Other·May 10, 2024

F689 42 CFR § 483.25 Free of Accidents / Supervision The facility must ensure that – (d)(1) The resident environment remains as free of accident hazards as is possible; and (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 3/28/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident (FRI) regarding resident safety. The facility failed to ensure Resident 1, who had history of falling, abnormalities of gait (walking) and mobility, and had moderately impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions), received care and services to prevent accidents and falls by failing to: 1. Revise and update Resident 1's Risk for Falls care plan to include frequent monitoring while in the wheelchair after the resident had a fall on 1/2/2024 and 3/5/2024. 2. Implement the facility's policy and procedure titled, "Fall Management Program," revised 3/2023 to provide Resident 1 with adequate supervision and assistance devices to minimize the risks associated with falls. 3. Monitor for the effectiveness of the care plan interventions and modify for a non-compliant resident. 4. Implement the facility's policy and procedure titled, “Post Fall Evaluation,” to include appropriate, person-centered interventions to reduce the potential for future falls. As a result, on 3/13/2024, Resident 1 had another fall, yelled for help and was found in his room on the floor. Resident 1 was transferred to the General Acute Care Hospital (GACH)1 via 911 where he was diagnosed with an acute (new) moderately displaced fracture (two or more portions of bone come out of proper alignment, more serious fracture, usually requires surgery to fix) of distal right fibula (bone on the outside of the ankle). A review of Resident 1's Admission Record indicated the facility admitted the 96-year-old male on 11/29/2022, with diagnoses including cachexia (loss of body weight and muscle), muscle weakness, history of falling, and abnormalities of gait and mobility. A review of Resident 1's History and Physical dated 12/15/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Situation-Background-Assessment and Recommendation (SBAR - a written communication tool that helps provide important information) Communication Form dated 1/2/2024, indicated the resident was found sitting on the bathroom floor with a skin tear at his right elbow. The SBAR indicated Resident 1 stated he hit the right side of his head and a 72- hour neuro-check was initiated. A review of Resident 1's Post Fall Evaluation / Interdisciplinary Team Review (IDT- a group of dedicated healthcare professionals who work together to provide you with the care you need, when you need it) dated 1/2/2024 indicated Resident 1 had unsteady gait and generalized muscle weakness related to the aging process. The IDT Review indicated Resident 1 continued to perform activities beyond his ability and was not compliant with the requirement to call for assistance when using the toilet, despite being educated to do so. According to a review of the Care Plan initiated on 1/2/2024, Resident 1 had an actual fall due to poor balance and unsteady gait. The care plan interventions indicated to encourage the resident to use the bell to call for assistance, keep call lights with reach at all times, and to start Resident 1 on Restorative Nursing Assistance (RNA) ambulation (walking with exercise to improve or maintain mobility and independence) for strength and mobility three times a week. A review of Resident 1's Physician's Progress Notes dated 2/1/2024, indicated the resident was non-compliant with care, did not call for assistance and wants to be independent beyond capacity. The notes indicated Resident 1 had recurrent (happening again) falls, and a diagnosis of osteoporosis (a disease that weakens your bones) which placed him at increased risk for recurrent fracture. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 3/1/2024, indicated the resident had moderately impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions), which was a change and decline in cognition compared to Resident 1’s H&P dated 12/15/2023. The MDS indicated Resident 1 required maximum assistance with showering, required partial/moderate assistance with toileting and personal hygiene, dressing upper and lower body, sit to stand, chair/bed to chair transfer, and toilet transfer. A review of Resident 1's SBAR Communication Form dated 3/5/2024, indicated Resident 1 had another fall (two months later) that was an assisted fall to the floor, as a facility staff was present with the resident, that resulted in a skin tear to Resident 1’s right elbow and forearm. A review of the Fall Risk Evaluation, dated 3/6/2024, indicated Resident 1 was oriented to person, place, and time, had one to two falls within the last three months, had a balance problem while standing/walking, and had 1-2 predisposing conditions (activities that can lead to the development of disease). The fall risk evaluation form indicated Resident 1 had a score of 10 and that a total score of 10 or greater indicated a high risk for potential falls. According to a review of the Physical Therapy (PT) Evaluation and Plan of Treatment dated 3/6/2024, Resident 1 was presented to therapy due to repeated falls in the facility with the most recent occurring on 3/5/2024. The PT evaluation form indicated Resident 1 had soreness to the right shoulder and left hip, the X-ray was negative for fracture but Resident 1 had decreased strength and safety awareness. A review of Resident 1's Post Fall Evaluation/IDT Review dated 3/7/2024 at 12:21 PM, indicated the resident lost his balance while standing up and using the urinal and was assisted to the floor by Certified Nursing Assistant (CNA) staff. The IDT Review indicated Resident 1 had episodes of confusion and forgetfulness and required partial to moderate assistance with transfers from his bed to his wheelchair and wheelchair to bed (which was the same level of assistance required prior to Resident 1’s 3/5/2024 fall). The level of assistance for transfers did not change. A review of Resident 1's Care Plan initiated on 3/10/2024, indicated the resident had an assisted fall due to loss of balance while using a urinal. The care plan interventions indicated to 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, place a floor mat on left side of the bed to minimize injury in case of fall reoccurrence and to provide skilled PT and Occupational Therapy (OT-therapy that focuses on helping people do all the things that they want and need to do in their daily lives). There were no new person-centered interventions to prevent fall and no increase in supervision or transfer assistance. A review of Resident 1's Care Plans initiated prior to 3/13/2024, did not indicate any care plans developed for Resident 1 regarding his non-compliance with care and calling staff for assistance. A review of Resident 1's SBAR Communication Form dated 3/13/2024, indicated the resident fell from his wheelchair and was heard calling for help. Resident 1 was found in his room, on the floor mat, on the left side of his bed. The SBAR form indicated Resident 1's ankle looked dislocated, and he was transferred to GACH 1 for further evaluation. The SBAR form indicated Resident 1 did not use the call light for assistance. According to a review of the X-ray from GACH 1 dated 3/13/2024, Resident 1 had an acute moderately displaced fracture of the distal right fibula (bone on the outside of the ankle). A review of Resident 1's GACH 1 Discharge Summary dated 3/16/2024, indicated Resident 1 sustained an ankle fracture that was reduced (push or pull the ends of the fractured bone until they line up) in the Emergency Room (ER), as the resident’s family refused an Open Reduction Internal Fixation surgery (ORIF- a surgical procedure for repairing fractured bone) and requested a non-operative management (not involving surgery). The discharge summary indicated Resident 1 had a long cast and would be discharged back to the facility. During an interview on 3/28/2024 at 12:22 PM, Restorative Nursing Assistant 1 (RNA) 1 stated, "On 3/13/2024, when Resident 1 fell, I was present in the facility. I was sitting in the hallway in front of the resident's room when I heard a scream. I went inside the room and found him [Resident 1] on the floor." During an interview on 3/28/2024 at 12:43 PM, Licensed Vocational Nurse 1 (LVN) 1 stated Resident 1 was not compliant with his care and did not use his call light for assistance. LVN 1 stated Resident 1 required assistance with his transfers, as he had three falls in 2024. LVN 1 stated, "On 3/13/2024, I was assigned to Resident 1 and around 2:50 PM, the CNA had just taken him to the restroom. Resident 1 remained on his wheelchair and tried to get into his bed without assistance." LVN 1 stated Resident 1 did not have a pad alarm on his wheelchair. During an interview on 3/28/2024 at 1:06 PM, Registered Nurse Supervisor (RN) 1 stated Resident 1 did not have a tab alarm on his wheelchair, and if there was a tab alarm it would have alerted the staff to assist him. On 3/28/2024 at 4:15 PM, during a concurrent interview and record review, Resident 1's care plan were reviewed with the Director of Nursing (DON). The DON stated, "Resident 1 was non-compliant and for non-compliant residents, we keep educating them. We provide CNAs they are already familiar with. The DON stated staff did not initiate a care plan for Resident 1's non-compliance with appropriate interventions. The DON stated there was no documentation that Resident 1's family member was informed about the non-compliance to use the call light for assistance. The DON also stated Resident 1 had dementia. During an interview on 3/29/2024 at 1:42 PM, the Director of Rehab (DOR) stated Resident 1 required assistance with transferring, as he was at high risk for falls. The DOR stated Resident 1 did not have strength in his legs, and he required constant reminders to call for help. In his mind, he thought he could get up on his own. However, his legs did not have the strength for him to get up on his own. The DOR stated Resident 1 did not have a bed alarm or chair alarm and a chair alarm would be a good intervention for Resident 1 which would alarm the staff before he tried to get up on his own. During an interview on 3/29/2024 at 4:08 PM, the DON stated the Falling Star Program (a fall prevention program, that focuses on promoting a safe environment and anticipating the patient's needs to prevent a fall) included residents with falls within the last three months. The DON stated "In the falling star program, we monitor residents closely. In addition to low beds, we have safety devises such as tab alarms, rooms close to the nurses' station, and frequent visual monitoring of the residents." The DON stated Resident 1 was part of the falling star program, but he did not have a tab alarm as part of his fall prevention interventions. A review of the facility's policy and procedure titled, "Post Fall Evaluation," revised 3/2023, indicated the purpose of this procedure was to provide guidelines for identifying the cause (s) associated with resident falls. Documentation: the following should be recorded in the resident's medical record, appropriate interventions taken to reduce the potential for future falls. A review of the facility's policy and procedure titled, "Fall Management Program," revised 3/2023, indicated the facility strives to provide each resident 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. Avoidable Accident was defined as an accident which occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or evaluate and analyze the hazards and risk and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards and risks as much as possible; and/or implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and if not reduce the risk of an accident; and/or monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice. The Fall Management Program policy indicated residents at risk for falling shall have a care plan that identifies individual risk factors and person-centered interventions, based on the risk factors. The facility nursing staff and/or the interdisciplinary team shall update the resident’s plan of care accordingly to reduce the risk for further occurrences of a fall and/or to reduce the risk (s) for significant injury related to falling. The facility failed to ensure Resident 1, who had history of falling, abnormalities of gait and mobility, and had moderately impaired cognition, received care and services to prevent accidents and falls by failing to: 1. Revise and update Resident 1's Risk for Falls care plan to include frequent monitoring while in the wheelchair after the resident had a fall on 1/2/2024 and 3/5/2024. 2. Implement the facility's policy and procedure titled, "Fall Management Program," revised 3/2023 to provide Resident 1 with adequate supervision and assistance devices to minimize the risks associated with falls. 3. Monitor for the effectiveness of the care plan interventions and modify for a non-compliant resident. 4. Implement the facility's policy and procedure titled, “Post Fall Evaluation,” to include appropriate, person-centered interventions to reduce the potential for future falls. As a result, on 3/13/2024, Resident 1 had another fall, yelled for h