Other·March 15, 2024

F689: 42 CFR § Free of Accident Hazards/Supervision/Devices. §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. 22 CCR § 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR §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 2/1/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident (FRI) about quality of care. The facility failed to ensure Certified Nursing Assistant 1 (CNA 1) provided care and services in accordance with the assessment and policies and procedures (P&P) to prevent Resident 1 from fall and injury. The facility failed to: 1. Provide Resident 1 two-person physical assistance when turning and repositioning as assessed in Resident 1's Minimum Data Set (MDS - standardized assessment and care planning tool) dated 12/20/2023. 2. Checking Resident 1's Low Air Loss mattress (LAL, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) to make sure the LAL mattress was on Static Mode (firm surface set in place and unlikely to move) before CNA 1 turned Resident 1 the right side while giving Resident 1 a bed bath. As a result, on 1/19/2024, at 11:30 a.m., Resident 1 fell from bed onto the floor sustaining a fracture (break of a bone) of the right distal (far from the center of the body) femur (thighbone) and experienced pain (unrated) on the right leg. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on 11/19/2020 and was re-admitted on 12/23/2022 with diagnoses including multiple sclerosis (MS -a disease that affect the nerves) and quadriplegia (paralysis [inability to move from the neck down]). A review of Resident 1's Care Plan for fall risk, revised on 1/19/2024, indicated Resident 1 was at risk for falls. The goal was for Resident 1 to be free from falls and the intervention included providing a safe environment for Resident 1. A review of Resident 1's Care Plan for self-care performance deficit, revised on 7/27/2023, indicated the goal was for Resident 1 to maintain current level of function in activities of daily living (ADLs, such as moving in bed, eating, dressing, personal hygiene, and bathing). The interventions included providing assistant from one to two staff for bed bath, turning, and repositioning in bed. A review of Resident 1's Fall Risk Evaluation, dated 11/26/2023, indicated Resident 1 was at risk for falls due to inability to walk, stand, or move without falling. The goal was for Resident 1 to be free from falls and the intervention included implementing fall risk precautions. A review of Resident 1's MDS, dated 12/20/2023, indicated Resident 1 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding), was usually able to communicate, and required substantial/maximal assistance (helper does more than half the effort; helper lifts or holds trunk or limbs) when rolling from lying on back to left and right side and returning to lying on back on the bed. The MDS also indicated Resident 1 was dependent on two or more staff for shower/bathing, dressing, personal hygiene, and lying down. A review of Resident 1's Nurses Progress Notes, dated 1/19/2024 and timed at 10:21 p.m., indicated Resident 1 complained of lower legs and lower back pain after the fall. The notes indicated the Medical Doctor (MD) was notified and ordered to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1) for X-rays of the lower back and both legs. A review of Resident 1's Change in Condition (COC - a deterioration in a resident's physical or mental condition) Evaluation completed by the DON, dated 1/19/2024 ant timed at 12:19 p.m., indicated on 1/19/2024, Certified Nursing Assistant 1 (CNA 1) was providing Resident 1 a bed bath and when CNA 1 was repositioning Resident 1, Resident 1 slipped from CNA 1's hands and fell to the floor. A review of the facility's Fall Investigation Report, dated 1/24/2024, indicated CNA 1 failed to ensure Resident 1's LAL mattress was on a static/firm mode while turning Resident 1 in bed on 1/19/2024. The report indicated Resident 1 fell out of bed and sustained a fracture of the right distal femur. Resident 1 was immediately transferred to the hospital due to pain. GACH 1 informed the facility that Resident 1 had a femur fracture. On 1/22/2024, Resident 1 was readmitted to the facility with a half cast, (the hard part of a splint [a rigid or flexible device that maintains in position a displaced or movable part] also used to keep in place and protect an injured part does not wrap all the way around the injured area). During an observation in Resident 1's room and concurrent interview with Resident 1 on 2/1/2024 at 3:26 p.m., Resident 1 was lying in bed. Resident 1 was not moving the right arm and the lower extremities. Upon interview, Resident 1 stated she was partially blind and unable to move her lower body. Resident 1 stated that during the bed bath (on 1/19/2024), CNA 1 was standing behind her, "I fell off the bed as soon as I turned over." On 2/2/2024 at 11:30 a.m., during an interview, CNA 1 stated that on 1/19/2024, CNA 1 was providing a bed bath to Resident 1 assisting Resident 1 turn to Resident 1's right side away from CNA 1, and Resident 1 fell from the bed to the floor. CNA 1 stated Resident 1 was on a LAL mattress CNA 1 stated CNA 1 saw "some kind of movement/motion" and that's when Resident 1 fell. CNA 1 stated Resident 1 was on the floor facing up and the resident's head was near the foot of the bed. CNA 1 stated Resident 1 could not move Resident 1's legs and her arms due to weakness CNA 1 stated a second staff should have assisted her to turn and bathe Resident 1. CNA 1 stated she did not ask another staff to assist with Resident 1's bed bath due to "no one was available." CNA1 stated, "I don't know how to use it (LAL mattress)." On 2/2/2024 at 12:44 p.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated that on the morning (unable to recall the time) of 1/19/2024, LVN 2 heard CNA 1 calling for help and went to assist. LVN 2 stated observing Resident 1 lying on the floor facing up. LVN 2 staff two staff providing bed bath for Resident 1 could have prevented Resident 1 from falling. During an interview on 2/2/2024 at 4:02 p.m., LVN 1 stated Resident 1's arms were weak, and Resident 1 was unable to move the lower extremities. LVN 1 stated Resident 1 needed two staff with ADLs. On 02/2/2024 at 5:55 p.m., during an interview, the DON stated two CNAs were "supposed" to perform ADLs on Resident 1. A review of the facility's P&P titled, "Positioning and Body Alignment," dated 01/01/2012, indicated, "staff must be aware of any limitation a resident may have in positioning." A review of the Low Air Loss (LAL) Mattress Instruction Manual Guide, undated, indicated staff must be carefully assessed for the best ways to keep the residents from harm, such as falling. Staff must identify safety risks involving the bed, mattress. The LAL mattress instruction indicated static mode was when the redistribute body mass over a greater surface area at the constant air pressure base on the resident comfort weight setting, and alternating pressure mode was alternating cell cycle with periodic pressure relief (pressure disturbed in wavelike movements). A review of the facility's P&P titled, "Fall Management Program," dated 03/31/2021, indicated, "The purpose of fall management program was to "provide residents a safe environment that minimizes complications associated with falls. Licensed nurse will complete a fall risk evaluation and document interventions for every Resident regardless of fall risk evaluation score." The facility failed to ensure CNA 1 provided care and services in accordance with the assessment and P&P to prevent Resident 1 from fall and injury. The facility failed to: 1. Provide Resident 1 two-person physical assistance (had help from another staff member) when turning and repositioning as assessed in Resident 1's MDS dated 12/20/2023. 2. Checking Resident 1's LAL mattress to make sure the LAL mattress was on Static Mode before CNA 1 turned Resident 1 the right side while giving Resident 1 a bed bath. As a result, on 1/19/2024, at 11:30 a.m., Resident 1 fell from bed onto the floor sustaining a fracture of the right distal femur and experienced pain (unrated) on the right leg. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result for Resident 1 and Resident 1.