Other·February 1, 2024

California Code Regulations, Title 22, section 72311 Nursing Service- General (a) Nursing service shall include, but not limited to, the following: (1) Planning of patient care, which shall include at the 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. (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. California Code Regulations, Title 22, section 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. Code of Federal Regulation, Title 42, 483.25 (d) Accidents. 483.25(d)(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. On December 5, 2023, an unannounced visit to the facility was conducted to investigate a facility reported incident related to a fall involving Patient A. As a result of the investigation, the California Department of Public Health (CDPH) determined that the facility failed to: a. Ensure fall risk assessments accurately reflect Patient A’s fall risk status; and b. Evaluate the care plan for effectiveness, update, and implement the plan of care developed on November 16, 2023. These failures resulted in Patient A having repeated falls on November 22, and December 4, 2023. Patient A sustained a right radius fracture (broken bone to right arm), laceration (deep cut) requiring sutures to the area above the right eyebrow, and a mildly displaced fracture of adjacent maxillary processes (two missing front teeth) after the fall on November 22, 2023, which required Patient A's transfer to the acute care hospital for medical intervention. On December 5, 2023, Patient A’s record was reviewed. Patient A was admitted to the facility October 24, 2023, with diagnoses that included, generalized muscle weakness, schizophrenia (mental illness characterized by symptoms like difficulty thinking, hallucinations and false belief about reality), depression, and bipolar disorder (mental illness that causes shifts in mood, ranging from extreme highs to lows). A review of Patient A’s “Fall Risk Assessment (screening tool used to identify how likely it is that the patient will fall),” dated October 25, 2023, indicated Patient A was a “Low Risk” for fall. A review of Patient A’s “Fall Risk Care Plan,” dated October 25, 2023, indicated the following interventions for fall prevention: a) anticipate and meet the patient's needs, b) ensure that the patient's call light is within reach and encourage the patient to use it for assistance as needed. Promptly respond to call light and other requests for assistance, and c) maintain a safe living environment, with room and halls free of clutter. A review of Patient A’s “Nursing- Change of Condition - Situation, Background, Assessment, Recommendation- Medical (COC SBAR)," dated November 16, 2023, indicated Patient A was found on the floor by the staff in the dining room and did not sustain any injuries. A review of Patient A’s “Actual Fall Care Plan,” dated November 16, 2023, indicated interventions that included the Interdisciplinary Team (IDT) meeting (a meeting where members of the care team work together to plan and coordinate a patient's care) to review and evaluate the cause of the fall. There was no documented evidence an IDT meeting was conducted after Patient A’s fall on November 16, 2023. In addition, there was no documented evidence a fall risk assessment was conducted after Patient A's fall on November 16, 2023. A review of Patient A’s “COC-SBAR,” dated November 22, 2023, indicated Patient A fell near the nurse’s station and sustained injuries which required a transfer to the acute hospital for further treatment. A review of Patient A’s “Fall Risk Assessment,” completed after the fall dated November 22, 2023, indicated Patient A was “Low Risk” for falls. The fall risk assessment did not indicate Patient A's gait and balance was assessed, and Patient A’s fracture was selected as a predisposing condition that can contribute to a fall. A review of Patient A’s “Nursing Progress Notes,” dated November 29, 2023, indicated Patient A was re-admitted to the facility on November 29, 2023, with diagnoses that included a right radius fracture, laceration requiring sutures to the area above the right eyebrow, and a mildly displaced fracture of adjacent maxillary processes. A review of Patient A’s “Fall Risk Assessment,” dated November 29, 2023, indicated Patient A was “Low Risk” for falls. There was no documented evidence an IDT meeting was conducted to evaluate and assess the cause of Patient A’s fall on November 22, 2023. In addition, there was no documented evidence Patient A’s fall care plan was updated after she was readmitted to the facility from the acute care hospital on November 29, 2023. A review of Patient A’s “COC-SBAR,” dated, December 4, 2023, indicated Patient A was found on the floor and it was an unwitnessed fall. The document further indicated Patient A did not sustain injuries and was not able to let the nurse know what happened. On December 5, 2023, at 9:26 a.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated prior to the fall that occurred on November 22, 2023, Patient A walked independently, unsupervised, and had pacing tendencies. On December 5, 2023, at 9:30 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated prior to the fall that occurred on November 22, 2023, Patient A frequently walked independently and paced quickly. CNA 1 stated she was not made aware of patients who had a high fall risk. On December 5, 2023, at 9:39 a.m., CNA 3 was interviewed. CNA 3 stated prior to the fall that sent Patient A to the hospital on November 22, 2023, Patient A was confused and needed reminders to slow down when walking but was allowed to walk unsupervised. On December 5, 2023, at 12:56 p.m., the Physical Therapist (PT) was interviewed. The PT stated Patient A was impulsive and had poor safety awareness on admission and needed frequent reminders for safety. The PT stated Patient A refused to use a front wheeled walker (an assistive device) and required supervision with walking following Patient A's first fall on November 16, 2023. The PT stated these reminders and education should have been relayed to the staff through education and in-service, but this was not done. The PT stated these safety/supervision interventions were relayed to nursing staff verbally and there was no follow-through if they were being implemented. On December 8, 2023, at 9:30 a.m., an interview with a concurrent medical record review was conducted with the Director of Nursing (DON), and she stated the following: a. An IDT meeting should be completed after each fall to determine the root cause, identify interventions to prevent future falls, and evaluate and update the fall care plan as necessary. Any updates should be communicated to the staff at shift report; b. A fall risk assessment should be completed after each fall. A fall risk assessment, and an IDT meeting was not done after Patient A’s first fall on November 16, 2023. These should have been done; c. The fall risk assessment completed by the licensed nurse on November 29, 2023, was inaccurate. The DON stated that fracture was not selected as a predisposing condition. Also, the IDT only conducted a “verbal” meeting to discuss Patient A’s fall; d. Patient A’s fall care plan and interventions were not updated after the patient's re-admission to the facility on November 29, 2023. The fall care plan should have been updated and implemented after Patient A's re-admission; e. Patient A’s falls on November 22 and December 4, 2023, may have been avoided if the IDT met and changed Patient A’s interventions appropriate to address Patient A's needs after Patient A's first fall on November 16, 2023; and f. The facility policy and procedure on fall management was not followed by the staff. A review of the facility’s policy and procedure titled, “Falls and Fall Risk Managing," dated January 2018 indicated, “...monitoring subsequent falls and fall risk: if a resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change intervention...” A review of the facility’s policy and procedure titled, “Assessing Falls and Their Causes,” dated January 2018 indicated, “...when a resident falls, a fall risk assessment is completed...” A review of the facility’s policy and procedure titled, "Care Plans, Comprehensive Person- Centered,” dated January 2018 indicated, “...care plan will include measurable objectives and timeframes...incorporate identified problem areas...the (The Interdisciplinary Care Team) IDT must review and update the care plan...when there has been a significant change in the resident's condition...when the desired outcome is not met...when the resident has been readmitted to the facility from a hospital stay..." As a result of the investigation, CDPH determined that the facility failed to: a. Ensure fall risk assessments accurately reflect Patient A’s fall risk status. b. Evaluate the care plan for effectiveness, update, and implement the plan of care developed on November 16, 2023. These failures resulted in Patient A having repeated falls on November 22, and December 4, 2023. Patient A sustained a fractured right arm, laceration requiring sutures to the area above the right eyebrow, and a mildly displaced fracture of adjacent maxillary processes (two missing front teeth) after the fall on November 22, 2023, which required Patient A's transfer to the acute care hospital for medical intervention. The above violations had a direct or immediate relationship to the health, safety, or security of the patients.