Other·October 17, 2024

Jurupa Hills Post Acute FATE-Complaint Intake CLASS A CITATION – ACCIDENTS California Code of Regulation, 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. California Code of Regulation, Title 22, section 72311, Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at 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. Code of Federal Regulations, Title 42, 483.25 (d) (1) Accidents. The facility must ensure that- (d)(1) The resident environment remains free of accident hazards as is possible; and (d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On August 5, 2024, at 8:54 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care and accidents. As a result of the investigation, California Department of Public Health (CDPH) determined that the facility failed to: a. Evaluate the effectiveness of the interventions to prevent falls; and b. Implement new interventions to address Patient A's repeated falls. As a result of these failures, Patient A had recurrent falls (total of 17 falls) from October 16, 2023, to February 13, 2024, while at the facility. Patient A’s fifth (5th) fall resulted in a laceration (cut) on the back of the patient's head and was treated in the Emergency Room (ER) with two staples (used to close wounds) placed on the laceration. Patient A’s 10th fall resulted in a skin tear on the right elbow. Patient A’s 16th fall resulted for the patient to be transferred to the general acute care hospital (GACH) and the patient sustained multiple left rib fractures (broken bone) and thoracic compression fractures (a break in a bone in the middle section of the spine). A review of Patient A’s “Admission Record,” indicated Patient A was initially admitted to the facility on October 12, 2023, with diagnoses which included spinal stenosis (spaces inside the bones of the spine get too narrow), chronic atrial fibrillation (irregular heartbeat that causes poor blood flow), emphysema (lung disease), history of falling, difficulty walking, and alcohol dependence. A review of Patient A’s “Fall Risk Observation/Assessment,” dated October 12, 2023, indicated a score of 26 (a high risk for falls is score of 16-42). A review of Patient A’s care plan, developed on October 12, 2023, indicated, “… Falls: Resident is at risk for falls with or without injury related to impaired safety awareness due to episodes of confusion and forgetfulness, history (hx) of falls, hx of alcohol dependence, anxiety, multiple medications, and hx of vertigo…Goal…Will have no serious injury til (sic) next review…Interventions/Tasks…Anticipate and meet needs…Educate/remind resident to call for assistance with all transfers…keep call light within reach and reorient during routine care…keep bed to lower position…keep personal items within reach…PT/OT (physical therapy/occupational therapy) eval (evaluation) as indicated…” A review of Patient A’s “Minimum Data Set (MDS- a standardized comprehensive assessment and care planning tool),” dated February 29, 2024, indicated the following: - Patient A had a Brief Interview for Mental Status (BIMS -a tool used to screen and identify cognitive condition of residents) score of 3 (severe cognitive impairment); and - Patient A required moderate to maximum assistance with ADL’s (activities of daily living includes bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating). Further review of Patient A’s medical records indicated the patient had multiple falls during his stay at the facility, and as follows: 1. On October 16, 2023, at 1:26 p.m. (First fall), the patient's “Change of Condition Evaluation,” indicated,"… resident found on floor near bed on both knees @ (at) 0930 (9:30 a.m.). pt (patient) awake and alert…. c/o (complain of) left rib pain. no redness or any discoloration noted to site. denies pain to touch. fall matts (sic) beside bed and call light noted within reach. MD (Medical doctor) notified…” A review of Patient A’s “Post Fall Review,” dated October 16, 2023, indicated, “Unable to independently come to a standing position, exhibits loss of balance while standing, Strays off the straight path of walking, requires hands-on assistance to move from place to place, uses short discontinuous steps and/or shuffling steps, Changes gait pattern when walking through doorways, has lurching, swaying, or slapping gait…” 2. On November 10, 2023, at 6:54 p.m., (Second fall), the patient's “Change of Condition Evaluation," indicated," … Resident (patient) was in hallway trying to sit in his wheelchair when the wheelchair rolled away and resident (patient) fell and landed on buttock. He did not hit his head and does not c/o any pain or discomfort at this time. MD notified and his order was to monitor patient for now…” A review of Patient A’s “Post Fall Review,” dated November 10, 2023, indicated, “… Exhibits loss of balance while standing, requires hands-on assistance to move from place to place, uses as assistive device, e.g. (example) cane, walker, etc.” 3. On November 14, 2023, at 7:35 p.m., (Third fall), the patient's “Progress Notes,” indicated,"… At 1530 (3:30 p.m.), Resident (patient) had an unwitnessed fall in the unit hallway. Resident (patient) stated he was attempting to get up to get coffee and forgot to lock his wheelchair. Resident (patient) stated he hit his head and complained of pain 7/10 (indicates severe pain). Resident (patient) was assisted by 2 (two) persons back into wheelchair and educated on risks and benefits of noncompliance with ADLs. MD was notified, RP (responsible party) notified. MD recommended to send to hospital due to patient being on blood thinner…” A review of Patient A's record did not indicate a post fall review was completed after the patient's fall incident on November 14, 2023. 4. On November 20, 2024, at 9:15 a.m., (Fourth fall), the patient's “Progress Notes,” indicated, “Staff reported res (resident) fell on the hallway. Res attempting to sit down without locking the wheelchair first. Res fell back and hit the head. Res is awake, alert with confusion as res baseline… Staff assisted res to bed. Body assessment no injury noted. Res denies any headache or dizziness. No redness or swelling. Denies any pain or discomfort… Educated res to call nurse for assistance and remind res to lock the wheelchair prior sitting on the w/c (wheelchair)…” A review of Patient A's record did not indicate a post fall review was completed after the patient's fall incident on November 20, 2023. 5. On November 28, 2023, at 7:23 a.m., (Fifth fall) the patient's “Change of Condition Evaluation,” indicated, “… Resident (patient) was on the floor at the foot of the bed holding on to the back of his head. Upon assessing resident (patient), he had a minor cut on the back of his head that was bleeding…” A review of Patient A’s “Progress Notes,” dated November 28, 2023, at 7:35 p.m., indicated, “… At 19:20 (7:20 p.m.,), resident (patient) returned from (name of the GACH) after being treated for laceration (cut) to scalp, had 2 (two) staples inserted to be removed in 7-10 days, keep dry for first 2 (two) days. Resident (patient) appears drowsy with slurred (not clear) speech…bed at lowest position, call light within easy reach…” A review of Patient A's record did not indicate a post fall review was completed after the patient's fall incident on November 28, 2023. 6. On November 28, 2023, at 11:38 p.m., (Sixth fall), the patient's “Progress Notes,” “… Resident (patient) found on floor by staff. Resident (patient) refused help from staff, attempting to strike nurses. Resident (patient) was assisted back to bed, MD, DON (Director of Nursing), and RN (Registered Nurse) notified immediately…” 7. On December 5, 2023, at 12:15 a.m., (Seventh fall), the patient's “Change of Condition Evaluation,” indicated, “… resident found sitting on floor at bedside, leaning on right side against his bed, body assessment and neuro checks (to check mental status and speech) performed…no visible injuries at time…he stated that he was trying to go to the bathroom and he fell down…Noncompliant with fall prevention, not utilizing call light, constantly attempts to get off bed unaided…” A review of Patient A’s “Post Fall Review,” dated December 6, 2023, indicated, “…Exhibits loss of balance while standing, strays off the straight path of walking, requires hands-on assistance to move from place to place, uses an assistive device, e.g. cane, walker, etc.…” 8. On December 9, 2023, at 6:30 p.m., (Eighth fall), the patient's “Change of Condition Evaluation,” indicated, “… CNA (certified nursing assistant) was helping resident (patient) to use restroom. while getting resident back on wheelchair resident (patient) lost balance and fell on his right side. CNA and resident (patient) denied hitting head. Resident (patient) c/o pain to right side of hip…. resident (patient) encouraged to stay in w/c and ask for assistance when needed…” A review of Patient A's record did not indicate a post fall review was completed after the patient's fall incident on December 9, 2023. A review of Patient A’s hip x-ray, dated December 12, 2023, indicated “bilateral hips no fractures… minor degenerative changes identified…” 9. On December 14, 2023, at 10:45 a.m., (Ninth fall), the patient's “Change of Condition Evaluation,” indicated, “… Resident (patient) stated he attempted to go to the restroom and fell. Resident (patient) verbalized pain to buttocks and head. RN assessed resident (patient) and no apparent dislocation or visible injuries. Resident (patient) was assisted to the wheelchair and then back to the bed…resident (patient) noted to have pain to buttocks and head...” A review of Patient A’s “Post Fall Review,” indicated, “…Exhibits loss of balance while standing, strays off the straight path of walking, requires hands-on assistance to move from place to place, uses an assistive device, e.g. cane, walker, etc.…” 10. On December 20, 2023, at 3:31 p.m., (10th fall), the patient's “Change of Condition Evaluation,” indicated, “… Resident (patient) attempted to stand on his own, upon standing resident (patient) witnessed to have tripped over footrest and land on right side next to wheelchair. Head to toe assessment rendered, small skin tear 1.5 x 1.2 cm (centimeters – unit of measurement) to right elbow noted. MD made aware…72-hour neurochecks...” A review of Patient A's record did not indicate a post fall review was completed after the patient's fall incident on December 20, 2023. 11. On December 23, 2023, at 7:30 p.m., (11th fall), the patient's “Change of Condition Evaluation,” indicated," … Resident (patient) observed trying to sit in wheelchair when he tripped on sneaker. He is alert, able to move all limbs, denies any pain, did not hit head, fell on right shoulder…” A review of Patient A’s “Post Fall Review,” dated December 23, 2023, indicated, “…Exhibits loss of balance while standing, requires hands-on assistance to move from place to place, uses an assistive device, e.g. cane, walker, etc., decrease in muscle coordination...” 12. On December 25, 2023, at 1:50 p.m., (12th fall), the patient's “Change of Condition Evaluation,” indicated, “… Resident (patient) noted to have unwitnessed fall. CNA passing the hallway noted that the resident was on the floor next to his bed laying on his back. Resident (patient) noted to have unwitnessed fall wearing nonskid socks. Resident (patient) noted to have pull pants down and a recently soiled brief…no complain of pain. Resident (patient) denies hitting his head and noted to have a minor scrape to right forearm no bleeding noted. Neuro checks started and patient assisted back to bed…” A review of Patient A’s “Post Fall Review,” dated December 25, 2023, indicated, “…Unable to independently come to a standing position, exhibits loss of balance while standing, strays off the straight path of walking, requires hands-on assistance to move from place to place, uses short discontinuous steps and/or shuffling steps, has lurching, swaying, or slapping gait, wears poorly fitting shoes...” 13. On December 30, 2023, at 4 p.m., (13th fall), the patient's “Change of Condition Evaluation,” indicated, “…Was called to Nurses station, on assessment, resident (patient) seen sitting on floor, stated he was trying to get up and fell to the floor, fall was unwitnessed by staff…Patient is alert, can move all limbs, no visible injuries noted…” A review of Patient A’s “Post Fall Review,” dated December 30, 2023, indicated, “…Exhibits loss of balance while standing, requires hands-on assistance to move from place to place, decrease in muscle coordination…” 14. On January 8, 2024, at 6:59 a.m., (14th fall), the patient's “Change of Condition Evaluation,” indicated, “… the resident is trying to stand up from the wheelchair. CNA and LVN (Licensed Vocational Nurse) keep telling the resident to stay but he never listens (sic), and he lose (sic) his balance standing up and fell on the floor…” A review of Patient A's record did not indicate a post fall review was completed after the patient's fall incident on January 8, 2024. 15. On January 11, 2024, at 4:29 a.m., (15th fall), the patient's “Change of Condition Evaluation,” indicated, " …Was called into resident's (patient’s) room re: fall. On assessment resident (patient) seen lying on floor out on hallway in supine position with knees drawn up. CNA verbalized that he was trying to grab a bottle off nurses' desk when he stumbled, fell backwards, hitting head against door frame. Neuro checks performed, is able to state name and move all limbs, c/o (complain off) having headache and back pain...” A review of “Post Fall Review,” dated January 11, 2024, indicated, “…Unable to independently come to a standing position, exhibits loss of balance while standing, strays off the straight path of walking, requires hands-on assistance to move from place to place, uses short discontinuous steps and/or shuffling steps, exhibits jerking or instability when making turns…” 16. On February 2, 2024, at 12:44 p.m., (16th fall), the patient's “Change of Condition Evaluation,” indicated, “…Loud noise heard down the hallway. Resident (patient) was found on floor in room next to bed A. RN notified. Resident (patient) assessed by charge nurse and RN resident (patient) assisted to side of bed. resident (patient) observed to be holding back of head and forehead. Resident (patient) unable to state how he fell…” A review of Patient A’s “Post Fall Review,” dated February 2, 2024, indicated, “…Exhibits loss of balance while standing, strays off the straight path of walking, requires hands-on assistance to move from place to place, uses short discontinuous steps and/or shuffling steps, changes gait pattern when walking through doorways, has lurching, swaying, or slapping gait, exhibits jerking or instability when making turns, wears poorly fitting shoes…” A review of the facility document titled, “Transfer Form,” dated February 2, 2024, at 2:57 p.m., indicated Patient A was transferred to the GAC