Other·February 16, 2023

California Code of Regulations, Title 22, section 72311 (a)(2) Nursing Service- General (a) Nursing service shall include, but not limited to, the following: (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 of Regulations, Title 22, section 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. Code of Federal Regulations, Title 42, section 483.25(d)(2) Accidents. The facility must ensure that- (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On October 31, 2022, at 8:15 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care issue. It was determined that based on observation, interview, and record review; the facility failed to provide supervision consistent with the needs, goals, care plan, and current professional standards of practice in order to eliminate the risk of an accidental fall to Patient A. Patient A was left unattended while in a wheelchair at Station 3 lobby. This failure resulted in Patient A getting up unassisted from the wheelchair, and falling face down to the floor, for the second time in 38 days, sustaining a right frontal subdural hematoma (SDH-a pool of blood between the brain and its outermost covering). Patient A was transferred to the acute care hospital for evaluation, and eventually expired on October 13, 2022 (14 days after the incident of fall on September 29, 2022). On October 31, 2022, a review of Patient A's record indicated the patient was admitted to the facility on October 16, 2020, with diagnoses that included encephalopathy (a brain disease that alters the brain function or structure), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), bipolar disorder (mood swings), and unsteady gait (abnormal or uncoordinated walking). A review of Patient A's history and physical, dated November 11, 2022, indicated Patient A did not have the capacity to understand and make decisions. A review of Patient A's Minimum Data Set (an assessment tool) dated July 15, 2022, indicated that Patient A had a Brief Interview of Mental Status (BIMS- a screening tool) Score of 02 (severe impairment in cognition [thinking process]). Patient A had exhibited physical and behavioral symptoms directed towards others, and rejection of care. Patient A's functional status required extensive assistance with one-person physical assist in most of his activities of daily living (ADLs) and used wheelchair for mobility device. The assessment further indicated Patient A's balance was not steady and only able to stabilize with staff assistance. A review of Patient A's Quarterly Fall Risk Assessment, dated July 28, 2022, indicated a score of 17 (high risk for fall). A review of Patient A's care plan, initiated on November 19, 2020, indicated, "Focus: At risk for fall R/T (related to) Use of BP (blood pressure) meds (medications), Balance problem, ASE (adverse side effects) from medication, agitation (shaken state of emotions), dementia, poor safety awareness, does not call for assistance prior to getting up from safe position, incontinence (lack of voluntary control over urination of defecation)...Interventions:...Position resident closer to activity personnel when in activity room for closer supervision...Prompt resident to adjust his placement in his wheelchair when he appears too close to the edge to prevent him from sliding off. Assist as needed...Call light within reach and staff to answer promptly...Encourage resident to call for assistance if needed...Maintain safe environment, room free of clutter..." A review of the Situation, Background, Assessment, Recommendation (SBAR- a communication tool between nurses and prescribers) Communication Form, dated August 22, 2022, indicated an unwitnessed fall incident on August 22, 2022, at 1:26 p.m. The Nursing Notes indicated, "Resident sitting on patio in wheelchair. Resident tried to stand up and fell and hit his head." Resident A sustained abrasion on the right forehead and treatment was conducted at the facility. A review of the Care Plan titled, "Unwitnessed fall," dated August 22, 2022, indicated, "Goal: Resident may have bilateral floor mats in place with bed in lowest position and call light and belongings within reach, to prevent falls X (for) 30 days...Interventions: Maintain safe environment, bed in lowest position, frequent checks on resident, call light and belongings all left within reach...Neuro checks X 72 hours..." The care plan developed related to unwitnessed fall of Patient A dated August 22, 2022, did not address the fall incident while the patient was out in the patio area. A review of the Fall Risk Assessment, dated August 23, 2022, indicated a score or 16 (high risk for fall). A review of the IDT (Interdisciplinary Team)-Incident Review, dated August 23, 2022, indicated Patient A, "has not had any prior incident of getting up unattended. It is noted that resident recently has been having changes in condition and there might be some increase in confusion associated with it." The IDT's Interventions/Recommendations indicated, "Resident is currently on PT (physical therapy) for rehab (rehabilitation) and will continue to address safety and therapeutic exercises. Will also alert rehab staff not to allow resident to go to the patio unattended by staff outside..." A review of the SBAR Communication Form, dated September 29, 2022, indicated Patient A had another unwitnessed fall on September 29, 2022, approximately 38 days after the first fall. The Nursing Notes documented, "Resident was found on floor beside of wheelchair, with head on floor...Redness and swelling above right eyebrow, no other injuries noted...Resident sent out to (name of hospital) for evaluation due to falling and hitting head..." A review of the IDT-Incident Review, dated September 30, 2022, indicated Patient A had a fall on September 29, 2022, at 12:10 p.m. The Description of the Incident documented, "About 12:00pm, resident was up on his reclining wheelchair with the high back slightly tilted back, situated at the station 3 lobby with a couple of other residents...At 12:10 pm, Staffer heard a thud as she was walking towards the nurse's station at station 3...she found resident lying on the floor, face down, in front of his wheelchair..." On October 31, 2022, at 11:45 a.m., an observation was conducted in the areas where Patient A had the fall incidents. The patio area, where Patient A's first fall incident happened on August 22, 2022, had cemented floor and located adjacent to the rehabilitation gym (formerly the activity room). The front lobby area, where Patient A's second fall incident happened on September 29, 2022, had carpeted floor and was located across Nurse Station 3. On October 31, 2022, at 11:45 a.m., during interview, the Director of Nursing (DON) stated Patient A was taken out from his room on September 29, 2022, at around 12 p.m., to be brought to the Dining Room for the lunch feeding assistance program. He stated Patient A required feeding assistance from the staff, and the patient (Patient A) was sitting in his reclining wheelchair in front of Nurse Station 3 with two other patients, while waiting to be brought by the staff to the Dining Room. The DON stated he had a brief conversation with Patient A at the front lobby just before the fall incident happened. The DON stated there was a staff at Nurse Station 3, who had briefly left the nurse station to assist another patient in the hallway. The DON stated there was no staff in the nurse station to supervise the patient around the time of the fall. At around 12:10 p.m., as the staff was walking back to Nurse Station 3, the staff heard a noise, like a thud, and saw Patient A on the floor, face down, in front of his reclining wheelchair. Patient A was assessed by the licensed nurses and noted abrasion with redness and swelling above the patient's right eyebrow. A neuro check and vital signs were conducted, and it was within normal limits. Patient A was sent to the hospital for further evaluation and treatment. On October 31, 2022, at 12:01 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated she was the charge nurse for Nurse Station 2 on September 29, 2022, where Patient A's room was located. LVN 1 stated Patient A's functional status had declined rapidly in August to September 2022. The patient's physician had indicated that Patient A's dementia was getting worse, and he became forgetful, combative, and noncompliant with his care and medications. LVN 1 stated Patient A was placed in front of Nurse Station 3 in the front lobby, around noontime on September 29, 2022, while waiting to be brought to the Dining Room for the feeding assistance program. LVN 1 stated the staff in Nurse Station 3 would usually monitor patients that are placed in the front lobby, while waiting to be brought to the Dining Room. A review of the acute care hospital history of present illness dated September 29, 2022, indicated, "...presents as fall from wheelchair. Patient does not participate in the interview as he in nonverbal. There is no reported usage of blood thinners. He was able to move all four extremities. Pupils appear to be equal; however, the patient becomes combative when testing for pupil reactivity. CT (computed tomography-diagnostic imaging procedure) scan of the head shows 2mm (millimeter-unit of measurement) right frontal SDH with no midline shift or mass effect..." A review of Patient A's acute care hospital record titled, "Deceased Discharge Summary, " dated October 13, 2022, indicated,"...Preliminary cause of death: R (right) frontal SDH after fall..." A review of Patient A's death certificate, indicated, "...Date of Death (October 13, 2022) ...Cause of Death. Subdural Hematoma...Blunt Force Head Trauma...Place of Injury...Rehabilitation Facility...Describe How injury Occurred...Unwitnessed Mechanical Fall..." On December 22, 2022, at 3:40 p.m., during a telephone interview with the DON. The DON clarified the documented IDT's Intervention/Recommendation, dated August 23, 2022, "...not to allow resident to go to the patio unattended by staff..." would include any areas within the facility building and not just the patio area. The DON stated Patient A was assessed as high risk for fall and a Falling Leaf flag was attached in his reclining wheelchair, so that the staff can frequently monitor the resident. The DON stated the staff at Nurse Station 3 had briefly left Patient A unattended, because she went to the hallway to assist another patient. As the staff was walking back to Nurse Station 3, it was at the same time when Patient A got up from his wheelchair without staff assistance, and fell to the floor. The staff heard a sound of a thud and found Patient A lying on the floor, face down, in front of his reclining wheelchair. The DON acknowledged there was a failure by the facility to implement the IDT's Intervention/Recommendation, not to allow the patient to be left unattended by the staff. A review of the facility's policy and procedure titled, "Falls and Fall Risk, Managing," dated March 2018, indicated, "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling...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 at risk or with a history of falls...The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling...If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions..." Therefore, based on observation, interview, and record review, the facility failed to provide supervision consistent with the needs, goals, care plan, and current professional standards of practice, in order to eliminate the risk of an accidental fall, to Patient A, when Patient A was left unattended while in a wheelchair at Station 3 lobby. This failure resulted in Patient A getting up unassisted from the wheelchair, and falling face down to the floor, for the second time in 38 days, sustaining a right frontal SDH. Patient A was transferred to the acute care hospital for evaluation, and eventually expired on October 13, 2022 (14 days after the incident of fall on September 29, 2022). This violation presented imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result, and was a substantial factor and direct proximate cause of Patient A's death.