Other·October 19, 2023

Facility: Yucaipa Hills Post Acute Event ID: RJOR11 Representing the Department, HFEN # 40171 Citation “A” REGULATORY VIOLATIONS: Title 42 of the Federal Code of Regulations §483.25(d)(2) Accidents. 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) The facility must ensure that – (2) Each resident receives adequate supervision and assistance devices to prevent accidents. Title 22 of the California Code of Regulations §72301. Required Services. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. §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. On May 31, 2023, at 11:15 AM, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Patient 1, a patient who was unsteady on his feet and had dementia (a condition characterized by impairment of at least two brain functions, such as memory loss and judgment. Symptoms include forgetfulness, limited social skills, and thinking abilities so impaired that it interferes with daily functioning). On April 13, 2023, Patient 1 had an unwitnessed fall when he was alone in his room while he was on one to one (1:1 – one staff to one patient direct monitoring and supervision) per a physician’s order. As a result of his injuries, Patient 1 had to be sent to the hospital for treatment and evaluation where he was diagnosed with a head injury, subdural hemorrhage (a pool of blood between the brain and its outermost covering), and a scalp laceration which required 3 staples. The facility failed to: 1. Provide supervision, monitoring, and support for Patient 1 on April 13, 2023, when Patient 1 sustained an unwitnessed fall while Patient 1 was supposed to be on 1:1 monitoring and the assigned staff member was not accompanying Patient 1. 2. Carry out a physician’s order for 1:1 monitoring of Patient 1. 3. Implement the facility’s policy and procedures for ensuring the safety and supervision of patients. These failures resulted in Patient 1 being hospitalized in critical condition. Patient 1, a 62 years-old male, was admitted on July 2, 2022, with diagnoses which included traumatic brain injury (head injury), dementia, unsteadiness on feet, epilepsy (a brain disorder that causes recurring seizures), schizoaffective disorder (a disorder characterized by a combination of hallucinations or delusions, and mood disorder symptoms such as depression or mania) and altered mental status (altered state of mental functioning). A review of Patient 1’s Minimum Data Set ( MDS - an assessment of the resident’s functional and health status), dated April 10, 2023, indicated Patient 1 had a severely impaired mental status according to the Brief Interview for Mental Status (BIMS – a screening tool used to determine mental status; A score of 13 to 15 suggests the patient is cognitively (the ability of the brain to think and reason) intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). Patient 1 scored a 4 (severely impaired). A review of Patient 1’s “Fall Risk Assessment” dated April 13, 2023, indicated Patient 1 was at “High Risk” for falls and had sustained “…3 or more falls in past 3 months.” A review of Patient 1’s “Initial Psychiatric Evaluation” dated April 11, 2023, indicated, “…Treatment Plan: …-Staff will assure the client of safety…Resident on monitoring for increased aggressive behavior and recent falls…” A review of Patient 1’s physician’s orders, an order dated April 10, 2023, indicated, “1:1 [one on one] monitoring by CNA [Certified Nursing Assistant].” During a telephone interview on August 8, 2023, at 4:48 PM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated he worked at the facility [name of facility] on April 13, 2023, when Patient 1 fell and sustained a head injury and had to be sent to the hospital. CNA 1 stated Patient 1 was one of the patients assigned to him during his shift. CNA 1 stated he could not remember which Licensed Vocational Nurse (LVN) told him that he was on a 1:1 (one to one) assignment with Patient 1 and that he needed to keep checking in on Patient 1 throughout his shift. CNA 1 stated he was also responsible to help other patients throughout his shift even though he was assigned 1:1 with Patient 1. CNA 1 stated when Patient 1 fell on April 13, 2023, Patient 1 was in his room with the door closed and was not accompanied by any staff members inside the room. CNA 1 stated at the time Resident 1 fell, he (CNA 1) was outside Resident 1’s room and was attempting to redirect another patient who was trying to open Patient 1’s door. CNA 1 stated he did not want Patient 1 to be woken up and that’s when he heard Patient 1 yell. As he opened the door and entered the room, he found that Patient 1 had fallen and hit the back of his head on the floor and was bleeding. CNA 1 further stated he was the first to respond to the fall. During an interview on August 16, 2023, at 12:15 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she was working at the facility [name of facility] on April 13, 2023, when Patient 1 fell during her shift. LVN 1 stated CNA 1 was assigned to do 1:1 monitoring with Patient 1 that day and when the resident fell, CNA 1 was outside the door of Patient 1’s room. LVN 1 further stated Patient 1 required 1:1 monitoring due to his history of falls and stated Patient 1 was unsteady on his feet. During an interview on August 16, 2023, at 4:15 PM, with CNA 2, CNA 2 stated he was working at the facility on April 13, 2023, when Patient 1 fell. CNA 2 stated CNA 1 was assigned to do 1:1 with Patient 1, because Patient 1 kept getting up all the time and had a history of falls. CNA 2 stated throughout his shift, he saw CNA 1 outside Patient 1’s room with the door closed on “multiple occasions” (could not quantify how many times). CNA 2 further stated when he saw CNA 1 outside Patient 1’s room, he (CNA 1) was just standing there and sometimes talking to staff but was not performing any particular tasks. CNA 2 further stated on other occasions when he saw other staff members assigned to 1:1 monitoring, they were in the room with Patient 1 and not outside the room with the door closed, but stated this time was different. During an interview on August 23, 2023, at 9:20 AM, with the Director of Nursing (DON), the DON stated Patient 1 had behaviors and would at times be unsteady on his feet and had physician orders for 1:1 (one on one) supervision. The DON stated her expectation was that if a staff member was assigned to do 1:1 (one on one) with a patient, they should always be in the room with the patient. The DON further stated any staff assigned to do 1:1 monitoring of a patient should be next to the patient or near them and in the line of sight of the patient at all times. The DON stated it would be unacceptable for a staff member to be outside a room of a patient on 1:1 monitoring with the door closed. The DON stated 1:1 monitoring is important for the safety of the patient and other patients within the facility. During a concurrent interview and record review, on August 23, 2023, at 9:46 AM, with the DON, the written statement from CNA 1, dated April 13, 2023, was reviewed. The statement indicated, “I, [name of CNA 1] making a statement about [name of Patient 1]’s fall incident. I was assigned to do “one on one” with [name of Patient 1]. Around 7:20 PM I was redirecting another resident not to get in into [sic] [name of Patient 1]’s room because I don’t [sic] want the patient to be disturbed onto [sic] his sleep. I heard [name of Patient 1] yell and I immediately came up to him and I found him laying [sic] on the floor…” The DON stated, “Reading the statement from the CNA, it sounds as though it was an unwitnessed fall.” The DON further stated it would have been unacceptable if the staff member was outside of the room of a patient with the door closed while on 1:1 monitoring. The DON further stated if the door is closed, the staff should be inside the room with the patient. During a concurrent interview and record review on August 23, 2023, at 11:26 AM, the DON provided an untitled document which listed incidents when Patient 1 fell in the facility for the month of April 2023. The untitled document dated April 1, 2023, through April 30, 2023, indicated Patient 1 had fallen three times in the month of April 2023 (April 7, 2023, April 9, 2023, and April 13, 2023). During an interview on August 23, 2023, at 4:00 PM, with CNA 3, CNA 3 stated she worked on April 13, 2023, when Patient 1 fell. CNA 3 stated she recalled seeing CNA 1 assigned to do 1:1 supervision for Patient 1 and stated she saw CNA 1 sitting in a chair outside Patient 1 ‘s room on multiple occasions while the patient was in the room with the door closed. During a review of Patient 1’s document titled, "[name of hospital]...ED [emergency department] Provider Report..." dated 4/13/23, the document indicated, "[name of Patient 1]...History of Present Illness...Fall Injury...62 y/o [year old] male...BIBA [brought in by ambulance] from [name of facility] after sustaining an unwitnessed fall today. Per EMS [emergency medical services] pt was noted to have a hematoma [a collection or pooling of blood outside a blood vessel] to the back of his head...he's had a total of 3 falls this week...CT [computated tomography- an imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body] scanning...Impression: Small posterior right parafalcine and tentorial subdural hemorrhage [bleeding in the posterior (rear) aspect of the brain], 3 mm [Millimeters - a unit of measure] in thickness...Posterior scalp 3 cm [centimeters - a unit of measure] partial-thickness laceration...3 staples placed without incident...Diagnosis: Altered mental status fall, close head injury, scalp laceration, subdural hemorrhage...Condition: Critical..." During a review of the facility’s policy and procedure titled, “Falls and Fall Risk, Managing,” revised March 2018, the policy indicated, “…Resident [patient] conditions that may contribute to the risk of falls include: …c. Delirium [a mental state in which you are confused, disoriented, and not able to think or remember clearly] and other cognitive impairment;…i. functional impairments… 3. Medical factors that contribute to the risk of falls include: …e. balance and gait [manner of walking] disorders…Resident [patient]-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 [patient]at risk or with a history of falls.” During a concurrent interview and record review on August 23, 2023, at 10:18 AM, with the DON, the facility’s policy and procedure titled, “Safety and Supervision of Residents [patients],” (undated), the policy indicated, “Our facility strives to make the environment as free from accident hazards as possible. Resident [patient] safety and supervision and assistance to prevent accidents are facility-wide priorities…4. Implementing interventions to reduce accident risks and hazards shall include the following routine checks of resident [patient]or 1:1 supervision to ensure safety…d. ensuring that interventions are implemented; and e. Documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently.” The DON stated the policy was not followed. During an interview on August 14, 2023, at 4:05 PM, with the DON, the DON stated the facility did not have a policy and procedure regarding 1:1 [one on one] supervision. In violation of the above cited standards, the facility failed to: 1. Provide supervision, monitoring, and support for Patient 1 on April 13, 2023, when Patient 1 sustained an unwitnessed fall while Patient 1 was supposed to be on 1:1 monitoring, and the assigned staff member was not accompanying Patient 1. 2. Carry out a physician’s order for 1:1 monitoring of Patient 1. 3. Implement the facility’s policy and procedures for ensuring the safety and supervision of patients. These violations present either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and constitutes a class “A” violation.