Other·May 9, 2024

Tracy Nursing and Rehabilitation Center The following reflects the findings of the California Department of Public Health during the investigation of: Complaint # CA00877821 Survey Event ID: WLWH11 Representing the Department, HFEN #43943, HFES #44260 State Citation A was written. Code of Federal Regulations, Title 42, Section §483.25(d)(2). Accidents The facility must ensure that - (2) Each resident receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 72311. Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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 1/11/24 at 10:08 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding resident safety/falls. The Department determined the facility failed to provide required supervision for Patient 1, who was dependent on staff for toileting and was left unattended while using the toilet. This failure resulted in Patient 1 attempting to get off the toilet independently without staff supervision which led to a fall and a head injury that resulted in Patient 1's hospitalization on 12/28/23 and subsequent death on 1/24/24. A review of Patient 1's "Admission Record," (a document that contains the resident's personal information) indicated Patient 1 was admitted to the facility on 12/21/23 with a history that included weakness to the right side of the body following cerebrovascular disease (also called cerebrovascular accident or stroke-damage to the brain from interruption of its blood supply) difficulty walking, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 1's "Discharge Summary," from the hospital, dated 12/21/23, in the section "CONDITION AT DISCHARGE," indicated, "...[Patient 1] Unable to ambulate due to severe stroke..." Further review of the section "Imaging," indicated, "...CT [computerized tomography scan - a series of images taken from different around the body] BRAIN WO [without] CONTRAST...Result Date: 12/18/23...Previously identified left sided subacute infarcts [infarction- injury or death of tissue resulting from lack of blood supply]..." are not well visualized...No hemorrhagic conversion [rupture of blood vessels after blood flow is restored after a stroke] or new acute infarcts...MRI [magnetic resonance imaging- imaging that uses strong magnetic fields to generate detailed images of organs, bones, muscles and blood vessels] BRAIN WO CONTRAST...Result Date: 12/18/23...No acute intracranial hemorrhage [brain bleed]..." A review of Patient 1's "Morse Fall Risk Screen," (an assessment tool used to determine the resident's risk of falls), dated 12/21/23 at 5:47 PM, indicated, Patient 1 scored a 41 on a scale of zero to 44. (The fall risk screening score scale is high risk = 45 and higher, moderate risk = 25-44, and low risk = 0-24). A review of Patient 1's "Care plan," dated 12/21/23, indicated, Patient 1 was at high risk for weakness and intolerance in participation of care and ADLs. For interventions, the Certified Nursing Assistant (CNA) was expected to observe Patient 1 for signs and symptoms of the inability to participate in care and activities of daily living (ADLs - an individual's daily self-care activities) and to assist Patient 1 with ADLs if needed. A review of Patient 1's "Care Plan," initiated on 12/22/23, indicated, Patient 1 was a high risk for falls and injury related to poor judgement and attempted to get out of bed unassisted. A review of Patient 1's "History and Physical Examination," dated 12/23/23, by the Physician (Phys), indicated, Patient 1 did not have the capacity to understand and make decisions. A review of Patient 1's "Care Plan," dated 12/23/23, indicated, Patient 1 had an Occupational Therapy focus (OT- therapy designed to develop, recover, and improve needed function for daily living) that included a self-care deficit as evidenced by needed assistance with lower body dressing and toileting hygiene. Patient 1's ADL independence fluctuated due to dementia, cognitive deficit (mental decline), and poor safety judgement. A review of Patient 1's "Minimum Data Set Section GG - Functional Abilities and Goals," (MDS - an assessment tool used to plan the care of a resident in nursing homes), dated 12/27/23, indicated Patient 1 was dependent (helper does all the effort and resident does none of the effort to complete the activity) on staff for toileting hygiene ([the ability to maintain the area between the anus and vagina], to adjust clothes before and after voiding [urine] or having a bowel movement [stool]). The record further indicated, Patient 1 utilized a manual wheelchair and walker, and was dependent on a helper for indoor mobility (walking from room to room with or without an assistive device [wheelchair or walker]). A review of Patient 1's "Post Fall Interdisciplinary Team Notes," (IDT- team members from different disciplines working together and sharing resources regarding resident care), dated 12/28/23 at 8:26 PM, by the Director of Nursing (DON) indicated, "...[Patient 1] had an episode of unwitnessed fall on 12/28/23 during am [day] shift around 1:15 PM. [Patient 1] was found sitting on floor in the bathroom with her head next to the sink. Visible injury noted to [Patient 1's] forehead on R [right] side temporal [head] location. Location bruised with bleeding noted...transfer [Patient 1] to ER [emergency room] for further eval [evaluation] and treatment...Root Cause...[Patient 1] scores 7 out of 15 on BIMS [Brief Interview for Mental Status- an assessment tool, 0 = severe cognitive impairment (problems with thinking, reasoning, memory, or attention) to 15 = intact cognition], requires assistance with ADLS, transfers and mobility..." A review of Patient 1's "Progress Notes," dated 12/28/23 at 1:56 PM, by Licensed Nurse (LN) 1 indicated, "...when asked by nurse what happened [Patient 1] stated, 'oh honey I don't know, I just tried getting up from the toilet to pull up my underwear and next thing you know I am on the floor'..." A review of Patient 1's "Progress Notes," dated 12/28/23 at 6:37 PM, by LN 2, indicated after the fall, Patient 1 was admitted to the hospital for a subarachnoid hemorrhage (bleeding in the space that surrounds the brain). A review of Patient 1's "Discharge Summary," from the hospital, dated 12/30/23, in the section "REASON FOR ADMISSION," indicated, "...[Patient 1]...recent admission on 12/21 (week ago) of acute CVA [cerebrovascular accident- damage to the brain from interruption of its blood supply]...patient recovered well and was discharged to skilled nursing facility for rehabilitation after starting on apixaban...[Patient 1] returns to hospital today [12/28/23] after suffering a fall in the toilet, noticed mild bleeding with hematoma [solid swelling of clotted blood within the tissues] on the right frontal area [front part of the brain]. In ED [Emergency Department], CT head showed small to moderate amount of subarachnoid hemorrhage on the left posterior side...and right prefrontal [frontal lobe of brain] scalp hematoma along with old right cerebellar [brain] infarct..." Further review of the section "HOSPITAL COURSE," indicated, "...Patient was admitted for traumatic subarachnoid hemorrhage after a fall while on apixaban...Given her advanced age, comorbidities, recent strokes ischemic [CVA] as well as subarachnoid hemorrhage, [Family Member 1] decided to initiate hospice care at care home and does not want [Patient 1] to go back to nursing home. Plan to discharge [Patient 1] to care home with hospice [focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life] today..." During a phone interview on 1/11/24, at 9:17 AM, Family Member (FM) 1 stated Patient 1 was not doing well since her fall on 12/28/23 and had limited speech after the event. FM 1 further stated Patient 1 was now on hospice. During an interview on 1/11/24, at 10:45 AM, LN 3 stated factors that increased Patient 1's risk for falls was a diagnosis of dementia, advanced age, and weakness. LN 3 stated staff should not have left Patient 1 unattended in the bathroom. During an interview on 1/11/24, at 12:35 PM, LN 1 stated the CNA should not have left Patient 1 in the bathroom without supervision. LN 1 stated Patient 1 was found on the floor of the bathroom with blood coming from her head. LN 1 stated Patient 1 was a risk for falls and had fallen prior to admission to the facility. During an interview on 1/11/24, at 12:57 PM, CNA 1 stated staff should have remained just outside of Patient 1's bathroom while Patient 1 was using the toilet. During an interview on 1/11/24, at 1:09 PM, CNA 2 stated when Patient 1 requested privacy while using the bathroom, staff should have given her privacy but remained in the room to provide immediate assistance after Patient 1 had completed using the toilet. During an interview on 1/11/24, at 1:45 PM, the Director of Staff Development (DSD) stated she and the DON investigated the events leading up to Patient 1's fall. The conclusion was made that the CNA assisted Patient 1 to the bathroom and then left Patient 1's room to perform another task. Patient 1 was later found on the floor of the bathroom with a head injury. The DSD stated the CNA should not have left Patient 1 alone while she was on the toilet. During a phone interview on 1/11/24, at 3 PM, CNA 3 stated she assisted Patient 1 to the toilet and then shut the bathroom door for requested privacy. CNA 3 further stated Patient 1 was still on the toilet when she left Patient 1's room to perform another task. CNA 3 stated her normal practice was to stay with the resident while he/she was in the bathroom. CNA 3 further stated she thought Patient 1 would wait for help before standing up. CNA 3 stated the DON and DSD talked to her about the incident and CNA 3 was told she should have remained with Patient 1 at all times when Patient 1 was in the bathroom. During a phone interview on 2/15/24, at 3:08 PM, Medical Doctor (MD) 1 stated he was Patient 1's primary physician. MD 1 further stated Patient 1 was no longer alive and he had to look up what her cause of death was. MD 1 stated Patient 1 was a high risk for falls due to her taking Eliquis (generic name apixaban- a blood thinner medication) and her diagnosis of dementia. MD 1 explained it was not appropriate to leave the resident alone on the toilet and staff should have remained with Patient 1 until she was done using the bathroom and then should have been helped back to bed or the wheelchair. During a subsequent phone interview on 2/15/24, at 5:40 PM, MD 1 stated Patient 1's cause of death was subarachnoid hemorrhage. A review of Patient 1's "CERTIFICATE OF DEATH" dated 1/29/24, indicated, "...DATE OF DEATH...01/24/2024..." The section "CAUSE OF DEATH," indicated, "...the chain of events, diseases, injuries, or complications that directly caused death...Immediate cause (final disease or condition resulting in death)... A. SUBARACHNOID HEMORRHAGE...Time interval between onset and death...1 MON [MONTH]..." A review of the facility's Policy and Procedure (P&P) titled, "Bathroom, Assisting a Resident to," dated 2/2018, indicated, "...Purpose: The purpose of this procedure is to assist the resident with ambulating to the bathroom. Preparation: Review the resident's care plan to assess for any special needs of the resident...Steps in the Procedure - Assist the resident to the bathroom. Close the bathroom door...Wait outside the door, if safety permits...When the resident has signaled or called for you, return to the bathroom. If the resident needs help in cleaning himself...Clean the perineum [area between the anus and vagina]...Assist the resident to stand...Reposition the resident's clothing..." Therefore, the Department determined the facility failed to provide required supervision for Patient 1, who was dependent on staff for toileting and was left unattended while using the toilet. This failure resulted in Patient 1 attempting to get off the toilet independently without staff supervision which led to a fall and a head injury that resulted in Patient 1's hospitalization on 12/28/23 and subsequent death on 1/24/24. These violations, jointly, separately or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.