Health inspection·April 4, 2024

42 CFR § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, 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. (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: (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 2/20/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the recertification survey investigation. On 11/7/2023, Resident 3 had a third unwitnessed fall after the facility did not provide sufficient services and care to ensure Resident 3, who was a high risk for falls, had a history of multiple falls, and impairment to both lower extremities, was free from accidents and falls by failing to: 1.Revise and update Resident 3's Actual Fall care plan to include frequent monitoring while in the wheelchair after the resident had a fall on 8/3/2023 and 9/17/2023. 2.Implement the Interdisciplinary Team (IDT, group of health care professionals with various areas of expertise who work together toward the goals of their clients) recommendations from 9/17/2023 for Resident 3 to utilize a Geriatric Chair (Geri chair - a large, padded chair with a wheeled base that can recline, a supportive chair designed to assist residents with limited mobility and provide more substantial support and comfort than a traditional wheelchair) when out of bed to prevent falls. 3.Collaborate with the rehabilitation staff or physical therapy staff during Resident 3's Post Fall and IDT review on 9/17/2023, for a comprehensive individualized plan of care. 4. Implement the care and services to be provided to Resident 3 to assist in attaining and maintaining her highest practicable quality of life, per facility policy titled, “Develop-Implement Comprehensive Care Plans," revised 3/2023. 5. Implement the facility's policy and procedure titled, "Fall Management Program," revised 3/2023 to provide Resident 3 with adequate supervision and assistance devices to minimize the risks associated with falls; and to provide an environment which remains as free from accident hazards as possible. As a result, on 11/7/2023, Resident 3, a 50-year-old female, had another unwitnessed fall from a wheelchair and was found on the floor. Resident 3 was transferred to the General Acute Care Hospital (GACH) 1 via 911 and sustained a nasal fracture, a hematoma to the forehead and a laceration to the nose. A review of Resident 3's Admission Record indicated the facility re-admitted the resident on 6/23/2015 with diagnoses including hemiplegia (paralysis of one side of the body), contracture (a fixed tightening of muscle, tendons, ligaments, or skin, causes a deformity and prevents normal movement of the associated body part) of muscle in the right hand, contracture of the right elbow, difficulty in walking, cognitive impairment (ability to think, understand, and reason) and glaucoma (a chronic, progressive eye disease caused by damage to the optic nerve, which leads to visual field loss). A review of the History and Physical dated 4/26/2022, indicated Resident 3 did not have the capacity to understand and make decisions due to a cognitive impairment. A review of the Resident 3's Situation, Background, Assessment, and Recommendation (SBAR) / Change of Condition (COC) documentation dated 8/3/2023, indicated the resident was found in the activities area lying on the floor after a fall from the wheelchair. The SBAR indicated a skin assessment was done without any injury noted and Resident 3 was able to move all extremities without discomfort. The SBAR further indicated Resident 3 was assisted to sit back in the wheelchair, then taken back to bed. A review of the Post Fall Evaluation / IDT Review documentation dated 8/3/2023 indicated Resident 3 had a fall on 8/3/2023 at 3:10 PM and slid out of the chair while in activities. The IDT Review indicated Resident 3 did not have any complaints of pain and the Range of Motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point) remained at baseline for the resident. The IDT Review indicated Resident 3 was to have frequent monitoring while in the wheelchair, physical therapy to screen the resident for future falls, and activities to provide one-to-one (1:1) room visits as needed. The IDT Review further indicated the facility would continue with the plan of care for risk for falls. The IDT Review indicated The Director of Nursing (DON), Dietary Supervisor (DS), Activities, and Rehab Therapy were present for the IDT meeting. According to a review of the Actual Fall care plan initiated on 8/3/2023 and resolved on 10/17/2023, Resident 3 was found lying on the floor next to her wheelchair. The care plan interventions indicated to check Resident 3's ROM, continue interventions on the at-risk care plan, encourage the resident to use the bell for assistance, keep the call lights within reach at all times, determine and address causative factors of the fall, monitor/document/report as needed for 72 hours any signs/symptoms of pain, bruises, change in mental status, sleepiness, inability to maintain posture, neuro-checks for 72 hours as ordered, provide 1:1 activities if bed bound, and a physical therapy consult for strength and mobility. The care plan did not indicate interventions to have frequent monitoring while in the wheelchair as indicated in the IDT Review documentation dated 8/3/2023 at 4:32 PM. A review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/14/2023, indicated the resident had severely impaired cognitive skills (never/rarely made decisions) for daily decision making and required total dependence one-person physical assistance for eating and toilet use. The MDS indicated Resident 3 required extensive assistance and two-person physical assistance for bed mobility and transferring, required extensive assistance and one-person physical assistance for dressing and personal hygiene, and the resident was not steady or only able to stabilize with staff assistance for surface-to-surface transfers. The MDS indicated Resident 3 had impairment to one side of the upper extremities (shoulder, elbow, wrist, hand); and impairment to both lower extremities (hip, knee, ankle, foot). The MDS indicated Resident 3 utilized a wheelchair and was always incontinent (having no or insufficient voluntary control over urination or defecation) of bowel and urine. A review of Resident 3's Fall Risk Evaluation dated 9/17/2023 indicated the resident was a high risk for falls due to being disoriented (confused and unable to think clearly), regularly incontinent, having poor vision status (with or without glasses), required use of assistive devices (i.e., cane, wheelchair, walker, or furniture), and 1-2 predisposing diseases. According to a review of the SBAR / COC documentation dated 9/17/2023, Resident 3 slid from the wheelchair onto the floor. The SBAR indicated Resident 3 showed no signs of pain and was able to move the lower extremities and left arm. A review of Resident 3's Post Fall Evaluation / IDT Review dated 9/17/2023 at 6:16 PM, indicated the resident was noted with an unwitnessed fall/slide to the floor from the wheelchair and was noted without injury. The IDT Review indicated the IDT recommended a Geri chair for Resident 3 when the resident was up in the wheelchair and that Resident 3 was not appropriate for restraints because the resident was totally dependent with activities of daily living. The IDT Review indicated the Assistant Director of Nursing (ADON), Social Services Director (SSD), Dietary Supervisor (DS) and the Administrator were part of the IDT, and the plan of care was to continue. The IDT Review did not indicate the Rehabilitation Staff or Physical Therapy staff was part of the IDT. A review of Resident 3's Actual Fall care plan initiated on 9/17/2023 and resolved on 11/8/2023, indicated a goal for Resident 3 to resume usual activities minimizing the risk of injury until the next review date. The care plan interventions indicated to check Resident 3's range of motion, continue interventions on the at-risk care plan, encourage the resident to use the bell to call for assistance, keep call lights with reach at all times, monitor/document/report as needed for 72 hours any signs/symptoms of pain, bruises, change in mental status, sleepiness, inability to maintain posture, neuro-checks for 72 hours as ordered, and to use extended footrest while up in wheelchair for support/safety. The care plan did not indicate interventions to use a Geri chair for Resident 3 when the resident was up in the wheelchair as indicated in the IDT Review dated 9/17/2023 at 6:16 PM. A review of Resident 3's Rehabilitation Screening Form dated 9/18/2023 indicated the resident had a history of falls in the past years with the most recent fall on 9/17/2023. The form indicated Resident 3 slipped out of the wheelchair, was currently on skilled rehabilitation, but did not indicate the IDT recommendations for a Geri chair. A review of the Physical Therapy Treatment Encounter Notes dated 9/20/2023 - 11/8/2023, did not indicate documentation Resident 3 was assessed for the appropriateness of use of a Geri chair. The Physical Therapy Treatment Encounter Notes did not indicate documentation Resident 3 was utilizing a Geri chair. According to a review of the IDT Progress Notes dated 9/25/2023 at 10:12 AM, due to Resident 3's recent fall, the resident was added to the "falling star" program for 3 months and then would be reevaluated. The note indicated Resident 3 was to have a yellow wrist band placed and a red star by name identifier on the door. The note indicated safety devices were to be noted in place and the plan of care was to continue. A review of Resident 3's IDT Progress Note dated 10/17/2023 at 2:45 PM, indicated the resident had a fall on 9/17/2023, was alert and oriented x1 (oriented to either person, place, time, or event) with a diagnosis of hemiplegia, abnormal posture, and mild cognitive impairment of unknown etiology. The progress note indicated Resident 3 had poor safety awareness at times and needed to be redirected. The note indicated Resident 3 was noted as maximum assistance with Activities of Daily Living (ADLs) and transfers, would remain on the falling star program and would be reassessed at the 3-month mark from the most recent fall. The note indicated the plan of care was to be noted as ongoing per the MD orders. A review of Resident 3's Physical Therapy Recert, Progress Report & Updated Treatment dated 9/27/2023 -10/23/2023, did not indicate documentation of Resident 3 utilizing a Geri chair. A review of Resident 3's SBAR / COC documentation dated 11/7/2023, indicated the resident had an unwitnessed fall from the wheelchair in the hallway. The SBAR indicated at around 12:58 PM, Registered Nurse (RN) was notified by Certified Nursing Assistant (CNA) that Resident 3 was on the floor in the hallway. The SBAR indicated Resident 3 was noted with a hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space, usually caused by a broken blood vessel that was damaged by surgery or an injury) to the forehead, a skin tear to the nose and lip with bright red blood. The SBAR indicated Resident 3 had a pain level rated at 5 out of 10 (zero indicating no pain and ten indicating the most severe pain) and was given Tylenol (pain reliever medication) 650 milligrams (mg). The SBAR indicated Resident 3 was assisted back in bed by physical therapy and the treatment nurse, 911 was called, and the resident's physician and the responsible party (RP) were notified. The SBAR indicated at 1:19 PM Resident 3 left the facility to General Acute Care Hospital (GACH) 1. A review of Resident 3's Emergency Documentation (ED) from GACH 1 dated 11/7/2023 at 1:44 PM, indicated the resident was brought into the Emergency Room (ER) by ambulance after being found down at their nursing home. The ED indicated Resident 3 was eating breakfast in the wheelchair, next thing, staff found the resident on the floor conscious. The ED indicated Resident 3 was noted to have a hematoma to the forehead, a 0.5 centimeters (cm) nasal bridge laceration (a deep cut or tear in skin or flesh) and received a Computed Tomography (CT, a medical imaging technique used to obtain detailed internal images of the body) of the cervical spine (neck), CT of the head, and the maxillofacial (bones of the face) completed. According to a review of Resident 3's CT of the head imaging result dated 11/7/2023, the images of the brain demonstrated there was central frontal and superior nasal (area at the front of the face) soft tissue swelling and hematoma. The result further indicated a focal (focal fracture occurs from a force applied to a small area of the body) comminuted (comminuted fracture occurs when a bone breaks into three or more pieces) and right nasal fracture. A review of Resident 3's Health Status Note dated 11/8/2023 at 12:08 AM, indicated the resident's discharge diagnosis was blunt trauma (injury of the body by forceful impact, falls, or physical attack with a dull object), contusion (bruise) of the lip, nasal fracture, nasal laceration, and traumatic hematoma of the forehead. The note indicated Resident 3 had left and right peri-orbital (area around the eyes) area bruises that were a bluish color, nasal area laceration, and glabella (the area of skin between the eyebrows and above the nose) area swelling. A review of Resident 3's Health Status Note dated 11/8/2023 at 5:09 AM, indicated Resident returned to the facility around midnight after being cleared by the GACH trauma physician (responsible for treating bone fractures, cuts, internal injuries, burns, and shock). During an interview on 2/22/2024 at 11:01 AM, Registered Nurse (RN) 1 stated she was working the day Resident 3 fell on 11/7/2023 and was found face down on the floor. RN 1 stated Resident 3 was bleeding, had a laceration on their nose bridge and had a hematoma on their forehead. RN 1 stated Resident 3 was sitting in their wheelchair and fell out of their wheelchair face down. RN 1 stated Resident 3 can be impulsive and will try to get up on her own. During an interview on 2/22/2024 at 11:30 AM, CNA 2 stated she was working the 7 AM - 3 PM shift on 11/7/2024 when Resident 3 fell. CNA 2 stated Resident 3 was sitting in a wheelchair, and she left the resident for a few minutes. Once she returned, she found the resident on the floor. CNA 2 stated Resident 3 was bleeding and had a bump on her forehead. CNA 2 stated when Resident 3 fell, the resident was in a wheelchair. CNA 2 stated, "Now she is put in a Geri chair when out of bed, so the resident doesn't fall." On 2/22/2024 at 12:43 PM, during an interview, the Director of Rehab (DOR) stated he assisted Resident 3 back to bed when the resident fell on 11/7/2024. The DOR stated he was part of the IDT meeting after the fall on 11/7/2023 and indicated the recommendation was for the Resident to utilize a Geri chair when out of bed. The DOR stated Resident 3 was