Other·September 6, 2022

42CFR §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 §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. 22 CCR § 72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. On 6/2/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint investigation about Resident 1’s quality of care. The facility failed to ensure Resident 1, who was at risk of falls and was on a low air loss mattress (LALM, an air mattress covered with tiny holes designed to let out air very slowly which helps keep the skin dry and wicks away any moisture as well as to relieve pressure), was provided side rails in bed for safety and fall prevention as requested by Resident 1’s Responsible Party 1 (RP 1) as Resident 1 was able to move in bed and could roll out of bed. As a result, on 5/17/2022 at 1:30 p.m., two days after admission to the facility for rehabilitation, Resident 1 fell from the bed onto the floor, requiring transfer to General Acute Care Hospital 1 (GACH 1) by Emergency Medical Services (EMS, paramedics). Resident 1 was diagnosed with acute cervical (neck) facture (bone break) of C5-C6 vertebrae (the neck bones number 5 and 6) and laceration (cut) on the right side of the forehead. After fracture repair surgeries, Resident 1 remained quadriplegic (paralyzed [unable to move] from the neck down and required a tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) and needed a ventilator (a breathing machine that moves air in and out of the lungs) for breathing. A review of Resident 1’s Admission Record indicated the facility admitted the resident, a 74-year-old female, from GACH 1 on 5/14/2022, with diagnoses including non-traumatic intracerebral hemorrhage (stroke, bleeding into the brain) in cerebellum (back section of the brain), facial weakness, hemiplegia (paralysis [inability to move] one side of the body), Stage IV (four) pressure ulcer (also named pressure sores or bedsores, deep wound that involves muscle, tendons, ligaments, and bone) of the sacrum (the portion of the spine between the lower back and tailbone), end stage renal disease (ESRD, total loss of kidney function), and dependence on renal dialysis (a treatment that takes over a person’s kidney function when the kidney stops working). A review of Resident 1’s Inter-Facility Transfer Report sent by GACH 1 with the resident on admission, dated 5/14/2022, indicated the resident was a high fall risk. A review of Resident 1’s nursing Clinical Admission Evaluation, dated 5/14/2022, indicated the resident had impaired range of motion (ROM, joint movement) on both arms and both legs. A review of Resident 1’s Fall Risk Evaluation, dated 5/14/2022, indicated Resident 1 scored 9 for fall risk. The fall risk evaluation also indicated the resident had decreased muscular coordination and use of assistive devices (cane, wheelchair, or walker) for gait and balance. However, Resident 1’s fall risk evaluation did not include any documentation on how to interpret the score for fall risk. A review of the facility’s undated blank copy for Fall Risk Evaluation, indicated “If the total score is 10 or greater, the resident should be considered at High Risk for potential for potential falls.” However, the fall risk evaluation form did not indicate how to interpret scores less than 10. A review of the Physician’s Order for Resident 1, dated 5/15/2022, indicated the use of a LALM and verify functioning every shift. A review of the Physician’s Order for Resident 1, dated 5/16/2022, indicated to provide the resident physical therapy (PT) and occupational therapy (OT) treatment five times a week for four weeks for therapeutic exercises, bed mobility, transfers, gait/stairs management, A review of Resident 1’s PT Treatment Encounter Note, dated 5/16/2022, indicated the resident required fall risk precautions. The PT note did not include the specific fall precautions. A review of Resident 1’s OT Treatment Encounter Note, dated 5/16/2022, indicated Resident 1 required fall risk precautions. The OT note did not include the specific fall precautions. A review of Resident 1’s OT Treatment Evaluation & Plan of Treatment, dated 5/16/2022, indicated Resident 1 stated being worried about falling. A review of Resident 1’s Care Plan, initiated on 5/16/2022, indicated Resident 1 was at risk for falls related to diagnoses. The goal was for Resident 1 to be free of falls through the review date of 8/14/2022. The interventions included placing the bed in the lowest position with LALM and providing a safe environment such as slide fails (side rails) as ordered. A review of Resident 1’s Active Orders as of 5/20/2022, did not indicate a physician’s order for bed side rails. A review of Resident 1’s Change of Condition (COC) Evaluation completed by Licensed Vocational Nurse 3 (LVN 3), dated 5/17/2022 and timed at 3:24 a.m., indicated the resident fell from bed at around 1:30 a.m. to the floor. Resident 1 had blood on the forehead, was helped back to bed. LVN 3 called paramedics and they transferred Resident 1 back to GACH 1. On 6/2/2022 at 2:28 p.m., during an interview, LVN 1 stated Resident 1 did not move but one time she observed the resident leaning towards the left side of the bed so she (LVN 1) repositioned Resident 1 to the middle of the bed. On 6/2/2022 at 3:37 p.m., during an interview, the Maintenance Supervisor (MS) stated on 5/16/2022, he changed Resident 1’s regular mattress to a LALM and installed Resident 1’s side rails on 5/17/2022 after Resident 1’s fall. On 6/2/2022 at 4:19 p.m., during an interview, the Director of Nursing (DON) stated the facility relies on the documentation from the transferring facility to provide care to the resident. The DON stated RP 1 requested on 5/16/2022 to have side rails on the resident’s bed and put them up for safety. The DON stated she did not grant RP 1’s request because the nursing staff needed to first assess if Resident 1 needed side rails up. The DON stated she believed Resident 1 was unable move in bed without assistance and did not need side rails. On 6/9/2022 at 10:15 a.m., during a telephone interview, Occupational Therapist 1 (OT 1) stated he evaluated Resident 1 on 5/16/2022. OT 1 stated Resident 1 had movements on both sides of her body, but one side was significantly weaker than the other. On 6/9/2022 at 2:00 p.m., during a telephone interview, Speech Therapist 1 (ST 1) stated she evaluated Resident 1 on 5/16/2022, who was able to move from side to side and the bed did not have side rails. ST 1 stated RP 1 pointed out to her on 5/16/2022 that Resident 1 did not have side rails and RP 1 requested side rails up in bed because Resident 1 could move and roll out of bed. ST 1 stated Resident 1’s bed should be lowered to the floor or side rails should be applied to the bed. ST 1 stated she facilitated a conversation between RP 1 and the DON on 5/16/2022 and witnessed RP 1 verbalize to the DON about the need for side rails and the DON told him they would take care of it. ST 1 stated anyone with a stroke was at risk for falls. On 6/14/2022 at 10:15 a.m., during a telephone interview, Physical Therapist 1 (PT 1) stated she evaluated Resident 1 on or about 5/15/2022 and the Resident 1 was able to turn from side to side. PT 1 stated Resident 1 needed minimal assistance to get to a vertical position (to rise straight up). However Resident 1 declined to stand up because the resident was not comfortable. PT 1 stated it was agreed to try to stand Resident 1 on the next visit. On 6/14/2022 at 3:48 p.m., during a telephone interview, LVN 3 stated on 5/17/2022 at 1:30 a.m., he found Resident 1 on the floor, on the right side of the resident’s bed, facing down. LVN 3 stated Resident 1 was on a LALM without side rails and that LALM are slippery. LVN 3 stated Resident 1’s bed was in the lowest position and the LALM was on top of the bed. LVN 3 stated Resident 1 did not move, the resident did not have side rails on the bed, and there were no floor mats. On 6/14/2022 at 4:27 p.m., during a telephone interview, LVN 4 stated Resident 1 was able to move her upper body. LVN 4 stated she once observed Resident 1’s legs positioned towards the edge of the left side of the bed, and she repositioned Resident 1 to the middle of the bed. LVN 4 stated Resident 1 could have benefited from the side rails because of the LALM that are slippery. LVN 4 stated the height of Resident 1’s bed was “Minimum. Wasn’t high.” LVN 4 stated she could not remember if Resident 1’s bed had side rails. LVN 4 stated RP 1 did not like that Resident 1’s room was “All the way at the end. He wanted a room change. Social service has to change rooms.” On 7/6/2022 at 12:30 p.m., during a telephone interview, RP 1 stated upon Resident 1’s admission to the facility he requested bed side rails up multiple times to prevent the resident from falling out of bed. RP 1 stated Resident 1’s bed was narrow and needed bed rails to prevent her from falling. RP 1 stated he requested for bed side rails multiple times but received push back from staff who told him that that they needed a direct order from the doctor to install bed side rails. RP 1 stated he asked the facility staff to read Resident 1’s chart from GACH 1 which indicated the resident needed close monitoring. RP 1 stated Resident 1 was still in GACH 1 as of 7/6/2022. RP 1 stated Resident 1 is now quadriplegic and on a ventilator for artificial life support. RP 1 stated he was now placed in a position to “pull the plug (remove from life support).” RP 1 stated he felt Resident 1 was robbed of her ability to rehabilitate after her miraculous rehabilitation from GACH 1 prior to going to the facility. On 7/18/2022 at 11:44 a.m., during a telephone interview, LVN 3 stated and confirmed Resident 1’s neck was not immobilized (to fix/support part of a body part to reduce or eliminate motion) when she was placed back in bed after the fall. A review of GACH 1 Neurocritical Care Attending Addendum note for Resident 1, dated 5/17/2022, indicated the resident had acute cervical spinal cord injury and the four extremities (legs and arms) were flaccid (paralyzed, unable to move) and with complaints of some difficulty breathing. Resident 1 was placed on a ventilator. The neurologist (a physician specializing in the branch of medicine dealing with disorders of the nervous system) documented, “At the time of my involvement, the patient’s condition was critical with high potential for death and/or physiologic deterioration secondary to acute spinal cord injury (and) acute respiratory failure.” A review of GACH 1 Hospitalist Progress Note for Resident 1, dated 5/18/2022, indicated Resident 1 underwent a C6 – C7 Anterior Cervical Discectomy and Fusion (ACDF, a surgery to remove damage disk or bone spurs in the neck), C3 – C7 laminectomy (a spinal surgery that removes a portion of a vertebra called lamina), and C2 – T2 posterior spinal fusion. A review of GACH 1 Hospitalist Progress Note for Resident 1, dated 5/27/2022, indicated Resident 1 underwent tracheostomy (surgical procedure to create an opening into the windpipe) on 5/26/2022 because Resident 1 was no longer able to breath independently due to spinal cord injuries. A review of the facility’s policy and procedures (P&P) titled, “Resident Rights,” revised 1/1/2012, indicated the following: 1. The facility will promote and protect the residents’ rights. Residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care, subject to the facility’s rules and regulations and applicable state and federal laws governing the protection of resident health and safety. 2. State and federal laws guarantee certain basic rights to all residents of the facility. These rights include, but are not limited to, a resident right to…Choose a physician and treatment and participate in decisions and care planning…Voice grievances and have the facility respond to those grievances in a prompt manner. 3. The facility makes every effort to assist each resident in exercising his/her rights by providing the following services: A. The facility’s staff encourages residents to participate in planning their daily care routines (including ADLs, activities of daily living) … 4. In order to facilitate resident choices, facility staff will inform (and regularly remind) the resident and family members of the resident’s right to self-determination and participation in preferred activities; gather information about the resident’s personal preferences on initial assessment and periodically thereafter and document these preferences in the medical record; and include information gathered about the resident’s preferences in the care planning process. A review of the facility’s P&P titled, “Bed Rails,” revised 12/4/2020, indicated that it is the facility’s policy to review the risks and benefits of bed rails with the resident or resident’s representative and obtain informed consent prior to installation. A review of the facility’s P&P titled, “Fall Management Program,” revised on 3/13/2021, indicated the facility will implement a fall management program that supports providing an environment free from fall hazards. The Interdisciplinary Team (IDT) and/or licensed nurse will develop a care plan according to the identified risk factors and root cause(s) per Care Area Assessment (CAA) guidelines. The policy also indicated IDT will initiate, review, and update the Resident’s fall risk status and care plan at the following intervals: on admission, quarterly, annually, upon identification of significant change of condition, post fall and as needed. A review of an undated LALM Owner’s Manual provided by the facility, indicated a warning that “this device (LALM) is designed to help provide pressure redistribution and may require other equipment. This may include but is not limited to; 1. Bedrails for repositioning and fall prevention…” The facility failed to ensure Resident 1, who was at risk of falls and was on a low air loss mattress was provided side rails in bed for safety and fall prevention as requested by Resident 1’s Responsible Party 1 (RP 1) as Resident 1 was able to move in bed and could roll out of bed. As a result, on 5/17/2022 at 1:30 p.m., two days after admission to the facility for rehabilitation, Resident 1 fell from the bed onto the floor, requiring transfer to GACH 1 by Emergency Medical Services. Resident 1 was diagnosed with acute cervical facture of C5-C6 vertebrae and laceration on the right side of the forehead. After fracture repair surgeries, Resident 1 remained quadriplegic from the neck down and required a tracheostomy and needed a ventilator for breathing. 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 Resident 1.