Health inspection·July 11, 2022

§ 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. 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 residents' choices. The facility failed to provide services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment, physician's order, and plan of care for one of three sampled residents (Resident 1) when licensed nurses failed to: 1. Complete Resident 1's post fall neurological assessment after unwitnessed fall incidents per facility's protocol 2. Accurately assess Resident 1 upon admission, and develop an individualized resident-centered care plan to address Resident 1's communication concerns. 3. Follow Resident 1's physician's order to do an X-ray (type of radiation called electromagnetic waves that creates pictures of the inside of the body) of left lower extremity (refers to the part of the body from the hip to the toes which includes the hip, knee, and ankle joints, and the bones of the thigh, leg, and foot). 4. Get a physician's order for Resident 1 acute hospital transfer for further evaluation and management upon identification of resident's persistent swelling, discoloration and pain on her left lower extremity. 5. Provide Resident 1's pain management as indicated. These failures resulted in inability to timely identify the presence of Resident 1's fracture that contributed to her discomfort, and compromised her health and care because of delayed acute hospital's evaluation, required treatment and surgical intervention. A review of Resident 1's face sheet indicated admission on 7/1/21 with diagnoses of Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks, and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with behavioral disturbance. Her minimum data set (MDS-an assessment tool) dated 7/7/21, indicated short and long term memory problems with severely impaired cognitive skills for daily decision making, and required extensive physical assistance of two staff on bed mobility, transfer, dressing; one person extensive assistance on eating, toilet use and personal hygiene; history of fall with minor injury; 1. A review of Resident 1's SBAR (Situation, Background, Assessment, and Recommendation/Request - a form of nurses progress notes to communicate with physician) dated 7/1/21 indicated Resident 1 had an unwitnessed fall when found sitting on the floor in her room and sustained skin tear on her left forearm. Resident had another unwitnessed fall on 7/14/21 when she was found lying on the floor by the lobby. During an interview and concurrent record review with registered nurse A (RN A) on 3/17/22 at 12:40 p.m., RN A upon review of Resident 1's clinical record confirmed the post fall "Neurological Flowsheet" dated 7/1/21 and 7/14/21 were not completed as per facility's policy and protocol. RN A stated Neuro checks should be completed by licensed nurses for any unwitnessed fall, and fall with possible head injury for 72 hours. A review of the facility's revised 4/2016 policy and procedure, "Accidents and Incidents-Investigating and Reporting", indicated the licensed nurses shall conduct neurological assessment of resident/s who had unwitnessed fall, any visual or suspected head injury and document the results on the Neurological Assessment form ...". A review of the facility's August 2002 revised policy and procedure, "Neurological Assessments", indicated neurological assessments are the responsibility of licensed nursing personnel and it should include determination of the state of consciousness, vital signs (temperature, pulse, respirations, blood pressure), pupillary reaction, motor ability. Document the date and time the procedure was performed and all assessment data obtained during the procedure. 2. A review of the IDT (interdisciplinary team-facility staff members from different departments who coordinate care provided to residents) "Post Fall Review" dated 7/2/21 indicated, Resident 1 was unable to relate what happened due to confusion and language barrier and spoke non-English language only. A review of Resident 1's "eINTERACT Change in Condition Evaluation" (COC) dated 7/14/21 indicated she had a fall, and the "Interdisciplinary Post Fall Review" dated 7/15/22 indicated, " LN responded to a loud noise and someone saying why from the lobby and noted resident lying on the floor on the left side on 7/14/21 at 22:00, Resident unable to tell what happened due to language barrier .....Assisted back to her wheelchair by three (3) staff." During an interview with certified nursing assistant B (CNA B) on 4/13/22 at 10:13 a.m., she stated Resident 1 was confused, spoke her native language and was unable to communicate her needs to staff using the English language. CNA B also stated, "can not understand her". During an interview on 4/13/22 at 10:40 a.m., licensed vocational nurse C (LVN C) confirmed Resident 1 did not speak English, could not understand resident's language and did not use any communication board when he communicated with her. During an interview on 4/13/22 at 11:32 a.m., licensed vocational nurse D (LVN D) stated she was unable to communicate with Resident 1 using the English language, and had not used any communication board except to rely on gestures and facial expressions. During an interview on 4/13/22 at 12:10 p.m., RN A confirmed Resident 1 spoke her native language, she was difficult to understand and had to call resident's son for interpretation. During the concurrent record review with RN A and the director of nursing (DON), the DON and RN A reviewed Resident 1's "Baseline Care Plan and Summary" dated 7/1/21 which assessed Resident's communication ability, and fall risk and they both confirmed the assessment was not accurate. The DON stated the assessment did not accurately reflect Resident 1's inability to understand and communicate easily with staff, and the need for an interpreter. The assessment did not also reflect Resident 1's risk for fall. RN A stated, Resident's son indicated resident had previously fallen at home. Both RN A and the DON concurred staff's admission assessment should be accurate as these were the bases for resident's plan of care. RN A reviewed Resident 1's care plan and also could not find any documented evidence that a care plan to address Resident 1's communication problem was developed. A review of the facility's 11/20/2017 revised policy and procedure, "Baseline Care Plan", indicated a baseline care plan provides an effective and person-centered care of the resident that meet professional standards of quality care shall be developed and implemented for each resident by the Interdisciplinary Team (IDT). It is developed within 48 hours post admission. A review of the June 2008 policy and procedure, "Residents with Communication Problems", indicated the facility will provide communication aids to all persons with sensory impairments. Staff will assess the resident's ability to communicate at the time of admission and as needed. Staff will provide adaptive devices as needed to enable the resident to communicate as effectively as possible. 3. A review of Resident 1's Nurses Progress Notes dated 7/16/21 indicated, " During bedside care, was noted with L LE (left lower extremity) generalized swelling plus guarding, screams in pain with mobility ....". A review of Resident 1's physician's phone order summary dated 7/17/21 included, "X-ray on her L LE STAT (immediately) for Swollen Left Lower extremity". A review of the "Radiology Report" dated 7/17/21 indicated , "TIBIA/FIBULA AP (anterior posterior) and LAT (lateral-side of), LEFT Results: No acute fracture or dislocation is seen.". The tibia and fibula are the two long bones located in the lower leg. The tibia is a larger bone on the inside, and the fibula is a smaller bone on the outside. AP and LAT (anterior or front, posterior or back and lateral or side). During a record review and concurrent interview with RN A on 3/17/21 at 1:15 p.m., RN A reviewed Resident 1's X-ray order dated 3/17/21. RN A stated the physician's order was X-ray of L LE which meant left lower extremity that included from hip to foot. RN A confirmed the X-ray done did not include the hip. During an interview with the minimum data set coordinator (MDSC) and DON on 3/17/22 at 3:32 p.m., the MDSC stated the licensed nurse who received the physician's phone order for the X-ray did not verify and make certain the correct body part/location to do x-ray of the left lower extremity that included the hip, thigh, knee down to the toes was done as ordered. During a follow up interview with RN A and the DON on 4/13/22 at 12:10 p.m., RN A stated she was focused on the x-ray results that there was no fracture and missed to check the X-ray was done on correct site/location of the body part. RN A also stated, the nurse should have taken another order to check the swollen body part which was the left hip. Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated registered nurses should follow the physician orders. 4. A review of Nurses Progress Note dated 7/17/21 indicated Resident 1's son and daughter in law visited resident on 7/17/21, and son expressed concerns over her mother's swelling on left side. A review of the "Nurses Progress" notes dated 7/17/21 indicated, "Received X-ray result for tibia/tibula AP and LAT, Left: No acute fracture or dislocation is seen, MD and RP son notified", on 7/18/21, Resident 1 was still noted with left lower extremity, was screaming and during incontinent (lack of voluntary control over urination or bowel movement) care and she became calm after the incontinent care, and on 7/19/21, Resident 1 was "still with episodes of screaming while 2 RCS (resident care specialist) was doing bedside/incontinent care; and stops screaming post care". A review of Resident 1's progress notes, Long Term Care Evaluation dated 7/23/21 indicated, "multiple bruising post fall noted on L LE", and the "Social Services Notes" dated 7/27/21 indicated Resident 1's son inquired about the doctor's visit and about resident's left leg swelling. A review of the "Nursing Progress" note dated 7/28/21 indicated, " Resident new onset of increasing pain as evidence by yelling and guarding pain of the left leg and hip when being given bed care and transfer, communicated to MD with no reply ....". A review of the "Nursing Note" dated 7/31/21 indicated, "was transferred to bed; noted r/l foot swelling ... ... screaming during bedside care given by 2 RCS then stops post care ...". A review of the "Progress Notes" dated 8/2/21, PT (physical therapy) screen completed , unable to tolerate STS (sit to stand) and walking due to LE swelling and guarding with minimal mobility despite pre-pain meds and worsening dementia ....". During an interview with CNA B on 4/13/21 at 10:10 a.m., CNA B stated she took care of Resident 1 regularly since admission and even after her fall incident. CNA B also stated Resident 1 "had a fracture on her left hip" because everyone could see the swelling and bulging on the hip few days after resident's fall. CNA B claimed Resident 1 complained of pain when moved every time she would provide care, and had reported always to her charge nurses including the presence of swelling on the left hip. During a record review and concurrent interview with RN A and the DON on 4/13/22 at 12:10 p.m., RN A stated she was focused on the x-ray results that there was no fracture and missed to check site/location of the body part that they did. The DON and RN A both confirmed there were documented evidences that nurses had consistently and repeatedly observed Resident 1 was screaming of pain during resident care since 7/17/21 . RN A stated, LVN C or RN D and herself (RN A) who were aware of the swelling on Resident 1's left hip should have taken another order to check the swollen body [art (left hip).The DON stated most of the staff assigned to Resident 1 were aware of the swelling and discoloration on resident's left hip, leg and foot. During an interview with registered nurse D (RN D) on 4/19/22 at 3:12 p.m., RN D stated she was Resident 1's regular charge nurse for evening shift. Reviewed with RN D her nurses notes from 7/17/21 to 8/6/21 and she confirmed Resident 1 started to have swelling and pain on her left hip since 7/17/21 after her fall on 7/14/21 and it persisted until her hospital transfer. RN D also validated resident had episodes of screaming of pain during ADL (activities of daily living such as personal hygiene, toileting, transfer, etc.) care. RN D also stated certified nursing assistant E (CNA E) and certified nursing assistant F (CNA F) reported to her regarding Resident 1's left hip swelling that they noted during provision of care. RN D concurred that the repositioning and movements during care could have contributed to Resident 1's pain. RN D stated she had informed her former DON about Resident 1's increased and widespread discoloration that extended on her mon pubis (rounded area in front of the pubic bones at the lower part of the belly. RN D concurred if the x-ray was performed on the correct body part and identified there was fracture then Resident 1 would have not suffered this much pain because she could have been sent out to acute and managed promptly. During the concurrent review with RN D, she confirmed Resident 1's "Head to Toe Skin Checks done on 7/23/21 indicated she had bruise on left side of head, left lower extremity, left inner and posterior thigh, mon pubis. During an interview with the primary care physician (PCP) on 4/19/22 at 4:15 p.m., he stated that left lower extremity would include all the joints including the hip. The PCP concurred if the nurse followed the physician's order to perform an x-ray on the correct body part then the fracture could have been identified earlier. During an interview with the activity supervisor (AS) on 4/19/22 at 4:40 p.m., the AS claimed Resident 1 had been attending and actively participating in the daily activities in the activity room prior to her fall on 7/14/21 but she was "different" after the fall. The AS stated Resident 1 had not attended the activities regularly, and if she attended she could not tolerate being up in her wheelchair log enough to finish any activity, and often exhibited facial grimacing, signs of discomfort. The AS stated having notified the former director of nursing about Resident 1's facial grimacing and changes in her activities. A review of the progress notes dated 8/6/21 indicated Resident 1 was transferred to acute hospital per her son's request. A review of the acute hospital's Emergency Department "ED PROVIDER NOTE" dated 8/6/21 indicated, "presents by ambulance from nursing home to the ED for fall on July 17. She seems to have left hip/thigh pain. Had x-ray done at the nursing home which supposedly showed no fracture. Patient seems to have continued pain in the left leg. Increased swelling ..... Anytime patient gets moved and palpated around her left hip and thigh, she started screaming ....She has a bruise over her pubic bone ... Also, patient is normally able to walk with a walker and assistance.". A review of the acute hospital's "Physician Discharge Summary dated 8/18/21 indicated R