Health inspection·December 20, 2024

Complaint number CA00639499 Title 22 72311 (a) Nursing Service -General (a) Nursing service shall include, but not limited to, the following: (2) Implementing of patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. Title 22 72523 (a) 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.  CFR §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is— (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). CFR §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; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On June 10, 2019, at 11:25 a.m., an unannounced visit was conducted at the facility to investigate quality of care issues. Based on interviews and records review, the California Department of Public Health (CDPH) determined that the facility failed to: 1. Notify the physician of changes in Patient A’s condition, when the patient had a new onset of right leg pain on April 29, 2019, in accordance with the facility's policies and procedures. 2. Evaluate and modify interventions to address Patient A's changes in health condition in accordance with the facility’s policies and procedures. 3. Conduct complete neurological assessments on April 26, 2019, in accordance with the facility's policies and procedures. 4. Provide adequate supervision and implement interventions to prevent further injuries for Patient A in accordance with the facility’s policies and procedures. These failures resulted in delayed provision of the necessary treatment; and repeated unwitnessed falls causing multiple fractures - specifically fractures of the right pelvis, right sacrum, and bilateral rib, subsequently leading to Patient A not being able to stand and walk. Patient A was transferred from the facility to a general acute care hospital (HOSP) after the third unwitnessed fall, where Patient A died less than 24 hours after being transferred from the facility. Patient A's record from HOSP 1 indicated the patient was admitted to HOSP 1 on April 13, 2019, after a fall at home. The "History and Physical," indicated the patient was awake, responsive and was able to move all four extremities without difficulty during that hospital admission. Patient A's facility medical record was reviewed. Patient A was 91 years old and was admitted to the facility on April 17, 2019, with diagnoses that included sequelae of cerebral infarction (stroke - refers to damage to tissues in the brain due to a loss of oxygen to the area), contusion of scalp (bruise on the scalp), difficulty of walking, lack of coordination, repeated falls, contusion of right knee (bruising), acute embolism (obstruction of an artery, typically by a clot of blood or an air bubble) and thrombosis (blood clots block veins or arteries) of unspecified deep veins of lower extremities (legs). A review of Patient A's facility document titled, "Admission/Readmission Data Collection," dated April 17, 2019, indicated, "Diagnosis: S/P (status post- after) Fall (4/13/2019) Hx: (history) of Dementia..." A review of Patient A's facility document titled, "Safe Resident Handling Screening Tool," dated April 17, 2019, indicated, "Recently patient S/P Mechanical fall from the ground noted weakness (sic) evaluated stroke in hospital and Dementia..." The document further indicated Patient A was able to bear weight on both legs and required one-person assistance. A review of Patient A's facility document titled, "Fall Risk Assessment, "dated April 17, 2019, indicated, "Type: Admission. Score: 13...If the total score is 10 or greater, the resident should be considered HIGH RISK for potential falls..." A review of a facility care plan for Patient A dated April 17, 2019, indicated, "Focus: At risk for fall s/t (sic) (due to) generalized weakness, unsteady gait, Hx (history) of falls, poor safety awareness, poor balance...Goal: Will be free from fall related injuries daily X (times) 90 days...Interventions:...Monitor for side effects of any meds (medications) that can cause: Gait disturbances...Weakness; Sedation; Lightheadedness: Dizziness; Change in mental status. LN (licensed nurse) to notify MD (medical doctor) if present. Monitor for S/S (signs and symptoms) of pain, swelling, change in function, mobility, or LOC (level of consciousness). Notify MD if present..." A review of Patient A's facility, "Minimum Data Set," (MDS- standardized assessment for the management of care) dated April 24, 2019, indicated a "BIMS (brief interview for mental status- screening tool to assess mental capability)," score of 1 out of 15 (scores 00-07 indicates severe impairment). A review of the facility progress note for Patient A titled, "Health Status Note," dated April 26, 2019, at 6:46 a.m., (First fall) indicated, "At around 11:00 pm. Patient in bed asleep…at around 12:45 a.m. while cna (certified nursing assistant) was doing her rounds, patient found lying on the floor, full body assessment done, vs (vital signs - heart rate, respiration rate, blood pressure, temperature and pain level) checked, patient able to move all extremities...patient unable to describe incident, stated she bumped her head on the wall...0 pain, 0 changes on (sic) loc (level of consciousness) noted, rn (registered nurse) supervisor assessed patient...patient able to stand with her two legs with full assist (sic). family (sic) made aware; M.D. notified." The Pain Evaluation Nurses Note dated April 26, 2019, at 12:45 a.m., indicated, "Post -fall...location of pain...back of head..." The document was signed by the nurse on April 29, 2019 (three days after the unwitnessed fall). A review of Patient A's "Neurological Assessment Flowsheet (documentation on specific assessment including level of alertness, hand grips, response to pain, range of motion, and pupil response done after unwitnessed fall to check for signs of head injury)," dated April 26 (no year indicated), did not indicate if Patient A's pupil response was normal or abnormal, or if her response to pain was normal, abnormal, or absent. Further review of Patient A's facility progress notes from April 26 through April 29, 2019, did not identify any documentation of any complaint of pain from Patient A until April 29, 2019; three days after her unwitnessed fall. A review of Patient A's "Nurses Progress Note," dated April 29, 2019, at 6:42 a.m., three days after the patient’s fall (first fall) indicated, "...Patient is alert to self with confusion. On Mtr (monitoring) for the above. Frequent checks performed during shift. Patient was up in wheelchair at beginning of shift. Had c/o (complaint of) R (right) leg pain 6/10. Administered pain med (medication) per md orders. Elevated legs on pillow when patient was in bed..." Further review of the nursing progress notes for Patient A, failed to identify any documentation that indicated the physician or family member had been notified of Patient A's new onset of complaint of pain to the right leg identified on April 29, 2019. A review of Patient A's facility document titled, "Physical Therapy Treatment Encounter Notes," dated April 29, 2019, indicated,"...Pain at Rest = 2/10: Frequency = Intermittent: Location: R (right) hip: Pain Description/Type: aching..." Further review of the Physical therapy notes indicated, "Pain with Movement = 5/10; Frequency = Intermittent; Location: R hip; Pain Description/Type: aching...Upon ambulation, patient was noted to have difficulty walking and c/o pain. Ambulation was then deferred for now. Charged (sic) nurse (nurse’s name) was informed of pain." A review of Patient A's "Occupation Therapy Treatment Encounter Note, "dated April 29, 2019, indicated, "Pain with Movement = 4/10; Frequency = Constant; Location: R hip; Pain Description/Type: Ache- nursing informed..." A review of Patient A's progress notes titled, "Treatment and IDT (interdisciplinary team) Progress Note," dated April 30, 2019, indicated, "called (name of physician) and received new order to continue treatment for general body and left knee carried out..." Further review of Patient A's progress notes titled, "Health Status Note," dated May 3, 2019, at 10:12 p.m., (second fall) indicated, "Patient is alert to person...Patient does have episodes of confusion. Patient was found laying (sic) on the floor in the room on the right side. Patient was given a full body assessment and has no visible injuries noted... (name of physician) notified of un-witnessed fall..." A review of a care plan for Patient A dated May 3, 2019, indicated, "Focus: Actual fall on 5/3/19 fall r/t generalized weakness, unsteady gait, Balance problem, Hx of multiple falls, Anti-anxiety medication, Memory problem, Poor safety awareness...Interventions: Monitor for side effects of any meds that can cause: Gait disturbance...Weakness; Sedation; Lightheadedness; Dizziness; Change in mental status. LN to notify MD if present..." Further review of care plan did not indicate new interventions to address the second incident of fall and prevent further incident of falls. A review of a facility progress notes for Patient A titled, "Nurses Progress Note," dated May 4, 2019, at 6:29 a.m., indicated, "...Able to move all extremities except RLE (right lower extremities) with limitation r/t (related to) an existing chronic contusion to R knee..." A review of facility progress note for Patient A titled, "Nurses Progress Note," dated May 24, 2019, at 4:06 p.m., (third fall) indicated, "v/s WNL (within normal limits) patient is alert to person, is able to make the needs known, patient was observed on floor (sic), no c/o pain and any discomforted noted (sic), family informed by nurse, (name of physician) notified of the patients un-witnessed fall..." A review of a facility progress notes for Patient A titled, "COC/SBAR (change of condition/situation, background, assessment and recommendation tool is provided below to aid in facilitating and strengthening communication between nurses and physicians)," dated May 25, 2019, at 5:58 p.m., indicated, "Transferred to E.R. (emergency room). Patient received at 3pm sleeping with eyes closed. At 5:30 While (sic) assisting patient’s roommate, solicited the assistance of CNA to reposition patient and noticed patient was nonresponsive to verbal/painful stimuli...unable to obtain B/P (blood pressure) ...Informed RN...and called 911. 911 arrived at 5:30...Patient transferred to (name of hospital) at 5:47 pm..." Patient A's record from HOSP 2 was reviewed. The Emergency Department Physician's Notes, dated May 25, 2019, at 6:13 p.m., indicated Patient A was, "...Unresponsive...Diminished breath sounds with very poor air movement...Possible abdominal distention..." HOSP 2’s CT Abdomen/Pelvis Report (radiology imaging test done to check for injuries or abnormalities of specified body parts) dated May 25, 2019, at 8:09 p.m., indicated, "...Reason for exam Abdominal Distention..." The Report indicated Patient A had, "...acute/subacute...fracture of the right sacral ala (tailbone)...acute/subacute mildly displaced fractures of the right superior and inferior pubic rami (right pelvic bones...age indeterminate compression fracture of the L3 (third lumbar spine) vertebral body..." The Emergency Department Physician's Addendum Notes dated May 26, 2019, at 6:15 a.m., indicated Patient A went into cardiopulmonary arrest (heart and breathing stopped) and passed away on May 26, 2019, at 5:18 a.m. (less than 24 hours after being transferred to HOSP 2). On June 10, 2019, at 1:30 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Patient A was very confused, weak, did not know where she was, and had balance problems. LVN 1 stated that if a patient had a fall at the facility, the nurses were to assess the patient, call the physician and the patient's family, look for visible injuries, signs of pain, and ask the doctor for X-rays for the patient. On June 10, 2019, at 2:15 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that any change in a patient's condition had to be addressed. The DON stated the nurses were to initiate the Change of Condition process, notify the physician and the patient's responsible party. The nurses were to assess for injuries, and document on the SBAR form. The DON stated if a patient was found on the floor, the nurses were to do neuro-checks (neurological assessment; see definition below), vital signs, assess, and observe the patient's behavior. The DON stated that if a fracture was suspected, the patient should be sent to the hospital for evaluation. The DON stated a neuro-check included assessment of the patient’s level of alertness, pupil response, movement, pain response, and hand grips, and if the checks were abnormal, the nurse should call the physician. During the concurrent record review, the DON verified Patient A's "Neurological Assessment Flowsheet(s) (document where staff documents the neuro-checks),"related to Patient A's unwitnessed falls at the facility, were incomplete. On June 10, 2019, at 3:30 p.m., the DON was further interviewed. The DON stated if a patient had sustained a fall at the facility, the nursing staff were to do hourly visual checks on the patient, keep the patient busy with activities, and use fall mats (padded mats) placed next to the bed. The DON stated the facility would also use a 1:1 sitter (staff assigned to supervise and stay with a patient for safety) if it was necessary. The DON continued the facility rarely provides a 1:1 sitter due to staffing challenges. When asked what measures the facility could have done to prevent Patient A from having further falls, the DON stated the facility could have met with Patient A's family, the hospice staff, and reviewed Patient A's medications. The DON stated Patient A's restlessness could have been a sign of pain. She stated the nursing staff "multi-tasked" when supervising patients. The DON stated the staff usually tried to keep patients busy with activities, keep the patients at the nurse’s station, or in the hall with them while they worked. On June 10, 2019, at 4:10 p.m., an interview was conducted with LVN 2. She stated Patient A was alert but confused and needed constant re-direction. LVN 2 stated Patient A's right knee was deformed, and Patient A acted uncomfortable when she was repositioned by staff. LVN 2 stated she had not talked to Patient A's family until May 25, 2019, when Patient A was found non-responsive in her bed. LVN 2 stated, on that day, Patient A was lying in bed with her eyes closed around 3:30 p.m., and when she went back into Patient A's room about 5 p.m., Patient A did not respond to verbal stimulation, and that Patient A's eyes were "fixed (no movement)." LVN 2 stated they called 911 and notified Patient A's doctor. She stated Patient A was then sent to the hospital. On June 10, 2019, at 4:25 p.m., an interview was conducted with LVN 3. LVN 3 stated Patient A came to the facility after a fall at home and had been very agitated. LVN 3 stated the nurses would bring Patient A to the nurses' station and have her sit in the wheelchair. LVN 3 further stated Patient A fell