Other·January 16, 2024

The following reflects the findings of the California Department of Public Health during the investigation of a facility reported incident number 860098. The inspection was limited to the specific facility reported incident investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the Department: 39763, HFEN A deficiency was issued for facility reported incident# 860098 at F tag 656. 42 Code of Federal Regulations part 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 resident's choices, including but not limited to the following: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (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: (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. California Code of Regulations, title 22, section 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 9/15/23, at 10:15 A.M. an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Resident 1's fall with fracture. Resident 1 is a 70-year-old male admitted to the facility on 6/28/23 with diagnoses including cerebral infarction (occurs as a result of disrupted blood flow to the brain and you may become paralyzed on one side of the body, or lose control of certain muscles), abnormalities of gait and mobility (when a person is unable to walk or move normally due to injuries, underlying conditions), and hypotension (low blood pressure - which can cause fainting or dizziness because the brain does not receive enough blood). Based on observation, interview, and record review, the facility failed to develop and implement comprehensive plan of care (CP- summary of a person's identified specific care needs, and current treatments and interventions to meet those care needs. CP helps nurses and other care team members organize aspects of resident care according to a timeline) to address risk for falls for one of two sampled residents (Resident 1). This failure resulted in Resident 1 sustaining a fall with fracture (break in the bone) to the anterior (near the front of the body or nearer to the head) column of the left acetabulum (the socket portion of the ball-and-socket hip joint) with extension of the fracture into the left superior (higher in position) and left inferior (lower in position) pubic rami (pubic rami are a group of bones that make up part of the pelvis (basin-shaped complex of bones that connects the trunk [central part of the body] and the legs), unnecessary hospitalization, and pain. During a review of Resident 1's "Fall Risk Observation/Assessment (FROA)," dated 6/28/23, the "FROA" indicated, Resident 1's score was 20 out of 42 (score of 16-42 indicated resident is at high risk for falls) high risk. During a review of Resident 1's "Baseline Care Plan Person-Centered Care Planning (BCP)," dated 6/29/23, the "BCP" indicated, there was no care plan developed to address Resident 1's risk for falls. During a review of Resident 1's "Admission Minimum Data Set (MDS - an assessment tool)," dated 7/3/23, the "MDS" indicated, Resident 1's BIMS (Brief Interview for Mental Status) score was 11 out of 15 (a score of 8 to 12 suggests the resident has moderately impaired cognition). The "MDS" indicated, Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for transfer (how a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) with two plus person assist, Resident 1 needed extensive assistance with locomotion on and off unit (how resident moves between locations in his/her room and adjacent corridor on same floor) with one person assist, and Resident 1 needed extensive assistance with toilet use (how resident uses the toilet, commode, bedpan, or urinal; transfers on/off toilet: cleanses self after elimination) with one person assist. During a review of Resident 1's "SBAR (situation, background, appearance, and review) Communication Form (SBAR)," dated 8/27/23, the "SBAR" indicated, Resident 1 had a fall incident while trying to go to the restroom without assistance. During a review of Resident 1's "IDT [Interdisciplinary Team- a group of health care professionals with various areas of expertise who work together toward the goals of their residents] - Fall," dated 8/28/23, the "IDT - Fall" indicated, "(Resident 1) requires extensive assist with ADLs (activities of daily living-activities related to personal care, which include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating)." During a review of Resident 1's "ED (Acute hospital-emergency department) Physicians Notes (EDPN)," dated 9/6/23, the "EDPN" indicated, "CT (computerized tomography - scan combines a series of X - ray images taken from different angles around your body and uses computer processing to create cross - sectional images [slices] of the bones, blood vessels and soft tissues inside your body) Pelvis. . . Indications: left hip pain, possible pelvic fracture. . . Conclusion: 1. Acute fracture of the anterior column of the left acetabulum with extension of the fracture into the left superior pubic ramus. 2. Acute fracture of left inferior pubic ramus. . . recommends no weightbearing [sic] for at least 2 weeks." During a concurrent observation and interview on 9/15/23, at 12:38 p.m. in Resident 1's room, Resident 1 was in bed and stated he went to the restroom in the middle of the night and fell (8/27/23). Resident 1 stated he would not be able to get out of bed until 9/26/23 (28 days). Resident 1 stated he was experiencing 10 out of 10 (7 - 10 = severe) pain since the fall incident. During an interview on 9/15/23, at 3:37 p.m. with Certified Nursing Assistant (CNA 1) CNA 1 stated she worked with Resident 1 on the day of the fall incident (8/27/23). CNA 1 stated she was never given a verbal report Resident 1 was at risk for falls and needed an extensive assistance with toilet use [with one person assist]. CNA 1 stated Resident 1 went to the restroom without assistance. CNA 1 stated Resident 1 did not have pain "before the fall but he (Resident 1) complains of pain a lot now (after the fall incident on 8/27/23)." During an interview on 9/27/23, at 11:38 a.m. with Admission Nurse (AN), AN stated she "completes a fall risk assessment on admission and if the score is high, resident is at risk for fall; a fall risk care plan should be developed." AN stated, nurses were supposed to give report to CNAs of all interventions needed to be put into place. During a concurrent interview and record review on 9/27/23, at 11:38 p.m. with AN, the facility protocol titled, "New Admission Nursing Check List," undated, was reviewed. The "New Admission Nursing Check List" indicated, ". . . 3rd Shift LN (Licensed Nurse) . . . Initiate Care Plans. . ." AN stated the protocol (Initiate Care Plans for fall risk) should be used and implemented during admissions process. During an interview on 9/27/23, at 3:18 p.m. with Director of Nursing (DON), DON confirmed there was no care plan developed to address Resident 1's risk for falls [6/28/23 to 8/28/23]. DON stated the expectation was for the nurses to develop and implement care plan to address Resident 1's risk for falls and to ensure interventions were effective. During a concurrent interview and record review on 10/17/23 at 10:51 p.m. with DON, the facility's policy and procedure (P&P) titled, "Falls and Fall Risk, Managing," revised March 2018, was reviewed. The P&P indicated, "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. . . Resident -Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls." DON provided no further information. During a concurrent interview and record review on 10/17/23 at 10:51 p.m. with DON, facility's P&P titled, "Care Plans, Comprehensive Person-Centered," revised March 2022, was reviewed. The P&P indicated, "1. A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT), with input from the resident, and his/her family or legal representative. 2. The Comprehensive person-centered care plan should be developed within the seven (&) days of the completion of the required MDS assessment. . . 6. The comprehensive, person-centered care plan should. . . b. Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible, including services that would otherwise be provided for he above, but are not provided due to the resident exercising his or her rights (including the right to refuse treatments). . ." DON provided no further information. In violation of the above cited standards, the facility failed to develop and implement Resident 1's person centered comprehensive fall risk care plan. This resulted in Resident 1 falling and sustaining a fracture of the anterior column of the left acetabulum with extension of the fracture into the left superior and left inferior pubic rami, unnecessary hospitalization, and pain. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm to Resident 1 would result and constitutes to a Class A citation.