 a.m., with CNA 2, CNA 2 stated she worked as per diem (as needed) in the facility, particularly on p.m. shifts. CNA 2 stated she was aware when Resident 1 fell on 12/22/2020. CNA 2 stated she took care of Resident 1 several times and was familiar with her care. CNA 2 stated, " ... [Resident 1] is alert ... knows me by name, confused at times ... Most of the time she would call out and not use the call light. She is a high risk for fall. She's impulsive (doing things or tending to do things suddenly and without careful thought) to a point but slow moving. She is very slow moving and moves very slowly. She needs help before she can get up ... She did have a pad alarm ... If a resident is a high risk for fall, we checked on them every 15 minutes and check the bed alarm if it is turned on. If the bed alarm was working and plugged correctly, [staff] would know if a resident tried to get up. There would be no reason [Resident 1] can unplug the bed alarm. She couldn't even move when she is in her wheelchair. We had to push her so I don't see how she can unplug her bed alarm on her own ... [staff] could hear her bed alarm because it makes a really loud sound ..." CNA 2 stated Resident 1's room was close to the nurse's station so if her bed alarm was plugged in the alarm pad box and was checked for proper placement, staff could have heard it [loud noise from pad alarm] when Resident 1 got up unassisted and could have prevented her fall. During a telephone interview, on 1/26/2021, at 12:21 p.m., with CNA 3, CNA 3 stated she was familiar with Resident 1's care. CNA 3 stated she was the p.m. shift nurse on 12/21/2020 and gave report to CNA 1 on the night shift. CNA 3 stated, " ... That day [12/21/2020], [Resident 1] got really agitated. She was trying to get up a lot, multiple times. She was moving a lot. I remember telling [CNA 1] that she was very agitated that time. She will sit on the edge of the bed trying to get up. She is a very high risk for fall ..." CNA 3 stated Resident 1 had a pressure pad alarm in the bed because she was a very high risk for falls. CNA 3 stated, "I remember her bed alarm makes a really loud sound. When a bed alarm is functioning, it flashes a red light in the [pad alarm] box when it's properly connected, and it makes a sound when resident moves or attempts to get up and we would hear it and check on the resident. She is a very high fall risk. She was so weak and confused. The bed alarm is very important for her and it's important for a bed alarm to be properly placed and connected to prevent a fall ..." CNA 3 stated it was the Licensed Nurse and CNA's responsibility to check at the beginning of the shift and during rounds if the pressure pad alarm is properly placed and connected. During a telephone interview on 1/26/2021, at 1:35 p.m., with the Director of Nursing (DON), the DON stated Resident 1 was alert with periods of confusion. The DON stated CNA 1 was employed through the registry/agency and provided care to Resident 1 on night shift on 12/22/2020. The DON stated Resident 1 had a pressure pad alarm in her bed because she was a high risk for falls and had history of falls in the facility. The DON stated Resident 1 had an unwitnessed fall back in 11/2020 with no injuries. The DON stated the pressure pad alarm was ordered by Resident 1's physician (MD) on 4/6/2020. The DON stated Licensed Nurses and CNAs should have known Resident 1 was a high risk for falls and had a pressure pad alarm in the bed. The DON stated CNA 1 should have checked at the beginning of her shift and in between shifts if Resident 1's pressure pad alarm was properly connected and functioning. The DON stated the purpose of a bed alarm was to notify staff when a resident would try to move or get up on their own unassisted to prompt staff to check on the resident. The DON stated, "It's important for the bed alarm to be inspected every shift and during their multiple rounds for functioning and if it's properly connected [to the alarm pad box]. That is the expectation for the bed alarm to be functioning and connected so when the resident gets up, the bed alarm will sound and alert the staff so staff can respond and prevent a fall." During a telephone interview on 1/26/2021, at 1:53 p.m., with Resident 1, Resident 1 stated, "I did get up on my own. I had a couple of falls last month (December 2020). I experienced some pain in my leg. I broke something and had a fracture. I went to the hospital for a few days. I am receiving pain medications for my fracture ..." Resident 1 stated she did not know if she has a pressure pad alarm in place or if she used the call light when she needs help. Resident 1 stated, " ... I don't know what an alarm is or call light. I just get up on my own without calling for help sometimes ..." During a review of Resident 1's "Admission Record" (a document with personal and medical information), dated 12/28/2020, the Admission Record indicated Resident 1 was admitted to the facility on 4/6/2020, with diagnoses which included Parkinson's disease, difficulty in walking, muscle weakness, dementia, anxiety and osteoarthritis. During a review of Resident 1's "Minimum Data Set (MDS - assessment of healthcare and functional needs) assessment," dated 10/9/2020, the MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS - assessment of cognitive status) score was 10 out of 15 points which indicated Resident 1 had moderate cognitive impairment in decision making during activities of daily living and required cues and supervision. The MDS assessment also indicated Resident 1 required the use of a bed alarm [pressure pad alarm] to monitor resident movement and to alert the staff when movement is detected. During a review of Resident 1's "Nursing Notes", dated 3/10/2020, the Nursing Notes indicated, "C