Other·January 13, 2025

F689 42 CFR §483.25(d) Free of Accidents §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; §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR §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. (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. On 10/7/24 at 12:23 p.m., an unannounced visit was conducted to investigate Resident 341's unwitnessed fall and multiple falls which resulted in left hip and left shoulder fracture. Resident 341 was a 96-year-old male resident with diagnoses of disorders of the bones, encephalopathy (brain dysfunction caused by a chemical imbalance in the blood that affects the brain) difficulty in walking, and muscle weakness. Based on interview and record review, the facility failed to implement its policy and procedure on "Care Plans, Comprehensive Person-Centered" for one of three sampled residents (Resident 341) to reduce the risk of falls and minimize injuries. This failure resulted in Resident 341 falling multiple times in four months and sustaining a fracture (broken bone) to his left hip and left shoulder requiring surgical repair for placement of plates and screws. Findings: During a review of Resident 341's "Admission Record (AR)," dated 4/2/24, the AR indicated, Resident 341 was admitted on 4/2/24. Resident 341 diagnosis including metabolic encephalopathy (brain dysfunction caused by a chemical im-balance in the blood that affects the brain) difficulty in walking, and muscle weakness (generalized). During a review of Resident 341's "Minimum Data Set (MDS- a resident assessment tool)," dated 04/2/24, the MDS indicated, Resident 341 had significant cognitive impairment (problem with a person's ability to think, learn, remember, use judgement, and make decisions) with a Brief Interview for Mental Status (BIMS-assesses mental processes) score of 7 (range of scores is from 0-15 with a score of 0-7 signifying significant impairment, score of 8-12 signifying moderate cognitive impairment and a score of 13-15 signifying cognitively intact. During a review of Resident 341's "Fall Risk Evaluation" (FRE) dated 4/4/24, the FRE indicated, "Fall Risk Evaluation Score: 11. . .High Fall Risk." During a review of Resident 341's "MDS" dated 7/8/24, the MDS indicated, Resident 341 required partial /moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for chair/bed-to-chair transfer and toilet transfer. A. During a concurrent interview and record review on 10/14/24 at 12:44 p.m. with Director of Nursing (DON), Resident 341 "Progress Notes" (PN), dated 7/12/24 was reviewed. The PN indicated, "IDT (group of professionals with different areas of expertise who work together to achieve a common goal). . .On 7/11/24 @ (at) 1:45 p.m. licensed nurse was notified by CNA (Certified Nursing Assistant) that (Resident 341) was observed on the floor in tv (television) room in front of sofa and w/c (wheelchair) was beside him. . .Recommendations: 72-hour nursing post fall review. . .72-hour neuro (neurological- to assess the function of the brain) checks, pharmacy IMRR (Interim Medication Regimen Review). . .rehabilitation post fall review. . .New Fall interventions: Physical Therapy (PT) to review (Resident 341) wheelchair brake management." There was no updated care plan noted on this fall incident (7/11/24). DON confirmed the findings and stated the care plan should have been updated after the fall incident. During a concurrent interview and record review on 10/14/24 at 12:44 p.m. with DON, Resident 341 IMRR dated 7/12/2024, was reviewed. The IMRR indicated, "Type of Review: Change of Condition. . .Fall. . .Recommendation. . .BMP (basic metabolic panel-a common blood test that can be used to screen for, diagnose, or monitor health conditions). . .TSH (thyroid stimulating hormone-blood test that measures the amount of TSH in the blood). . .BP (blood pressure). . .HR (heart rate). . .Check orthostatic (blood pressure taken when standing up from a sitting or lying position) BPS (blood pressures) Q (every) Shift X (times) 3 days. Notify MD (Doctor of Medicine) if resident experiences orthostasis (drop in blood pressure when standing)." There was no evidence of the recommendations being implemented. DON confirmed the findings and stated the IMRR recommendations should have been implemented. B. During a concurrent interview and record review on 10/14/24 at 12:44 p.m. with DON, Resident 341 Care Plan (CP) dated 7/18/24 was reviewed. The CP indicated, "[Resident 341] had an unwitnessed fall with no injury on 7/18/24. . .Interventions. . .Monitoring for 72 hrs (hours) for any delayed injuries. . .Pharmacy IMMR. . .Rehab (Rehabilitation post fall evaluation) . . .Staff advised to do frequent (frequency not indicated) rounds on resident. . ." There was no IDT noted and no evidence of the frequent rounds being implemented. DON confirmed the findings and stated there should have been an IDT conducted and DON was unable to provide evidence of frequent rounding." C. During a review of Resident 341's "IDT-Interdisciplinary Post Event Note (IDT)," dated 8/23/24 was reviewed. The IDT indicated, "Two staff members notified this writer that resident was on his buttock on the ground floor of his restroom with noted urine on the floor. . .Date and Time of Event 8/22/24 7:45 p.m.. . .New Interventions. . .neuro-check. . .Rehab (rehabilitation) Referral. . .Care Plan Revision. . ." During a concurrent interview and record review on 10/14/24 at 12:44 p.m. with DON, Resident 341's CP dated 8/23/24 was reviewed. The CP indicated, "Resident [341] sustained an unwitnessed fall w/o [without] injury on 8/22/24. . .Continue s/p (status post-shorthand term used to describe a patient's condition after a specific event or procedure) neuro check monitoring. . .monitor for any delay injuries & or pain. . .Notify MD of any changes." There were no new interventions implemented after the fall. The interventions indicated were the same as the fall incident on 7/18/24. DON confirmed the findings and stated the facility should initiate new interventions after the fall incident on 8/22/24. D. During a concurrent interview and record review on 10/14/24 at 12:44 p.m. with DON, Resident 341's IDT dated 9/18/24 was reviewed. The IDT indicated, "On 9/16/24 @ 2145 (9:45 pm) license nurse was notified of an observed fall and rushed to his side. He (Resident 341) was asked what happened and stated in that he did not know, and his back and head were hurting. . .CNA stated (Resident 341) was walking out of his room, his shoes were unbuckled, he started stumbling and lost his balance and before the CNA could intervene (Resident 341) fell and hit his head on the tile. . .Date and time of event 9:45 p.m. . .Injury Present. . .Yes. . .Indicate Injury. . .Resident noted to have two staples to his R (right) upper eyebrow, report also determined a contusion (bruise) to right elbow. . .New Interventions. . .Neuro-Check. . .Medication Review. . .Rehab referral. . ." There was no CP developed or new interventions implemented after the fall incident on 9/16/24. DON confirmed the findings and stated there should have been a care plan developed and new interventions implemented after the fall incident on 9/16/24. During a concurrent interview and record review on 10/14/24 at 12:44 p.m. with DON, Resident 341 IMRR, dated 9/23/24 (Medication review from fall incident on 9/16/24) was reviewed. The IMRR indicated, "Type of Review: Change of condition. . .Fall. . .Recommendation. . .BMP. . .BP. . .HR. . .Check orthostatic BPS Q Shift X3 days. Notify MD if resident experiences orthostasis." There was no evidence of the recommendations being implemented. DON confirmed the findings and stated the IMRR recommendations should have been implemented. E. During a concurrent interview and record review on 10/14/24 at 12:44 p.m. with DON, Resident 341's CP dated 9/22/24 was reviewed. The CP indicated, "Resident had an unwitnessed fall with no suspected injuries on 9/22/24. . .Interventions. . .Assist resident to the restroom as needed. . .Maintain bed at a low safe position. . .provide pain management as needed. . .report abnormal vital signs and any complications to MD." There was no IDT completed after this fall incident on 9/22/24. DON confirmed the findings and stated there should have been an IDT completed after the fall incident on 9/22/24. F. During a concurrent interview and record review on 9/14/24 at 12:44 p.m. with DON, Resident 341's "Change in Condition Evaluation (COCE)," dated 9/28/24 was reviewed. The COCE indicated, "The change in condition. . .Falls. . .9/28/24. . .Resident attempts to self-transfer from bed to chair and chair to bed. Resident should be monitored for attempting to transfer without assistance. . ." The CP was not revised, there were no new interventions implemented and there was no IDT completed after the fall incident on 9/28/24. DON confirmed the findings. G. During a review of Resident 341's "PN" dated 10/4/24, the PN indicated, "IDT. . .On 10/1/24 @ 9 p.m. this nurse heard a low cry for help. . . [Resident 341] was observed laying on the ground floor on his right side near the entrance to [Resident 341's] room. He was wearing sweatpants that were around his knees and he was not wearing any shoes. . .@ 2300 [11 p.m.] [Resident 341] was receiving care and cried out in pain. . .was reassessed and observed guarding his left arm. . .Dr [Doctor]. notified and directed he be sent to the ER [emergency room] due to SP [status post-after] fall with pain to left upper extremity. . .Contacted ER. . .who stated that he is admitted with a fracture to the left femur [bone of the thigh] and left shoulder." During a review of Resident 341's "History and Physical Report (H&P)," dated 10/2/24, the H&P indicated, "Patient [Resident 341] is . . .year-old male with. . .history of recurrent fall who presented to the emergency room via EMS [emergency medical services] from SNF [skilled nursing facility] for unwitnessed fall. . .Assessment and Plan. . .Left shoulder displacement [not in alignment] & hip fracture. . .Recurrent unwitnessed fall. . ." During a review of Resident 341's hospital "Imaging Report (IR)," dated 10/2/24, the IR indicated, "Patient [Resident 341] fell today with injury to the left hip, left hip pain. Findings: acute [severe and sudden in onset] impacted [lodged or wedged] left sub-capital [fracture in the neck of the thigh bone] hip fracture." During a review of Resident 341's "IR" dated 10/2/24, the IR indicated, "Left shoulder pain today. . .Impression: Impacted comminuted [bone broken into more than two pieces] fractures proximal [near the center] humerus [the bone of the upper arm]." During a review of Resident 341's hospital "Consultation," dated 10/2/24, the Consultation indicated, "X-ray of the left shoulder was obtained. It revealed a fracture of the upper shaft of the left humerus with little impaction and mild displacement. X-ray of the left hip revealed subcapital fracture. . .Recommendations: Left hip surgical procedure was discussed. I explained that I will put a screw and the plate." During an interview on 10/14/24 at 12:44 p.m. with DON, DON stated after a fall incident "It was the responsibility of the nurse to put in a short-term care plan and then within one business day an IDT should be held to discuss the root cause of the fall and determine an intervention to address the cause of the fall." DON stated a new intervention should be implemented after each fall and the recommendations from the IMRR should be implemented. During a review of the facility's policy and procedure titled "Care Plans, Comprehensive Person-Centered" dated 3/22, the P&P indicated, "Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. . .When possible interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. . .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. . .The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met. . ." During a review of the facility's policy and procedure (P&P) titled "Falls-Clinical Protocol" dated 3/18, the P&P indicated, "Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. . .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. . .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. . .If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling. . .and also reconsider the current interventions." In violation of F689 §483.25(d) Accidents, the facility failed to reduce the risk of falls and minimize injuries when: 7/11/24 Resident 341 sustained a fall, and care plan was not updated, 7/18/24 Resident 341 sustained a fall, and no IDT meeting conducted, 8/23/24 Resident 341 sustained a fall, and no new fall interventions were implemented, 9/16/24 Resident 341 sustained a fall, and no new fall interventions were implemented, and care plan was not updated, 9/22/24 Resident sustained a fall, and no IDT meeting conducted, 10/01/24 Resident 341 sustained a fall resulting in fracture to his left hip and left shoulder requiring surgical repair for placement of plates and screws. This violation presented either imminent danger that serious harm would result or a substantial probability that death or serious physical harm would result and constitutes an "A" citation.