Other·February 6, 2024

Event ID #: ZHN111 Intake #: CA00837686 F - 684 Quality of care: § 483.25 § 483.25 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 residents' choices. §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, (A) An accident involving the resident, which results in injury and has the potential for requiring physician intervention. (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) or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). § 72311 Nursing Services (a)Nursing service shall include, but not be limited to, the following: (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. (E)Any untoward response or reaction by a patient to a medication or treatment. (G)The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety, or security of the patient. § 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 4/24/23, a complaint was reported to the Department that about a year ago, on 7/4/22, Resident 1 sustained an unwitnessed fall and the nurses failed to perform and document nursing assessments to determine if the resident may have sustained a head injury. Resident 1 died on 7/5/22. On 7/4/22, Resident 1 had an unwitnessed fall resulting in confusion. Resident 1 was not thoroughly monitored after the fall. On the following morning, Resident 1 was found unresponsive and pronounced deceased. Based upon interview and record review, the facility failed to perform neurological assessments (a series of questions and or motor tests in the event of a sudden change in condition to detect brain function) for Resident 1 following an unwitnessed fall that could have identified the need for prompt emergent medical treatment. The facility further failed to provide Resident 1 with emergency basic life support when the resident was found unresponsive with no vital signs (pulse rate, temperature, respiration rate, and blood pressure). A record review of Resident 1's hospital records, dated 6/23/22 indicated, the resident was admitted to the hospital's intensive care unit (ICU, provides the critical care for patients with serious health issues that can be life-threatening), on 5/23/22 with a diagnosis of subarachnoid hemorrhage (SAH, bleeding in the space that surrounds the brain), caused by a fall at home. The records also indicated, the resident's condition became stable, and the resident was to be discharged to a skilled nursing facility because he needed skilled nursing care on a continuous basis and rehabilitative services. The record review of Licensed Vocational Nurse 1 (LVN 1) nurse's progress notes titled, "Alert Charting," dated 7/1/22 at 7:29 a.m., indicated Resident 1 was admitted to the skilled nursing facility on 6/30/22, and described on admission as, "alert and oriented x 2-3" (orientation to person, place, and/or time). The record review of LVN 1's notes titled, "Situation, Background, Assessment, Recommendation (SBAR)," dated 7/4/22 at 2:21 a.m., indicated Resident 1 had an unwitnessed fall and was found lying on the floor next to his bed, on 7/4/22 at 12:00 a.m. The notes indicated the resident was, "alert and oriented x 1-2 (resident knew who he was but was not fully aware where he was and what time it was) with confusion and was not able to explain the reasoning for his fall." In a phone interview with LVN 1, on 5/18/23 at 9:48 a.m., LVN 1 stated, she informed the Medical Doctor (MD) about Resident 1's unwitnessed fall. LVN 1 stated MD had ordered neurological assessments every 4 hours for 24 hours. During a concurrent interview and record review, on 5/9/23, at 12:03 p.m., with the Director of Nursing (DON), the nurses' progress notes dated, 7/4/22 and 7/5/22, indicated the nurses monitored Resident 1's vital signs but did not perform complete neurological checks every 4 hours as MD ordered. A review of LVN 2's progress notes, dated 7/5/22 at 7:15 a.m., (the day after the unwitnessed fall), indicated Resident 1 was found without vital signs and expired (dead) at 5:20 a.m. During a phone interview with LVN 2, on 5/10/23 at 10:29 a.m., LVN 2 stated she did not perform Resident 1's complete neurological assessment on 7/5/23 during her shift, and before the resident expired, because she thought doing neurological checks was only checking the resident's safety, vital signs, and alertness. LVN 2 was not able to describe the proper procedure in performing complete neurological checks. In a phone interview with the Deputy Coroner (DC), on 5/19/23 at 9:15 a.m., DC stated, with Resident 1's diagnosis of subarachnoid hemorrhage due to a mechanical fall at home, the facility should have done complete neurological assessments and sent Resident 1 to the hospital for further evaluation of possible head trauma after the unwitnessed fall. During a review of the facility's policy and procedure (P&P) titled, "Neurological Assessment," dated October 2010 indicated, "Neurological Assessments are indicated: upon physician order; following an unwitnessed fall... any change vital signs or /neurological status in a previously stable, the resident should be reported to the physician immediately." The P&P also indicated, "Steps in the procedure include: ...Perform neurological checks with the frequency as ordered; Determine resident's orientation to time, place and person; Observe resident's speech and speech clarity; Check pupil reaction; Determine motor ability; Determine sensation in extremities; Check eye opening, verbal, and motor responses..." Also, "The following information should be recorded in the resident's medical record: the date and time the procedure was performed, the name and title of the individual(s) who performed the procedure, all assessment data obtained during the procedure, how the resident tolerated the procedure..." These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.