Other·January 8, 2018

California Department of Public Health CA230000802 02/16/2016 COUNTRY CREST POST-ACUTE 50 Concordia Ln Oroville, CA 95966 PREFIX TAG B000 Initial Comments ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE B000 A Citation F 323 §483.25(d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2)Each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to prevent an avoidable fall with injury for one of three residents receiving physical therapy services (Resident 1). Resident 1 was left unattended in a bed that was raised to a height of three feet above the floor. Resident 1 fell out of the bed sustaining a broke right upper leg, a broken nose and a subarachnoid hemorrhage (bleeding in the area between the brain and the tissues that cover the brain that can cause a coma, paralysis, and even death). The facility's Record of Admission, dated 8/28/15 at 10:30 am, showed that Resident 1 was admitted to the facility on that date with diagnoses that included lower back pain, muscle weakness and dementia. She required monitoring following surgical treatment for a pressure sore on her lower back/buttocks area. Post-operative care included the continuous use of a wound vacuum (a device that provided continuous suction to the wound) to assist with the wound healing process and therapies for strengthening and rehabilitation. Licensing and Certification Division STATE FORM 6899 LYPO11 California Department of Public Health CA230000802 02/16/2016 COUNTRY CREST POST-ACUTE 50 Concordia Ln Oroville, CA 95966 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE Resident 1's Admission Nursing Assessment, dated 8/28/15, described the resident as alert to person with moderately impaired thought processes. Resident 1 was noted to be on bedrest and required total assistance for bed mobility. Physician orders, dated 8/28/15, included orders for Physical Therapy and Occupational Therapy (PT & OT) five times a week for two weeks, to evaluate and treat muscle weakness and debilitation. PT and OT treatments included therapy exercise, therapy activity for positioning in bed, and caregiver training. Physician orders, dated 9/8/15, showed that PT and OT services were increased to five times a week for eight weeks. Both services focused on increasing Resident 1's strength and mobility, both in bed and in transferring from the bed to a wheelchair. The Occupational Therapy Recertification and Updated Plan of Treatment for the certification period 9/8/2015 - 11/8/2015 defined Therapeutic Activities as: bed mobility activities to increase functional skills, and training in rolling, scooting, and bridging to facilitate bed mobility and transferring. OT assessed Resident 1's current level of function as: bed mobility equals total dependence with attempts to initiate. The PT Therapy Progress Report, dates of services 9/8/2015 - 9/15/2015 identified that Resident 1 required maximum assistance with bed mobility and the use of side rails. The short term goal was for Resident 1 to be able to move in bed using side rails and minimal assistance. On 9/22/15, Diathermy, the use of high Licensing and Certification Division STATE FORM 6899 LYPO11 California Department of Public Health CA230000802 02/16/2016 COUNTRY CREST POST-ACUTE 50 Concordia Ln Oroville, CA 95966 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE frequency current to generate heat and increase blood flow to specific areas of the body promoting wound healing, was added to Resident 1's plan of treatment. In an interview, on 11/19/15 at 10 am, Physical Therapist (PT 1) stated that he worked with Resident 1 the day she fell out of bed. According to PT 1, Resident 1 was dependent on staff for changes in her position while in bed. PT 1 stated that he administer the Diathermy treatment to Resident 1 while she was in her room lying in bed and the bed was in the high position. Upon completion of her treatment PT 1 stated that he lowered Resident 1's bed to approximately three feet from the floor. Because Resident 1 was uncomfortable about men touching her, PT 1 left the room to find a female certified nursing assistant (CNA) to assist in reposition Resident 1 in her bed. Upon finding a female CNA (CNA 2) and telling CNA 2 that Resident 1 needed assistance in her bed, PT 1 left and returned to the PT/OT therapy room. PT 1 stated that he did not think a fall was possible for Resident 1 because she never moved. In a phone interview, on 12/18/15 at 11 am, CNA 3 stated that on 9/29/15 at approximately 4:00 pm she was working in the area of Resident 1's room. CNA 3 said she saw Resident 1 receiving a treatment from PT 1. CNA 3 stated that Resident 1 was in bed and the bed was in a high position during the treatment. CNA 3 stated that a few minutes later she heard a loud noise and immediately ran into the hallway and then to Resident 1's room. When CNA 3 entered Resident 1's room she found the resident laying on the floor. CNA 3 stated that no one else was in the room at that time and that the bed was in a higher than normal position. CNA 3 said she yelled for help and then asked Resident 1 if she was okay. CNA 3 said that Resident 1's face Licensing and Certification Division STATE FORM 6899 LYPO11 California Department of Public Health CA230000802 02/16/2016 COUNTRY CREST POST-ACUTE 50 Concordia Ln Oroville, CA 95966 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE looked swollen around her eyes, nose and forehead, and that her knee (thinks it was the right) was swollen. Licensed Vocational Nurse (LVN 4) responded to the room and assessed Resident 1. CNA 3 stated that she remembered that Resident 1's bed had to be lowered before she and LVN 4 could put Resident 1 back into bed. During a phone interview, on 12/22/15 at 1 pm, CNA 2 described her account of what happened to Resident 1 on 9/29/15. CNA 2 stated, at approximately 4:00 pm she was in another resident's room assisting that resident out of the restroom when PT 1 came in and asked her to assist repositioning Resident 1 in her bed. CNA 2 stated that she told PT 1 she was busy changing another residents briefs and would be there to assist him as soon as possible. CNA 2 stated that shortly after that she heard a noise and then heard an overhead page, STAT (immediate response) to Resident 1 room. The STAT call was because Resident 1 was found on the floor. CNA 2 stated that when PT 1 asked her to assist repositioning Resident 1, PT 1 never indicated that Resident 1 was left alone, that the bed was left up in a high position, and that the side rails were down. CNA 2 stated that she does not know how Resident 1 fell out of the bed since she (CNA 2) had never seen Resident 1 physically move. Nurses notes, written by LVN 4 on 9/29/15, contained the following entries. At 5 pm, "Resident (1) was found on the left side of the bed on floor, Resident was lying in side lying position with right leg on top of left. Resident was bleeding from her forehead and it's bruised. Right knee is swollen with bruise on. MD notified. New orders for x-ray. R/P (responsible party, son) notified regarding the fall." At 6 pm, "X-ray were taken, waiting on the report. Resident in bed eating dinner." At 6:50 Licensing and Certification Division STATE FORM 6899 LYPO11 California Department of Public Health CA230000802 02/16/2016 COUNTRY CREST POST-ACUTE 50 Concordia Ln Oroville, CA 95966 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE pm, "X-ray report received, MD notified." The findings on the x-ray report, dated 9/29/15 at 6:38 pm, were that Resident 1 broke the bone in her right upper leg just above the knee. The bone broke into fragments and the end of one broken bone was firmly driven into the other. "Acute distal femoral fracture with impaction at the fracture site." The nurses note continued, "New orders to send patient (Resident 1) to ER (emergency room). Ambulance called. Family and Resident notified." At 7:30 pm, "Resident (1) went to hospital." The Emergency Room Physician Note, dated 9/29/15 at 7:52 pm, contained a physical assessment of Resident 1, laboratory blood test results, and radiology test findings. The results of Resident 1's CT scan of her head read, "Finding Considered Critical to Patient Care: Minimal subarachnoid hemorrhage..." Additionally, Resident 1 had had a broken right upper leg, and nasal bone fractures with soft tissue swelling and bruising. Resident 1 was admitted to the hospital and treated for her injuries. Therefore, the facility failed to prevent an avoidable fall with injury when Resident 1 was left unattended in a bed that was raised to a height of three feet above the floor resulting in a broken right upper leg, a broken nose and a subarachnoid hemorrhage. The violation of this regulation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. Licensing and Certification Division STATE FORM 6899 LYPO11