Other·May 17, 2024

F684 42 CFR § 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.

F689 42 CFR §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)(2) Nursing Service -General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR §72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On 12/22/23, an unannounced visit was conducted at the facility to investigate a complaint regarding Quality of Care/Treatment: Patient Safety/Falls. The facility failed to ensure supervision was provided to Patient 1 who was assessed to be high risk for falls, totally dependent on staff for transferring, and required close monitoring (staff made rounds and observed the patients at risk of falling) when Patient 1 was left sitting in her wheelchair in the hallway without staff watching and/or supervising her on 6/3/23, at 6:45 a.m., when staff went inside another patient's room. This failure resulted in Patient 1 falling on the floor and sustaining a subdural hematoma (occurs when a blood vessel in the space between the skull and the brain is damaged; blood escapes from the blood vessel, leading to the formation of a blood clot that places pressure on the brain and damages it) on the right temporal region (a region at the side of the head behind the eyes). This blunt force injury of her head was the immediate cause of her death after 15 days in the general acute care hospital (GACH). Patient 1's Admission Record indicated she was admitted to the facility on 8/10/22 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), epilepsy (characterized by recurrent brief episodes of involuntary movement that may involve a part of the body or the entire body and are sometimes accompanied by loss of consciousness and control of bowel or bladder function), muscle weakness, abnormality of gait and mobility, and a history of falling. Patient 1's "Nursing Fall Risk Evaluation", dated 8/10/22, 8/25/22, and 5/24/23, indicated that Patient 1 was at high risk for falls. Patient 1's Minimum Data Set (MDS, a clinical assessment tool), dated 4/8/23, indicated that Patient 1's cognition was moderately impaired, and she needed extensive assistance (staff provide weight-bearing support) with one-person physical assist in transferring to moving between surfaces including to or from bed, a chair, her wheelchair, and in and out of a standing position. Patient 1's "Change of Condition", dated 8/24/22, at 3:50 p.m., indicated on 8/24/22, at around 3:50 p.m., Patient 1 was witnessed standing up from her wheelchair and holding on to the hallway rail. Patient 1 slightly lost her balance. A staff went to Patient 1 and assisted her slowly to the floor. Patient 1's Interdisciplinary Team (IDT, a group of healthcare professionals who work together to provide the patients with the care they need) Notes, dated 8/25/22, indicated that the IDT recommended that Patient 1 should be on closely monitored by group patient monitor staff (a staff assigned to make rounds and observe the patients who are at risk for falling). Patient 1's "Change of Condition", dated 1/25/23, at 1:06 a.m., indicated on 1/25/23, at 1:06 a.m., Patient 1 was found on her room floor and wrapped in her blanket. Patient 1 sustained a 4 centimeter (cm, a metric unit of length) by 4 cm bump on the right side of her forehead. Patient 1's activities of daily living (ADLs, a person's daily self-care activities) care plan, dated 5/24/23, indicated that Patient 1 was totally dependent on one staff for transferring. Patient 1's at risk for fall care plan, dated 5/2/23, indicated that the interventions included were that the facility would closely monitor Patient 1 by group patient monitor staff and frequently check Patient 1 for safety and needs to attain a goal that Patient 1 would not sustain a serious injury related to a fall. Patient 1's "Change of Condition", dated 6/3/23, at 6:45 a.m., indicated on 6/3/23, at 6:45 a.m., Patient 1 was up on her wheelchair in the hallway and that certified nursing assistant A (CNA A) went inside a room to collect the garbage. When CNA A walked out of the room, he noted Patient 1 was on the floor on her right side. Patient 1 apparently had fallen and had sustained a 3 cm by 3 cm bump on her right frontal area. This fall incident resulted in Patient 1 being transferred to the GACH on 6/3/23 for further evaluation and management. During an interview with CNA A on 2/8/24, at 2:20 a.m., he stated he could not recall the date but could recall the incident that happened (referring to the incident that happened on 6/3/23) as it was about the end of the night shift when Patient 1 was up in the wheelchair in the hallway. CNA A stated he was in Patient 1's room helping Patient 1's roommate. When he walked out of the room, he saw Patient 1 on the floor. During an interview with license vocational nurse B (LVN B) on 2/8/24, at 10:45 a.m., she stated she could not recall the date but could recall the incident that happened (referring to the incident that happened on 6/3/23) as it was about the end of the night shift. Patient 1 was up in the wheelchair in the hallway. There were no staff there with Patient 1 at that time because everybody was busy because it was the end of the shift. Then a CNA notified her that Patient 1 had fallen. She came over and saw that Patient 1 was on the floor, and upon assessment Patient 1 had sustained a bump on her forehead. She called the physician and received an order to send Patient 1 to the GACH emergency room via 911 for further evaluation and treatment. Patient 1's Emergency Provider Report, dated 6/3/23, indicated Patient 1 was brought in by ambulance for a fall off her wheelchair at the facility that morning, and that Patient 1 had a right forehead hematoma (a localized swelling that is filled with blood caused by a break in the wall of a blood vessel). Patient 1 was admitted to the GACH for further monitoring and management and remained admitted in the hospital from 6/3/23, until the date of her death on 6/18/23. Patient 1's head computed tomography scan (CT scan, an imaging test that uses a series of X-rays and a computer to create detailed images of the bones and soft tissues) Diagnostic Imaging Report, dated 6/3/23, indicated Patient 1 had sustained a 3.5 millimeter (mm, a metric unit of length) subdural hematoma right high temporal region. Patient 1's Discharge Summary from the GACH, dated 6/18/23, indicated Patient 1 was pronounced dead at around 9:35 p.m. on 6/18/23. Patient 1's Certificate of Death, dated 6/23/23, indicated that blunt force injury of her head from her fall on 6/3/23 was the immediate cause of her death. During an interview with the director of nursing (DON) on 2/13/24 at 2:35 p.m., she stated she was on vacation at the time Patient 1 fell on 6/3/23. The DON further stated that Patient 1 was supposed to have someone watching her. During an interview with the MDS Assistant (MDSA) on 2/14/24 at 4:35 p.m., she reviewed Patient 1's clinical record and stated since Patient 1 needed extensive assistance with one-person physical assist in transferring, staff should have watched Patient 1 while she was in the wheelchair because Patient 1 would have fallen if she stood up by herself. During an interview with the DON on 2/16/24 at 11:20 a.m., the DON stated Patient 1 was placed in a wing in the facility with other patients who were at risk for fall. The DON also stated that in morning shift and evening shift, a group patient monitor staff would make rounds in the wing and observe the patients, but during night shift, there was no group patient monitor staff assigned but the CNA were supposed to observe the patients in the wing. However, during the time Patient 1 fell on 6/3/23, at 6:45 a.m., Patient 1 was left sitting in her wheelchair in the hallway by herself, completely unmonitored and unsupervised. The facility's policy, "Fall Management Program," dated 3/2023, indicated "The facility strives to provide each patient with adequate supervision and assistance devices to minimize the risks associated with falls ... Avoidable accident is an accident which occurred because the facility failed to: ... Implement interventions, including adequate supervision and assistive devices, consistent with a patient's needs, goals, care plan, and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident." In violation of the above cited standards, the facility failed to ensure that each patient receives adequate supervision and assistance devices to prevent accidents, including but not limited to: the facility failed to ensure supervision was provided to Patient 1 who was assessed to be high risk for falls, totally dependent on staff for transferring, and required close monitoring when Patient 1 was left sitting in her wheelchair in the hallway without staff watching and/or supervising her on 6/3/23, at 6:45 a.m., when staff went inside another patient's room. This failure resulted in Patient 1 falling on the floor and sustaining a subdural hematoma on the right temporal region. This blunt force injury of her head was the immediate cause of her death after 15 days in the GACH. This violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the patient.