Other·March 27, 2024

Watsonville Post Acute Center Recertification Survey (72NT11) Exit date: 3/8/24 F689 §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. From 3/4/24 to 3/8/24, an unannounced recertification survey was conducted at the facility. The facility failed to implement fall-related interventions for Resident 32 when staff did not document Resident 32's skid mat (non-slip material) was in place on 6/17/23, when staff did not ensure Resident 32's sensor pad alarm (device that emits an audible alarm when pressure is removed from the sensor pad to alert the caregivers; such as, when the user gets out of a bed or wheelchair) orders were transcribed in the administration records for nurses to document pad placement and functioning, and when the facility failed to provide evidence of periodic staff training on the operation of the sensor pad alarm and daily device testing of the sensor pad alarm per manufacturer's recommendations. These failures in fall-related interventions led up to Resident 32's fall on 6/17/23, from which Resident 32 suffered a fractured clavicle (broken collar bone). Review of Resident 32's Post-Fall Review, dated 6/17/23, indicated the following: "Resident 32 was self-ambulating [moving about] in a wheelchair in the hallway and had an unwitnessed fall on 6/17/23 at 4:23 p.m. ... Resident was observed lying on his right side in the hallway across from room 5. Resident was several feet away from wheelchair. Resident's knees were bent towards chest and arms were in front, but bent at elbows ... IDT [interdisciplinary team, a group of health care professionals from diverse fields who work toward a common goal for residents] met to review Res [Resident 32's] recent falls which resulted in Fx [fracture] to R [right] clavicle ... Resident was more alert ... and self propelling throughout the facility more than usual. Res was noted with discoloration to right shoulder the following morning, MD [Doctor of Medicine] advised to transfer to ER [emergency room] where non-displaced [bone cracks or breaks and maintains proper alignment] clavicle Fx was noted ... Upon further investigation it was determined that the pad alarm was in place, but did not sound. Facility staff to be provided in-service regarding proper placement/use of pad alarms." Review of Resident 32's Imaging Report, dated 6/18/23 indicated, "4 views of the right shoulder were performed ... There is a nondisplaced fracture of the distal clavicle (a break in the collar bone on a side away from a person's midline)." Review of Resident 32's Admission Record, printed 3/6/24, indicated the resident was admitted to the facility with diagnoses including dementia (a group of conditions affecting thinking and social abilities that interferes with daily functioning) and chronic obstructive pulmonary disease (a condition that affects airflow in the lungs and makes it difficult to breathe). Review of Resident 32's Post-Fall Reviews for 2022 indicated the resident had 11 fall incidents in 2022. Review of Resident 32's Post-Fall Reviews for 2023 indicated the resident had 12 fall incidents in 2023. Review of Resident 32's Post-Fall Reviews for 2024 indicated the resident had two fall incidents in 2024. Review of Resident 32's minimum data set (MDS, an assessment tool), dated 6/13/23, indicated he required extensive assistance with one person for bed mobility and transfers. Review of Resident 32's Quarterly Risk Data Collection Tool/Fall Risk Assessment, dated 6/14/23, indicated Resident 32 was at risk for falls. Review of Resident 32's physician orders indicated, "Pad alarm in wheelchair at all times for fall precautions," dated 2/14/22, "Bed alarm [type of sensor pad alarm] when in bed at all times for fall precautions," dated 2/14/22, and "[brand name of a skid mat product] to wheelchair cushion at all times," dated 8/24/22. Review of Resident 32's Treatment Administration Record (TAR, record of treatments given) for June 2023, indicated a physician order for, "[brand name of a skid mat product] to wheelchair cushion at all times every shift," that was not signed by a nurse on 6/17/23 evening shift (3 to 11 p.m.) to indicate whether the order was carried out. Review of Resident 32's Medication Administration Record (MAR, record of medications given) for June 2023 and TAR for June 2023, yielded a lack of documentation to indicate Resident 32's pad alarms were on his wheelchair and bed at all times and whether they functioned. During an interview and record review with the nurse supervisor (NS) on 3/8/24 at 12:26 p.m., he stated it is the licensed nurse (LN) and certified nursing assistants' (CNA) responsibility to check that fall interventions are in place. The NS stated it is also the LN's and CNA's responsibility to check if safety devices, like pad alarms are functioning. The NS stated Resident 32's fall interventions, including the [brand name of a skid mat product], floor mat, and concave mattress (type of mattress with raised sides) are to be signed by nurses in the MAR or TAR when carried out; however, the physicians' orders for pad alarms were not transcribed in Resident 32's MAR; and that, they should have been in order for documentation of their positioning and functioning. The NS confirmed that Resident 32's Post-Fall Review, dated 6/17/23, indicated the IDT determined Resident 32's pad alarm did not sound. He stated he did not remember the reason Resident 32's pad alarm failed to sound. During an interview on 3/8/24 at 2:29 p.m., the NS confirmed Resident 32's [brand name of a skid mat product] placement was not signed in the TAR for the evening shift of 6/17/23. The NS stated he could not confirm whether the [brand name of a skid mat product] was checked. During an interview on 3/8/24 at 10:15 a.m. with the administrator-in-training (AIT), in-service training on the operation of the pad alarms was requested. During an interview with the director of staff development (DSD) on 3/08/24 at 10:21 a.m., in-service training on the operation of the pad alarms was requested. The DSD did not provide any in-service training on the operation of the pad alarms, even though it was requested of her again on 3/08/24 at 3:05 p.m. During an interview and concurrent record review with the NS on 3/8/24 at 3:04 p.m., he searched through an in-service binder for in-service training regarding the operation of pad alarms. The NS provided a copy of an in-service on pad alarms, dated 10/12/22, and stated it was for checking placement of the pad alarms only, and otherwise excluded instructions on the usage/operation of pad alarms. The NS stated he did not think there was an in-service on the usage/operation of pad alarms. During an interview with the NS on 03/08/24 at 3:13 p.m., he stated he would look in a different binder for in-service training regarding the usage/operation of pad alarms; however, no evidence of such in-service training was provided. Review of the facility's policy, "Falls and Fall Risk, Managing," revised 2/7/24, indicated, "In conjunction with the attending physician, licensed staff will identify and implement relevant interventions to try to minimize serious consequences of falling." Review of an undated sensor pad(s) manufacturer's "Installation and Use Instructions" indicated, "We recommend that all caregivers receive periodic training in the operation of these systems and that the devices are tested daily." In violation of the above cited standards, the facility failed to implement fall-related interventions for Resident 32 and the facility failed to provide evidence of periodic staff training on the operation of the sensor pad alarm and daily device testing of the sensor pad alarm per manufacturer's recommendations. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of residents.