Other·September 8, 2023

REGULATION VIOLATION(S) 42 C.F.R. §483.25(d)(1)(2) 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. 42 C.F.R. §483.21(b)(1) and (b)(2)(i)-(iii) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at § 483.10(c)(2) and § 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (2) A comprehensive care plan must be- (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under § 483.24, § 483.25, or § 483.40; and (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 22 CCR § 72311(a)(1)(A) and (a)(1)(C) 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. (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. Findings: On 7/19/22 at 10:10 AM, the California Department of Public Health conducted an unannounced visit to investigate a complaint regarding a fall with a fracture. On 5/9/22 at approximately 11:50 AM, the facility staff attempted to transfer Resident 1 in a Sara Flex Lift (a lift support aid which encourages residents to pull themselves up into a standing position) to his wheelchair in place of the Hoyer Lift (a lift used for dependent residents requiring two caregivers to facilitate safe patient transfers), which was the device recommended by Physical Therapy and the Interdisciplinary Team. The facility failed to update the custom care plan to reflect Resident 1's need for a Hoyer Lift and therefore failed to keep the resident free from accidents and hazards by: 1. Failing to update Resident 1's custom care plan to reflect the Physical Therapy and Interdisciplinary Team's input that Resident 1 needed a Hoyer Lift. 2. Using a different assistance device leading Resident 1's legs to go limp and causing Resident 1 to let go of the support bar and remain in the sling unable to assist with the transfer. As a result of the facility's failures, Resident 1 suffered a traumatic injury that resulted in a right knee fracture, a hematoma (when an injury causes blood to collect and pool under the skin) to the right calf. At the facility, Resident 1's hematoma wound worsened into 100% necrotic (dead body tissue) and required bone tissue debridement (the surgical process of removing skin and bone close to and surrounding an infected wound associated with bone injuries or diseases), and Resident 1 ultimately expired on 6/13/22. A record review of a facility form titled "Admission Face Sheet Record" indicated Resident 1 was a 90-year-old resident admitted to the facility on 1/30/02. Resident 1 was admitted to Ward 2D (Skilled Nursing) on 1/27/19. Resident 1's diagnoses included but were not limited to unspecified osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), chronic pain, dizziness, dementia with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function) abnormalities of gait, and spondylosis (often used to describe degenerative arthritis of the spine). A record review of a facility form titled "Interdisciplinary Progress Notes (IDN)" dated 5/9/22 indicated two Certified Nursing Assistants (CNA) attempted to transfer Resident 1 to his wheelchair using the Sara Flex Lift. CNA 1 lifted Resident 1 and tried to transfer Resident 1 to his chair with the help of CNA 2. Resident 1 informed the CNAs that his legs were "going out." According to the IDN, Resident 1's legs "got limp." Resident 1 let go of the support bar and was unable to support himself. He remained on the sling but was not able to assist the CNAs to transfer him back to bed. The Nurse Practitioner (NP) saw Resident 1 and transferred the resident to the local emergency department. A record review of a facility form titled, "Transfer Physician's Order (TPO)" dated 5/9/22 indicated an order was written for Resident 1 to transfer to an outside hospital due to acute pain and swelling of the right knee and right medial calf after a fall occurred during a transfer with an assistive device (Sara Steady Flex). A record review of a facility form titled, "Investigation Report (IR)" dated 5/13/22 indicated facility staff interviewed Register Nurse (RN )1, Resident 1's assigned RN, and stated two CNAs were transferring Resident 1. RN 1 stated Resident 1's legs gave out and Resident 1 let go of the support bar. Resident 1 remained in the sling almost in a sitting position. The IR further indicated RN 1 stated Resident 1 had no unusual behavior or change of condition prior to the incident and staff had been using the same transferring device with no incident. The IR indicated when Resident 1's legs became weak, and Resident 1 let go of the bars it caused his knees to bend against the rubber part of the transfer device. A record review of a facility form titled, "Interdisciplinary Resident Fall Investigation and Intervention" dated 5/10/22 indicated Resident 1 was bed bound and needed assistance all the time when transferring. He required a three person assist with transferring. A record review of a facility form titled; "Physician's Orders Suggested Non-Medication Admission Orders (PO)" dated 5/10/22 indicated Resident 1 was readmitted to the facility on 5/10/22. The admitting diagnosis was mildly displaced right tibial tubercle fracture (knee fracture). The PO indicated Resident 1's activity level to be non-weight bearing on the right leg for six (6) weeks with a brace in place. The PO included a wound care consult with the Wound Care Specialist Doctor. A record review of a facility form titled; "List Patient Notes" dated 3/11/21 indicated a Physical Therapy Assessment was completed on 3/11/21. The form indicated Resident 1 was dependent for all mobility needs and a Hoyer lift was recommended to be used to get Resident 1 out of bed and into Resident 1's manual wheelchair. No documentation was found of a Physical Therapy Assessment to justify the use of a Sara Flex for Resident 1. A record review of a facility form titled, "Interdisciplinary Team Conference" (IDT conference) dated 2/23/22 indicated Resident 1 was a total assist (the resident was unable to do any part of activities of daily living [ADL] task, even with assistive devices, without the assistance of another person) with the use of a Hoyer lift for transfers. A record review of a facility form titled, "Care Plan: Custom Care Plan" run date 2/22/22 indicated a nursing intervention for Resident 1 to be transferred by a one-person assist using the Sara Flex. This intervention was initiated on 12/31/19. It was not updated to reflect the IDT conference recommendation of using a Hoyer lift for transfers. An interview with Minimum Data Set (MDS- tool for implementing standardized assessment and for facilitating care management in nursing homes) Coordinator 1 was conducted on 7/26/22 at 12:45 PM. MDS 1 stated Resident 1 was being transferred with a one-to-one person assist using the Sara Flex prior to the fall. MDS 1 explained the different dates on the Care Plan. The run date meant the day the care plan was printed. The "init by" was the date the intervention was "initiated". Resident 1 had an IDT meeting on 2/23/22 and the care plan was printed 2/22/22. IDT had a discussion with Resident 1's family because Resident 1's health had been declining. In the IDT meeting, the IDT determined that the resident should be using a Hoyer lift. MDS 1 stated after each meeting they notified the Supervising Registered Nurse (SRN) or charge nurse on the new recommendations discussed by the IDT. According to MDS 1, best practice was to have a referral for PT and Occupational Therapy (OT) for assessment to determine what device to use. MDS 1 stated that if her signature was on the IDT meeting it meant she notified the SRN or shift lead of the recommendation to use the Hoyer lift. MDS 1 verified her signature on the IDT meeting. An interview with Physical Therapist (PT) 1 was conducted on 7/26/22 at 11:51 AM. PT 1 stated PTs were responsible for conducting the lift assessments. PT 1 stated they located an assessment dated 3/11/21 for Resident 1 in the chart. PT 1 stated Resident 1 was assessed as an extensive assist (the resident was not able to perform or complete ADL without another person to aid in performing the complete task, by providing weight-bearing assistance) for transfers. The recommendation was for a Hoyer lift to be used for transfers. PT 1 stated PT got involved when a referral was generated by the doctor or nursing staff. A PT assessment would be required for the use of a Sara Flex because those types of lifts required residents to be more involved in the transfer process. PT 1 stated the Sara Flex or Sara Steady Lifts required the resident to have some trunk control and hand use to be able to grasp and hold on to the handle. PT 1 stated they were not able to locate an assessment for the use of a Sara Flex. An interview with RN 1 was conducted on 7/19/22 at 1:02 PM. RN 1 stated the staff had been using the Sara Flex to transfer Resident 1. RN 1 stated that when a resident needed to use any type of lift, the Resident should be assessed by OT. After the assessment, the OT recommended the type of lift that was the safest for the resident to use during transfers. An interview was conducted with the Director of Nursing (DON) on 7/19/22 at 1:45 PM. The DON indicated that the IDT was responsible for determining the type of lift a resident should use. The care plan is then reprinted with the new interventions. The nursing staff was responsible to lead all communication with staff such as new interventions. A record review of a facility untitled form dated 5/12/22 indicated the right medial calf was noted with discoloration and scattered blisters and some areas with pinpoint openings with scattered serosanguineous (common type of wound drainage secreted by an open wound in response to tissue damage) exudate (drainage). The affected area measured 19 x 15 centimeters (cm). A record review of a facility form titled, "Interdisciplinary Progress Notes (IDN)" dated 5/15/22 indicated the resident was readmitted to the facility with purplish discoloration to the right calf and blister. The affected area measured 19.5 x 20 cm. The resident was admitted to Hospice (a type of health care that focuses on the care of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) with the diagnosis of Cerebral Atherosclerosis (a disease that occurs when the arteries in the brain become hard, thick, and narrow due to the buildup of plaque (fatty deposits) inside the artery walls. A record review of facility form titled, "Physician's Orders Suggested Non-Medication Admission Orders dated 5/10/22 indicated "wound care/SWOC (wound care doctor) consult: DX (diagnosis) RLE (Right Lower Extremity) bulbe (ball shape); eval (evaluate)/treat." A record review of a facility form titled, "Physician's Orders" dated 5/12/22 indicated to cleanse the right lower leg discoloration with wound cleanser or normal saline gently, pat dry, apply betadine paint, cover with foam dressing, then wrap with rolled gauze to secure, daily until resolved. A record review of a facility form titled, "Physician's Order" dated 5/15/23 indicated to clean the right leg hematoma with open blisters with wound cleanser, pat dry and cover with Optifoam (non-adhesive dressing) three times per week. Veteran's Home doctor will manage non hospice problem. A record review of a facility form titled "Progress Note Wound Care (PNWC)" dated 5/16/22 indicated the etiology of the wound to the right leg was trauma from a medical device brace used after fracture. The recommendation was to discuss with the orthopedic surgeon (ortho) about a different immobilizer or brace that would not create wounds. A record review of a facility form titled; "Progress Note Wound Care (PNWC)" dated 5/30/22 indicated the hematoma on the right leg likely worsened from trauma from the brace. The wound tissue was 100% necrotic (dead body tissue) and required bone tissue debridement (the surgical process of removing skin and bone close to and surrounding an infected wound associated with bone injuries or diseases). The wound doctor had a discussion with Resident 1's daughter regarding the wound condition and it was decided that Resident 1 was going to be discharged from Hospice and sent to the Emergency Room for further treatment. The PNWC indicated the likely underlying hematoma and bleeding into the leg had caused a cesspool for bacteria to grow and causing a rapid breakdown of the skin and wound. The PNWC indicated the brace likely contributed to the breakdown of the wound. Between 5/18/22 and 5/29/22 there were no nursing notes on Resident 1's wound care or status, and no change of condition assessment or documentation was ever completed. An interview with Wound Specialist Doctor (WSD) 1 on 9/7/22 at 12:13 PM was conducted. WSD stated during his visit on 5/16/22 and 5/23/22 the affected area looked like a bruise. After both visits, he advised the unit supervisor and the nurse to call the orthopedic doctor to discuss the option of a different brace. WSD stated, he was concerned the brace may had been contributing to the injury. Interview with RN 2 was conducted on 9/7/22 at 12:34 PM. RN 2 stated the wound doctor wrote an order to call the orthopedic doctor regarding the brace. RN 2 stated he was not sure if the call was made or documented. There was no documentation that the patient ever saw the orthopedic doctor, and the brace was never changed. An Interview with Patient's 1 Responsible Party (RP) was conducted on 10/18/22 at 11:25 AM The RP stated Resident 1 passed away on 6/13/22. An interview was conducted with the Hospice Medical Director (HPM) on 10/19/22 at 3:43 PM HPM stated in general a dementia resident would have a gradual decline in health however if the dementia resident had a fall or a fracture that would speed up the resident's demise. The HPM stated Resident 1 was referred to hospice after the fall and fracture. HPM added that due to hospice regulations, HPM was not able to use the fall and failure to thrive as a primary diagnosis therefore he documented as a secondary diagnosis. HPM stated he documented it a secondary diagnosis because Resident 's prognosis might had been different without the fall. Therefore, the facility failed to protect Resident 1 to be free from accidents by not updating the care plan when Resident 1 had a fall that resulted in a right knee fracture, a hematoma to the right calf and ultimately Resident 1 expired on 6/13/22. 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.