Other·December 12, 2023

Health and Safety Code Section 1424 (d): Class "A" violations are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. Title 42, Federal Code of Regulations, Section 483.25, Subdivision (d) Quality of care is a fundamental principle that applies to all treatment and care provided to facility patients. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: (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. The Department determined during the investigation of a facility reported incident and complaint, the facility failed to protect Resident 1 from wheeling herself out to the patio and opening an unlocked gate. As a result of this failure, Resident 1 fell eight steps in her wheelchair and sustained a closed fracture of left distal radius (broken wrist), rotator cuff tear (a rip in the group of four muscles and tendons that stabilize your shoulder joint and let you lift and rotate your arm) to her left shoulder, compression fracture of L1 vertebra, and compression fracture of T6 vertebra (two broken bones of the spine). Review of Resident 1's clinical records (face sheet) set forth that Resident 1 was a 94-year-old female, originally admitted on 2/1/10 with diagnoses including but not limited to, vascular dementia (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage), Alzheimer's disease (progressive type of dementia beginning with mild memory loss), and sarcopenia (age related, involuntary loss of skeletal mass and strength). Review of Resident 1's "Minimum Data Set," (MDS - a comprehensive assessment), dated 11/15/22, the MDS indicated, Resident 1 was usually understood and usually understood others, vision was moderately impaired (limited vision but can identify objects), had a "Brief Interview for Mental Status - BIMS," score of 3 (The BIMS test is used to get a quick snapshot of how well a resident is functioning cognitively at the moment and ranges from 0 - 15. A score of 3 indicates Severe cognitive impact). Resident 1 required extensive assistance of one person for bed mobility, transferring, toilet use and personal hygiene. Resident 1 was not able to walk, used a wheelchair and was able to wheel self. Review of Resident 1's "Treatment Administration Record," (TAR - is a report detailing treatment administered to a resident by health facility), dated January 2023 and February 2023, the "TAR" indicated, during the month of January 2023, Resident 1 had 45 episodes of leaving the facility without assistance and 91 episodes of wandering around the facility and into other residents' rooms. From February 1, 2023, through February 4, 2023, Resident 1 had 10 episodes of leaving the facility without assistance and 7 episodes of wandering around the facility and into other resident's rooms. Review of Resident 1's, "Attending Note," dated 2/5/23, the Note indicated, "94 (YOF year-old female), wheelchair bound, was able to navigate through a door in the back station with her wheelchair and then attempt to go downstairs where she fell sustaining injuries to her face and head. She was taken to VCMC ER where she had laceration repair. I discussed with the ER doctor, who said she did not have a subdural hematoma on imaging and had a non-displaced wrist fracture requiring a splint ..." Review of Resident 1's, Nurse Note," dated 2/9/23, the Note indicated, "Note Text: ... Noted with several fractures on left shoulder, left arm and thoracic-lumbar area ..." Review of Resident 1's hospital records, "Physician Progress Note," dated 2/8/23, indicated, Resident 1 was confirmed to have a closed fracture of left distal radius (broken wrist), rotator cuff tear, compression fracture of L1 vertebra, and compression fracture of T6 vertebra (two broken bones of the spine). During a concurrent observation and interview on 2/7/23, at 12 p.m., with the Director of Nursing (DON), the patio was observed where Resident 1 was found after a fall on 2/4/23 around 12:50 p.m. The patio had a gate in front of eight steps leading to the back parking alley. The doorway to the patio currently is outfitted with an alarm when the door is opened, and the gate currently has a lock on it. DON stated, "At the time of the fall on 2/4/23 there was no door alarm, and the gate was always closed but there was no lock on it. The facility took those measures after the incident. Resident 1 had two wander guards (lightweight bracelet device that emits an alarm to alert staff when a resident lingers near an exit or attempts to leave), one on the wheelchair and one on the resident's ankle. Resident 1 also had a removable Velcro lap belt, which sounded an alarm when the resident fell. Licensed Nurse (LN 1) heard the alarm and Resident 1 calling for help and found Resident 1 at the bottom of the stairs that lead to the back parking lot, still attached to the wheelchair. Resident 1 had moderate bleeding from the forehead and a skin tear to right forearm. (Resident 1) complained of everything spinning, 911 was called immediately." During an observation of the patio, the patio was measured by the surveyor. The patio is 11 feet, 5 inches to the gate, the gate is 3 feet, 2.3 inches in width with an unlocked latch that Resident 1 was able to reach and open. Past the gate was a stairway downward consisting of 8 stairs, measuring 8 feet, 6 inches long. Resident 1 had opened the exit door at station 2 that led out to the patio, while in her wheelchair. The exit door was unlocked and lacked a working Wanderguard alarm. During an interview on 2/7/23, at 1 p.m., with Licensed Nurse (LN 1), LN 1 stated, on day of the injury LN 1 was alerted to the sounds of Resident 1 calling out for help and the sound of her self-release Velcro wheelchair seat belt alarm. Resident 1 was found lying on the concrete, head facing the stairs on her left side in fetal position still attached to her wheelchair with the seat belt detached. During an interview on 4/3/23, at 1:48 p.m., with Licensed Nurse (LN 1), LN 1 stated, Resident 1 is notably an exit seeker, constantly going to the front entry looking for her mom. Resident 1 requires extensive assistance with her activities of daily living, and is redirectable, but can be more restless than usual at times. She will curse in Spanish if agitated, will go into other residents' rooms, and take their belongings, and tries to get out of bed or wheelchair by herself. On the day of the fall, Resident 1 woke up before noon and began roaming around the facility in her wheelchair. LN 1 stated, she went on break around 12:45 and came back 5-10 minutes later when she took a phone call at the nurse's station, which is when she heard Resident 1's seat belt alarm. During an interview on 4/3/23, at 10:30 a.m., with Administrator (ADM), ADM stated, there were no working alarms at the patio exit by station 2 prior to the accident. When asked if there should have been a door alarm or working Wander guards on the exit by station 2, ADM stated, "In retrospect, yes." During an interview on 4/3/23, at 2:03 p.m., with Licensed Nurse (LN 2), LN 2 stated, on the day of the injury, she witnessed Resident 1 trying to go out of the front door earlier that day, LN 2 described the front entryway as Resident 1's "favorite exit seeking door," and stated that Resident 1 constantly requires redirection, and is also known to go into other people's rooms. LN 2 stated she ran outside after hearing the commotion and saw Resident 1 at the bottom of the stairs. During an interview on 4/4/23, at 1:30 p.m., with Certified Nurse Assistant (CNA 1), CNA 1 stated, she is regularly assigned to Resident 1's care. CNA 1 stated that Resident 1 likes to wander, can be difficult to redirect at times as she can start cursing in Spanish at staff. Once up in her wheelchair she goes around the entire facility, trying to exit, and goes into other residents' rooms. CNA 1 added, "We know to keep our eyes on her at all times, I'm already familiar with her behavior but the Charge Nurses remind us as well." Review of the facility's policy and procedure (P&P) titled, "Falls - Clinical Protocol," dated March 2018, under the section titled, "Monitoring and Follow-up" the P&P indicated, "2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling...b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented." Review of the facility's P&P titled, "WANDERGUARD, Code alert, etc. Resident Monitoring System," (undated), The P&P indicated, "Policy: It is the policy of this facility to provide a safe and secure environment to ensure the safety of any resident attempting to elope from the facility. It is our policy once an elopement risk evaluation has identified a resident at risk; the following steps are implemented in conjunction with the Elopement Prevention Policy. Procedure: 1. The Nurse, Social Services IDT, or designee determines if resident needs to be placed on a monitoring device system...5. The Nursing Department or designee tests the monitoring device wore on resident at least weekly or as determined by the facility...6. The Maintenance Department or designee tests the monitoring system at identified exit points at least weekly using the testing equipment/device provided by the manufacturer to ensure proper working condition and will document testing on the Monitoring Device testing log...8. Nursing staff or designee will notify administrator and/or DON of the system failure. Then the facility begins back up procedures to safeguard against elopements. (Conduct visual checks for residents with monitoring devices and record checks utilizing the POC CNAs task)." The facility was unable to provide a P&P for accidents and supervision. The facility failed to protect Resident 1 from falling down eight steps in her wheelchair. As a result of this failure, Resident 1 sustained multiple injuries, including several debilitating fractures. As a result of these injuries, Resident 1 is unable to wheel herself around the facility and is only able to be upright in a chair for a short time. In addition, Resident 1 must wear a TLSO brace due to vertebrae fractures that she tries to take off and finds uncomfortable. Resident 1's pain medication and antianxiety medication frequencies have been increased due to increased pain and anxiety. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.