Health inspection·August 28, 2024

River View Post Acute The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported Incident CA00911881 Survey Event ID: GUMQ11 State Citation A was written. Code of Federal Regulations, Title 42, Section §483.25(d) Accidents. The facility must ensure that -- (d)(1) The resident environment remains as free of accident hazards as is possible; and (d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 72523(a). Patient Care Policies and Procedures (a) Patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 7/30/24, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a Facility Reported Incident regarding resident safety/falls. The Department determined the facility failed to provide a safe environment for one of three sampled residents (Resident 2), when the staff failed to secure the bath blanket (used to cover residents after a shower) under Resident 2 while transporting Resident 2 from the shower using a shower chair. This failure led to the blanket becoming caught in the wheel of the chair, causing the chair to stop abruptly and tip forward. As a result, Resident 2 sustained a fall on 7/25/24, with a fracture to her left medial malleolus (bony bump on the inner side of the ankle) and left fibula (leg bone between the knee and ankle), increased pain, and decreased mobility, with the potential for skin breakdown and other negative health outcomes. A review of Resident 2's clinical record, "ADMISSION RECORD," indicated Resident 2 was admitted to the facility in 2022 with diagnoses which included bilateral (affecting both sides) osteoarthritis of the knee (disease that causes joint pain and stiffness) and age-related osteoporosis (a condition in which bones become weak and brittle). A review of Resident 2's clinical record, "Minimum Data Set [MDS a resident assessment tool which identifies care needs]" dated 6/13/24, indicated, " ...Section J Health Conditions ...Pain Management ...at any time in the last 5 days, has the resident ...A. Received a scheduled pain medication regimen?..." The documentation indicated, "0 [for No]" " ...B. Received PRN pain medication OR was offered and declined? ..." The documentation indicated, "0 [for No]" " ...C. Received non medication intervention for pain? ..." The documentation indicated, "0 [for No]" " ...Pain Presence ...Have you had pain or hurting at any time in the last 5 days? ..." The documentation indicated, "0 [for No]." A review of Resident 2's clinical record, "MDS" dated 6/14/24, in section C, "Brief Interview for Mental Status (BIMS) Evaluation," indicated a score of 15, on a scale of 0-15 with a range of 13-15 suggesting Resident 2's memory was intact. A review of Resident 2's clinical record, "Progress Notes," dated 7/25/24, at 3:35 PM, indicated " ...resident had a fall on hallway during transport on shower chair to room after shower around 1530 [3:30 PM]. Per CNA [Certified Nurse Assistant] she saw resident going forward and she grabbed her upper body and assisted her to the ground meanwhile her left leg got cough [sic] on the shower chair, another staff member helped to get leg down, writer hear the yelling of resident and assisted resident and assessed, per resident her left knee down to her ankle were in pain, with the assistance of other staff members patient was assisted to her wheelchair and taken to room... A call was made to MD [Medical Doctor] who gave order for stat [urgent] X ray..." A review of Resident 2's clinical record, "Progress Notes," dated 7/25/24, at 8:04 PM, indicated, " ...Post Fall Evaluation ...Fall Details: Date/Time of Fall: 07/25/2024 3:15 PM Fall was witnessed ...Activity at time of fall: being transported in shower chair [transport chair]. Reason for fall was evident. Reason for fall: shower blanket got wrapped in transport chair and caused resident to fall forward ...Pain: Vocal complaints of pain ...left knee. Pain score 8 [a scale of 0 to 10 used to measure pain. 7 - 10 is considered severe] ..." A review of Resident 2's care plan dated 7/25/24, indicated " ... [Resident 2] has had an actual fall with serious injury ...contributing factors ... During transport in shower chair with bath blankets possibly dragging on floor ...Monitor/document/report ...to MD for s/sx [signs and symptoms] Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation ..." A review of resident 2's clinical record, "Progress Notes," dated 7/25/2024, at 9:59 PM, indicated "...resident arrived back from [hospital name] ... At approximately 2110 [9:10 PM] ... Discharge diagnosis closed fracture [fracture where the skin remains intact with no protrusion of bone] of proximal [upper] end of left fibula ... sprain of left ankle... Resident arrived to [sic] facility with a left knee immobilizer in place as well as an ace bandage [stretchable cloth used to wrap around a sprain to provide gentle pressure and reduce swelling] wrapped around left ankle... Resident stated her pain remains at an 8..." A review of Resident 2's care plan dated 7/26/2024, indicated " ... [Resident 2] has actual/potential for acute pain r/t [related to] Closed fracture of proximal left fibula ...Sprain of left ankle ...Residents pain will be alleviated with interventions ...Administer ... norco [a narcotic pain reliever] ...as per orders ...give 1/2 hour before treatments or care ..." A review of Resident 2's care plan dated 7/26/2024, indicated " ...The resident has potential for impairment to skin integrity of the (left leg) r/t (related to) immobilizer use ...Monitor left leg skin for any changes ..." A review of Resident 2's x ray reports dated 7/29/24, indicated " ...Subacute [beginning to heal] fracture of the proximal left fibula ... Avulsion fracture [occurs when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone] of the left medial malleolus. The age of the fracture is indeterminate (not clearly known) ..." During an interview on 7/30/2024, at 11:42 AM, in Resident 2's room, Resident 2 stated at the time of the fall she was being transferred in a shower chair, from the shower room to her bedroom. Resident 2 further stated she had a blanket covering her and the blanket became caught under a wheel which caused the chair to stop abruptly and pitch her forward. Resident 2 stated she landed on her knees and hands. During an interview on 7/30/24, at 2:50 PM, CNA 2 stated at the time of the fall she had been transferring Resident 2 in the shower chair, from the shower room to her bedroom. CNA 2 further stated she had placed bath blankets over the front and the back of Resident 2. CNA 2 stated during transport the chair suddenly tilted forward, and CNA 2 reached out to catch Resident 2 who fell onto her knees. A review of Resident 2's clinical record, "Order Listing Report," indicated: "...Norco Oral Tablet 5 325 MG [milligrams a unit of measure] ...Give 1 tablet by mouth every 6 hours as needed for pain management...Order Date 7/18/24 .... DC [discontinued] Date 7/26/2024 ..." " ...HYDROcodone [narcotic pain reliever] Acetaminophen [non-narcotic pain reliever] Tablet [brand name for norco] 5 325 MG ...Give 1 tablet by mouth every 6 hours as needed for pain management ...Order Date 7/25/24 .... DC Date 7/26/2024 ..." " ...Norco Oral Tablet 5 325 MG ...Give 1 tablet by mouth every 6 hours for pain management ...Order Date 7/26/24 .... DC Date 7/29/2024 ..." " ...Norco Oral Tablet 5 325 MG Give 1 tablet by mouth every 8 hours ...Order Date 7/29/24 ...DC Date 7/30/2024 ..." " ...tramadol HCL [narcotic pain reliever] Oral Tablet 50 MG Give 1 tablet by mouth every 8 hours as needed for breakthrough pain/moderate pain ...Order Date 7/29/2024 ..." A review of Resident 2's Medication Administration Record (MAR) for July 2024 indicated " ...MONITOR FOR PAIN 0-3 = MILD 4-6=MODERATE 7-10=SEVERE every shift Order Date 3/10/2023 ..." The pain levels were documented as follows: From July 1 to 18, the MAR indicated pain levels of zero on both AM (day shift) and PM (evening) shift (12-hour shifts); On July 19 the AM shift documented a pain level of 7; From July 19 PM shift to July 23, the MAR indicated levels of zero; On July 24 the MAR indicated a level of 8 on the PM shift; On July 25 the MAR indicated a level of 8 on PM shift; On July 26 the MAR indicated a level of 6 on the AM shift and 4 on the PM shift; On July 27 the MAR indicated a level of 5 on the AM shift and an 8 on the PM shift; On July 28 the MAR indicated a level of 6 on the AM shift and a 7 on PM shift; On July 29 the MAR indicated a level of 7 on the AM shift and of 8 on the PM shift; On July 30 the MAR indicated a level of 8 on the AM shift and 7 on the PM shift. A review of Resident 2's MAR for July 2024, indicated medication administration as follows: 7/25/24-Norco 5 325 mg was administered at 4:10 PM for a pain level of 9. 7/26/24-Norco 5 325 was administered at 12:07 AM for a pain level of 8 and at 6:31 AM for a pain level of 9. 7/26/24-Hydrocodone APAP 5 325 mg was administered at 1:52 PM, for a pain level of 9. 7/26/24-Norco 5 325 was administered at 6 PM, for a pain level of 9. 7/27/24-Norco 5 325 mg was administered on a routine schedule per a change in physician orders, at 12 AM, 6 AM, 12 PM and 6 PM. All pain levels were recorded as 5. 7/28/24-Norco 5 325 mg was administered on a schedule at 12 AM, 6 AM, 12 PM and 6 PM. Pain levels were recorded as 12 AM = 9, 6 AM= 9, 12 PM = 6, and 6 PM = 7. 7/29/24-Norco 5 325 mg was administered on a schedule at 12 AM, 6 AM, and 12 PM. All pain levels were recorded as 7. 7/29/24-Norco 5 325 mg was administered on a revised schedule at 8 PM. The pain level was recorded as 8. 7/30/24-Norco 5 325 mg was administered on a schedule at 4 AM and 12 PM. Pain levels were recorded at 4 AM as 8 and at 12 PM as 5. During an interview on 7/30/24, at 4:36 PM, the Director of Nurses (DON) confirmed Resident 2's fall and subsequent injuries were due to the bath blanket becoming caught in the wheel of the shower chair. The DON stated it was her expectation that staff would ensure blankets were tucked in and not hanging below the resident's knees when they were transported in shower chairs. During a telephone interview on 8/1/24, at 8:22 AM, the Medical Director (MDir) stated Resident 2's fall was an unfortunate event and could have been prevented. The MDir further stated the fall affected Resident 2's lower extremity mobility and caused her increased pain. The MDir stated the pain medications prescribed were not enough at first. The MDir further stated he had to change Resident 2's pain medication to be given on a schedule. The MDir stated the scheduled medication was not enough and Resident 2 began to experience confusion and due to Resident 2's confusion, he ordered a different pain medication. The MDir stated it still was not enough. Resident 2 was uncomfortable and too confused. The MDir stated Resident 2 was transferred to the hospital on 7/31/24 due to confusion. A review of a facility policy titled, "Safety and Supervision for Residents," Revised April 2021, indicated " ...Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities ...The facility oriented and resident oriented approaches to safety are used together to implement a systems approach to safety, which considers hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly ..." Therefore, the Department determined the facility failed to provide a safe environment for one of three sampled residents (Resident 2), when the staff failed to secure the bath blanket under Resident 2 while transporting Resident 2 from the shower to her room, using a shower chair. This failure resulted in Resident 2 sustaining a fall on 7/25/24, with a fracture to her left medial malleolus and left fibula, increased pain, and decreased mobility, with the potential for skin breakdown and other negative health outcomes, and required the resident be transferred to an acute care hospital for pain management and related confusion behavior. This violation of the federal statute and state regulation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 2, and constitutes an A citation.