Other·April 17, 2023

The following reflects the findings of the California Department of Public Health during the investigation of Facility Reported Incident (FRI) #: 809209 42 Code of Federal Regulations §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan- (i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Updated information based on the details of the comprehensive care plan, as necessary. On 11/2/22 at 10:28 AM, an unannounced visit was conducted at the facility to investigate the facility reported incident regarding resident fall with injury. Resident 1 was an 89-year-old female who was admitted to the facility on 10/23/22 with diagnoses of Acute Kidney Failure (a sudden decline in the ability of kidneys to work), vascular dementia (changes to memory, thinking, and behavior due to decreased blood flow to the brain) and a history of falling. Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for one of three sampled residents (Resident 1) with a history of falls that included the necessary information for staff to ensure the safety and well-being of Resident 1. This failure resulted in Resident 1 falling, breaking her right hip and transfer to a local hospital for surgical repair. During a review of Resident 1's "Admission Record" (AR), the AR indicated, the facility admitted Resident 1 on 10/23/22. Resident 1's diagnoses included: urinary tract infection (UTI, infection of the urinary pathway), vascular dementia (changes to memory, thinking, and behavior due to decreased blood flow to the brain) and a history of falling. During a review of Resident 1's "Minimum Data Set," (MDS - an assessment tool), dated 10/26/22, Resident 1's MDS indicated, Resident 1 had significant cognitive impairment with a Brief Interview for Mental Status (BIMS, assesses mental processes) score of 5 (score of: 13-15 cognitively intact, 8-12 moderate impairment, 0-7 significant impairment). During a concurrent interview and record review on 11/2/22, at 4:20 PM with Director of Nursing (DON) and Administrator, Resident 1's "Nursing Admission Data Collection," dated 10/23/22, was reviewed. Resident 1's Nursing Admission Data Collection indicated the following: Resident 1 had one or two falls during the last 90 days; Required assistance with going to the bathroom; Confined to a chair; not able to maintain balance when changing from sitting to standing without physical assistance; was unable to stand. Resident 1's Nursing Admission Data Collection indicated Resident 1 was at risk for falls. Resident 1's Nursing Admission Data Collection stated, "If resident's total score is 10 or more, initiate fall risk interventions and document on Interim Care Plan." Administrator stated, Resident 1's fall risk score was 18, and any score above 10 identified the resident as at risk for falls. During a concurrent observation and interview on 11/2/22, at 10:31 AM, with Interim Assistant Director of Nursing (ADON), outside Resident 1's room, ADON stated, "Normally a star sticker is placed on the name plate to indicate the resident is at risk for falls." ADON stated "No, it [the star sticker] is not there." During a concurrent observation and interview on 11/2/22, at 10:36 AM, with DON, outside of Resident 1's room, DON stated, "No, there is no star [on Resident 1's name plate]." During an interview on 11/2/22, at 1:46 PM, with Certified Nurse Assistant (CNA) 2, CNA 2 stated, residents at risk for falls have a star sticker on the door. During an interview on 11/2/22, at 2:05 PM, with LVN 3, LVN 3 stated, a star will be placed on the name plate outside the door of a resident's room, when a resident is identified at risk for falls. During an interview on 11/2/22, at 2:14 PM, with LVN 2, LVN 2 stated, she was familiar with and provided care to Resident 1. LVN 2 stated, Resident 1 needed "a lot of assistance". LVN 2 stated, upon admission, if the resident was identified as risk for falls, they qualified for the Falling Star Program (facility program for recognizing residents at high risk of falls, which includes placing a star next to the resident's nameplate outside the resident's room). During an interview on 11/2/22, at 2:40 PM, with CNA 1, CNA 1 stated, she cared for Resident 1. CNA 1 stated, "I did not know anything about the Resident being a fall risk." CNA 1 stated, "I do not recall seeing a star sticker on the door and [I] did not receive report [that Resident 1 was a fall risk]." During an interview on 11/3/22, at 2:48 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she first cared for Resident 1 on 10/26/22. LVN 1 stated, Resident 1 was "fairly" new to the facility. LVN 1 stated, she was one door down from Resident 1's room, when a person from the dietary department came out of Resident 1's room and asked if Resident 1 was allowed to get up out of bed on her own. LVN 1 stated, she rushed to Resident 1's room and found Resident 1 on the floor, on her back, at the foot of her bed. During an interview on 1/10/23, at 10:45 AM, with Registered Dietitian (RD), RD stated, she visited Resident 1's room on 10/26/22 to interview Resident 1. RD stated, Resident 1 was confused and not able to answer the questions. RD stated, Resident 1 was sitting on the side of the bed and started to get up. RD stated, she told Resident 1 to "hold on, wait," while she got someone to help. RD stated, she left the room to find a nurse. RD stated, she told the nurse "I don't know this resident [Resident 1] well, is she [Resident 1] ok to get out of bed?" During a review of Resident 1's "Collaborative Care Review" signed by Administrator on 11/2/22 [date of inspection], Administrator entered a summary that indicated, "10/25/22 [sic, actual date of fall 10/26/22] - Nurse informed by RD resident trying to get up on her own. Nurse immediately responded and found resident on the floor at the foot of the bed lying on her back. Resident complained of right hip pain. Noted large skin tear to right elbow scant bleeding. Recommend STAT [immediately] x-ray of hip and elbow. Clean skin tear and cover with sterile dressing. Send to [local hospital] ER for evaluation. MD [Medical Doctor] and RP [Responsible Party] notified. Add to falling star program upon return." During a concurrent interview and record review on 11/2/22, at 4:20 PM with DON, Resident 1's "Care Plan" titled "The resident is at risk for falls," dated 10/23/22, was reviewed. Resident 1's "Care Plan" indicated, the facility initiated the Falling Star Program for Resident 1 on 10/27/22 (the day after Resident 1 fell and broke her hip). DON stated, the facility initiated the Falling Star Program [for Resident 1] on 10/27/22, the day after Resident 1's fall, four days after the facility admitted Resident 1 and four days after the facility assessed Resident 1 as a high fall risk. Resident 1's "Care Plan" did not indicate the following: Resident should not sit on the side of the bed. Additional lighting or night light. Place resident close to nursing station. Ensure consistent toileting schedule. Keep room free of clutter. Maintain safe environment. During a review of Resident 1's "Progress Notes," dated 10/26/22, at 3:47 PM, the "Progress Notes" indicated, "Resident [1] had unwitnessed fall at end of shift. Dr. [Doctor] transferred resident [Resident 1] to ER [emergency room] for evaluation. She [Resident 1] c/o [complains of] right hip pain also sustained [acquired a] large skin tear to right elbow." During a review of Resident 1's "Result Type: Hip Rt [Right] 2-3 Vw [View] Report," (X-Ray report), dated 10/26/22, the "X-Ray Report" indicated, Resident 1 had a "Slightly displaced intertrochanteric fracture (broken hip bone). Orthopedic [doctor who specializes in treatment of muscle/bone injuries] consult recommended." During a review of Resident 1's "Progress Notes," dated 10/28/22, at 19:52 [7:52 PM], the "Progress Notes" indicated, "This is a nursing admission note for [Resident 1]: 10/28/22 @ [at] 17:00 [5 PM], 89 years old from [hospital]. . . s/p [status post, after] ORIF [Open Reduction Internal Fixation - surgery to repair the broken hip bone] . . ." During a concurrent interview and record review on 1/10/23, at 10:40 AM, with Administrator, the facility's policy and procedure (P&P) titled "Falls Prevention" revised 10/21, was reviewed. The P&P indicated, "B. Falling Star Program 1. The Falling Star Program shall be initiated at the time the increased risk for falling is identified and approaches shall be outlined on the care plan for all disciplines." Administrator stated, "all disciplines" was the same as the Interdisciplinary Team (IDT). Administrator stated, RD would be included on the team and was expected to identify residents at risk for falls by the falling star sticker on the resident's name plate outside the door. During a review of the facility's P&P titled, "Falling Star Program," revised 10/2016, the P&P indicated, "Policy Overview ...The Falling Star Program is designed to facilitate recognition of residents who are at risk for falls. When residents are determined to be at risk of falls, they will be referred to the Falling Star Program. . . A star will be placed next to the nameplate outside his or her room and on adaptive devices the resident uses outside of their room, to indicate to care providers that this resident is at risk for falls." During a review of the facility's P&P titled, "Falls Prevention," revised 10/21, the P&P indicated, "A. Fall Risk Data Collection ...c) If the resident scores above a 10 in Fall Risk Data Collection, he/she shall be placed on the Falling Star Program. Resident's Care Plan shall reflect that he/she is at a higher risk for falls and identifies approaches that are to be taken." In violation of the above cited standards, the facility failed to ensure a baseline care plan for falls was developed and implemented to ensure the safety and well-being of Resident 1. This failure resulted in Resident 1 falling, breaking her right hip requiring a transfer to a local hospital for surgical repair. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and represents a class "A" citation.