Other·April 28, 2023

42 CFR § 483.25 (d) Accidents. The facility must ensure that- (1) The resident environment remains as free of accident hazards as is possible; and (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. (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. 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 10/24/2022, the California Department of Public Health (CDPH) received a facility reported incident (FRI) indicating Resident 1 fell and sustained an acute fracture (broken bone) to the left subcapital neck (fracture line that extends through the junction of the head and neck of long bone in the upper leg). On 12/23/2022, the CDPH conducted an unannounced visit at the facility. The facility failed to: 1. Inspect Resident 1’s bedrails routinely per the bed manufacturer's recommendations to prevent Resident 1 from falling from the bed to the floor during while Certified Nursing Assistant (CNA) 2 was performing care to the resident. 2. Follow the manufacturer’s recommendations for the use of bedrails. As a result, CNA 2 was performing morning care for Resident 1 and instructed Resident 1 to hold on to the siderail for support. The siderail broke and Resident 1 fell to the floor breaking her left hip bone. Resident 1 was transferred to a general acute care hospital (GACH) for emergency care. Resident 1 was a 68-year-old-female admitted to the facility on 7/8/2019. Resident 1’s diagnoses included obstructive pulmonary disease ([COPD] a disease that causes airflow blockage and breathing-related problems), hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness) following cerebral infarction (brain injury caused by the interruption of blood flow to part of the brain) affecting left nondominant side, and osteoarthritis (a disorder that happens when the cartilage in the joints breaks down over time, causing pain during movement). During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 9/22/2022, the MDS indicated Resident 1 was rarely able to understand or be understood by others. The MDS indicated Resident 1 required a one person assist with bed mobility, locomotion (movement between locations), dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 1 was a two person assist with transfers to and from bed, chair, wheelchair and standing position. During a review of Resident 1’s Fall Risk Assessment dated 9/22/2022, the fall assessment indicated Resident 1 was at high risk for falls. During a review of Resident 1’s History & Physical (H&P) dated 10/11/2022, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Care Plan titled "Resident is at risk for falls/injury” dated 7/22/2019, the care plan intervention indicated the facility was to provide safety instructions to Resident 1 regarding transfers and activities of daily living when appropriate. During a review of Resident 1’s Interdisciplinary team ([IDT], a team of clinicians from different disciplines, working together for the resident’s benefit) notes dated 10/22/2022, at 4:01 p.m., the IDT indicated per Resident 1’s doctor, Resident 1 was at risk for pathological (caused by disease) fracture related to demineralization of the bone (loss of minerals from a person’s bones that makes bones more prone to fracture) or possible inflammation (swelling) of the bone due to osteoarthritis. During a review of Resident 1’s Radiology ([x-ray] series of tests that take pictures or images of parts of the body) Report dated 10/22/2022, the radiology report indicated Resident 1 had an acute left subcapital neck (fracture line that extends through the junction of the head and neck of femur) fracture. During a review of Resident 1’s Change of Condition (COC), dated 10/22/2022 at 6:55 a.m., the COC indicated on 10/22/2022, at 5:55 a.m., CNA 2 was rendering care to Resident 1 when CNA 2 turned Resident 1 towards herself, Resident 1 slid from the bed. The COC indicated CNA 2 was unable to break the fall due to Resident 1’s weight and the resident fell on her left side. During a review pf Resident 1’s Incident Report dated 10/23/2022, the incident report indicated Resident 1 had a witnessed fall with injury. The incident report indicated CNA 2 provided care to Resident 1 when the accident occurred, and CNA 2 attempted to hold and prevent Resident 1 from falling but was unsuccessful. During a review of Resident 1’s General Acute Care Hospital (GACH) consultation report, dated 10/24/2022, the GACH report indicated Resident 1 was not a candidate for surgical intervention for the fractured femur. The GACH report indicated Resident 1 was monitored for pain and referred to physical therapy (field of medicine that improves mobility, restores function, reduces pain, and prevents further injury by using a variety of methods, including exercises, and stretches) for evaluation and treatment. During a telephone interview on 12/28/2022 at 7:40 a.m., with CNA 2, CNA 2 stated on 10/22/2022 at 5:55 a.m., during morning care, CNA 2 told Resident 1 to hold on to the bed rail for support and to turn to her right side towards the window and away from CNA 2. CNA 2 stated she (CNA 2) continued to clean Resident 1 and placed the chuck (bed pads that protected beds and other surfaces from bodily fluids) underneath Resident 1’s buttock. The right-side bedrail went down and caused Resident 1 to roll off the bed to the floor on her left side. CNA 2 stated she observed the bedrail was broken. During a concurrent interview and record review on 12/29/2022 at 10:53 a.m., with the Maintenance Supervisor (MS), the facility’s maintenance logs dated January 2022 to December 2022 were reviewed. The logs did not indicate residents bed rails were cleaned and checked. The MS stated he did not routinely check bedrails because bed rails were usually up. The MS stated bedrails were only checked if something was wrong with the bedrails. The MS stated he fixed Resident 1’s bedrail after he was notified by CNA 2 the day Resident 1 fell approximately two months ago. The MS stated on 10/2022, after Resident 1’s fall, CNA 2 notified him (MS) Resident 1’s bed rail was not locking properly, and the bedrail would fall when pressure was put on the bed rail. The MS stated he observed the right side of Resident 1’s bedrails was not locking because the black lock latch underneath the bedrail was not attached properly. The MS stated the bedrail latch was displaced and made the bedrail malfunction when a lot of pressure was placed on the bedrail. The MS stated he did not have the owner’s manual for the bed or bedrails and did not know how often the bed rails should be checked. During an email correspondence from a representative (Rep) of the bed manufacturer (for Resident 1’s bed) dated 12/30/2022 at 8:53 a.m., the email indicated residents’ bedrails were not designed to support residents with lifting themselves in bed or as a support to get in and out of bed. The bedrails could be used for slight adjustments or movements but never for the sole purpose of support or movement because it could cause the bedrails to break. The email indicated for residents requiring extra support, trapeze bars (a gymnastic or acrobatic apparatus consisting of a short horizontal bar suspended by two parallel ropes) should be used. The email also indicated bedrails were to keep residents from falling out of bed and the nuts, bolts and screws should be checked often to make sure everything was tight and secured. During a review of an undated manufacturer’s manual for residents’ beds, the manual indicated to check monthly that all screws were tight and not loosened and inspect monthly for signs of cracking, frame, or any deterioration. The manual indicated regular maintenance of bed and accessories were required to ensure proper operation. The manual also indicated casters (set of small wheels fixed to the legs or base of a heavy piece of furniture so that it could be moved easily) and axle bolts (screws) were to be checked for tightness. During a telephone interview on 2/8/2023 at 11:44 a.m., with the MS, the MS stated it was important to perform maintenance on residents’ beds and accessories for safety and to prevent accidents. The MS stated he should have followed the manufacturer’s manual for safety checks. The MS stated he only had basic knowledge on how to maintain residents’ beds and accessories. During an interview on 2/8/2023 at 4:58 p.m., with the Director of Nursing (DON), the DON stated bedrails were considered an assistive device during incontinent care because a resident could hold on to the bedrail for support. The DON stated if the manufacturer’s recommendations were not followed, it could cause residents to have accidents such as falls and fractures. The DON stated it was very important to perform maintenance on residents’ beds including bedrails according to the manufacturer’s manual for residents’ safety. During a telephone interview on 2/9/2023 at 7:24 a.m., with the Director of Rehabilitation (DOR), the DOR stated before Resident 1’s fracture she had full Range of Motion ([ROM] movement at a given joint in a specific direction) to her left and right hip that consisted of bending the hips more than 90 degrees (unit of measurement) and rotating her hips. The DOR stated after Resident 1’s accident on 10/22/2022, Resident 1 did not have full ROM to the left hip compared to her right hip. The DOR stated he did not expect Resident 1 to have full ROM to her left hip anytime soon because the resident’s left hip was broken and unstable. The DOR stated Resident 1 was at risk for loss of ROM and contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to her left hip because Resident 1 was not ambulatory and not able to perform full ROM due to the fracture. The DOR stated the benefits of full ROM to joints was to prevent contractures. During a review of the facility’s undated policy and procedures (P&P) titled "Pathological/spontaneous Fractures- Reducing Risks", the P&P indicated a pathological fracture occurred when a bone breaks in an area weakened by another disease process. The P&P indicated reducing risks included two- people or lift transfer/re- positioning as needed. During a review of the facility’s undated P&P titled "Promoting Safety, Reducing Falls," the P&P indicated by simply focusing on fall preventions, caregivers can enhance the quality of life for residents, promote their independence, maintain their highest practical level of functioning. The P&P indicated the caregivers should inspect assistive devices routinely to make sure they are in good repair and working order with no missing or loose parts. During a review of the facility’s undated P&P titled "Equipment", the P&P indicated the facility will provide equipment for care of residents in the amount necessary to meet anticipated needs of the resident. The P&P indicated other equipment will be provided on a dedicated- patient basis. The P&P further indicated the equipment will be clean, maintained, and replaced as needed. The facility failed to: 1. Inspect Resident 1’s bedrails routinely per the bed manufacturer's recommendations to prevent Resident 1 from falling from the bed to the floor while CNA 2 was performing care to the resident. 2. Follow the manufacturer’s recommendations for the use of bedrails. As a result, CNA 2 was performing morning care for Resident 1 and instructed Resident 1 to hold on to the siderail for support. The siderail broke and Resident 1 fell to the floor breaking her left hip bone. Resident 1 was transferred to a GACH for emergency care. 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.