Other·December 8, 2023

F689 (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §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 72311(a)(1)(B)(2) 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: (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 10/17/2023, the California Department of Public Health (CDPH) received a complaint alleging Resident 1 fell out of bed and sustained a closed head injury (a non-penetrating injury to the brain with no break in the skull) while a Certified Nursing Assistant (CNA 1) was providing care to Resident 1. On 10/26/2023 CDPH conducted an unannounced visit to the facility to investigate the complaint. As a result of the investigation, the CDPH determined Resident 1, who required a two-person physical assist for bed mobility, fell out of bed while being repositioned by CNA 1. The facility failed to ensure CNA 1 did not turn and reposition Resident 1 alone without the assistance of another staff as required by Resident 1's care plan. This resulted in Resident 1 falling from bed and sustaining a left parietal (near the back and top of head) scalp hematoma (an injury that causes blood to collect and pool under the skin resulting in a spongy, rubbery, lumpy feel) with laceration (a deep cut or tear in the skin or flesh). This deficient practice placed Resident 1 at risk for serious complications associated with a head injury including a brain injury, fractures (partial or complete breaks in the bone) and death. On 10/14/2023 Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment of her head wound. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 76-year-old female, was admitted to the facility on 12/7/2020 with diagnoses including dysphagia (difficulty swallowing), contractures (when muscles, tendons, joints, or other tissues tighten or shorten leading to a deformity) of the right and left knee and muscle weakness. A review of Resident 1's History and Physical (H&P), dated 1/22/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/10/2023, indicated Resident 1's cognitive skills for daily decision-making were severely impaired. The MDS indicated Resident 1 was totally dependent on staff for bed mobility and required a two or more-persons physical assistance with bed mobility. A review of Resident 1's Situation, Background, Assessment, and Recommendation ([SBAR] a technique which is used to facilitate prompt and appropriate communication within the healthcare team), dated 10/14/2023, and timed at 9 a.m., indicated Resident 1 fell while CNA 1 turned and repositioned her by himself, while Resident 1 was in bed. The SBAR indicated Resident 1 slid off the bed, hit her head on the dresser located beside Resident 1's bed, then landed on the floor. A review of Resident 1's Transfer Form dated 10/14/2023, and timed at 11:33 a.m., indicated Resident 1 was transferred to a GACH for evaluation and treatment related to her fall. A review of Resident 1's GACH Admission Record, indicated Resident 1 was admitted to the GACH on 10/14/2023 at 6:30 p.m. A review of the GACH H&P, dated 10/15/2023, indicated Resident 1 sustained a fall with head trauma resulting in a hematoma and left parietal scalp laceration. A review of Resident 1's head Computed Tomography ([CT] an imaging test used to detect internal injuries by providing cross-sectional images of bones, blood vessels and soft tissues in the body) scan dated 10/15/2023, indicated Resident 1 had a left parietal scalp hematoma. A review of Resident 1's General Surgeon Consultation report, dated 10/15/2023 indicated Resident 1 had a left parietal occipital (back of head) scalp hematoma measuring 3.0 centimeters ([cm] a unit of measurement) by 3.0 cm with a small laceration with scabbing and eschar (dead tissue that forms over healthy skin and then, over time, falls off). During an interview on 10/26/2023, at 12:06 p.m., CNA 2 stated Resident 1 could not get up by herself or move from side to side on her own and required two people to assist when she was turned and repositioned. CNA 2 stated when two people are required to turn and reposition a resident, a staff member should stand on each side of the resident's bed to prevent the resident from falling off the bed. During a concurrent interview and record review with the MDS Nurse on 10/26/2023 at 1:23 p.m., Resident 1's Activities of Daily Living ([ADL] task required to independently care for oneself such as eating, bathing, dressing, grooming and toileting) Performance Self Care Deficit Care Plan dated 12/21/2020, was reviewed. The Care Plan Indicated Resident 1 had muscle weakness and osteoarthritis (mechanical wear and tear on the joints). The Care plan interventions included moving Resident 1, while in bed, using a two-person assistance. The MDS Nurse stated the purpose of the Care Plan was to assist the nursing staff in providing individualized care to residents based on their needs. The MDS Nurse stated, if the staff had followed Resident 1's care plan to use two people when moving Resident 1 in bed, Resident 1's fall could have been prevented. During a telephone interview on 10/26/2023 at 1:59 p.m., CNA 1 stated he raised Resident 1's bed to the level of his (CNA 1) waist (approximately three to four feet from the ground), to change Resident 1's bed linens. CNA 1 stated he was standing behind Resident 1, on the left side of Resident 1's bed, with Resident 1's backside facing him (CNA 1), when Resident 1 leaned to her right side. CNA 1 stated Resident 1 rolled off the bed and hit her head on the bedside dresser before she fell to the floor. CNA 1 stated he was not able to prevent Resident 1 from falling off the bed because he was on the opposite side of the bed from where Resident 1 fell and he did not have enough time to prevent Resident 1 from falling. CNA 1 stated it would have been safer if another staff assisted him when he repositioned Resident 1. CNA 1 stated he was not aware Resident 1 required two people to assist with turning and repositioning Resident 1. During a concurrent interview and record review with the Director of Rehabilitation (DOR) on 10/26/2023 at 2:38 p.m., Resident 1's Occupational Therapy Notes for 10/2022 were reviewed. The Occupational Therapy Notes indicated Resident 1 required a total assistance with bed mobility and rolling left to right. The DOR stated Resident 1 was a full assist, required two or more persons to roll from left to right because Resident 1 could not roll by herself. The DOR stated Resident 1 does not have a protective reaction (how resident would guard or protect themselves if they were falling) due to her immobility and contractures of her upper and lower extremities. The DOR stated there should have been two staff members assisting with Resident 1's repositioning to prevent her from falling out of bed. During a concurrent interview and record review with the Director of Nursing (DON) on 10/26/2023 at 2:56 p.m., Resident 1's Interdisciplinary Team ([IDT] team members from different departments working together, with a common purpose, to set goals, make decisions that ensure residents receive the best care) notes dated 10/26/2023, and timed at 1:03 p.m., were reviewed. Resident 1's IDT notes indicated Resident 1 had a fall while CNA 1 was turning and repositioning Resident 1 by himself. The IDT notes indicated Resident 1 slid off the bed and hit her head on the dresser that was beside her bed, and then landed on the floor. The DON stated CNA 1 reported to her that he was repositioning Resident 1 without assistance when the incident occurred. The DON stated Resident 1's fall should not have happened and could have been avoided if there was another staff member standing with Resident 1 and assisting him (CNA 1) in holding Resident 1 while he (CNA 1) was changing Resident 1's bed linen. During an interview on 10/28/2023 at 12:51 p.m., the Director of Staff Development (DSD) stated when a resident requires two or more people to assist with bed mobility and is totally dependent on staff with moving from side to side in bed, there should always be another CNA assisting to prevent the resident from falling off the side of the bed. A review of the facility's policy and procedure (P/P) titled, "Activities of Daily Living (ADL), Supporting," revised 3/2018, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, in accordance with the plan of care, including appropriate support and assistance with mobility. A review of the facility's P/P, titled "Falls and Fall Risk, Managing," revised 3/2018, indicated 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 the complications from falling. A review of the facility's CNA Job Description revised 10/2020, indicated duties and responsibilities include monitoring and evaluating the resident's response to care plan interventions in accordance with facility policies, and to review care plans daily to determine if changes in the resident's daily care routine have been made on the care plan. The facility failed to ensure CNA 1 did not turn and reposition Resident 1 alone without the assistance of another staff as required by Resident 1's care plan. This resulted in Resident 1 falling from bed and sustaining a left parietal scalp hematoma and laceration. This deficient practice placed Resident 1 at risk for serious complications associated with a head injury including a brain injury, fractures, and death. On 10/14/2023 Resident 1 was transferred to a GACH for evaluation and treatment of her head wound. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.