Other·March 29, 2024

F689: 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 2/27/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident safety. The facility failed to provide the necessary assessments, care, and services for Resident 1 to prevent falls, by failing to ensure two staff members transferred Resident 1 from wheelchair (WC) to bed. On 2/25/2024, certified nurse assistant 1 (CNA 1) attempted to transfer Resident 1 from a WC to a bed without the assistance of another staff member and without the use of a Hoyer lift (an assistive device that allows patients in hospitals and nursing homes and people receiving home health care to be transferred between a bed and a chair or other similar resting places). As a result, on 2/25/2024, Resident 1 fell from the WC onto the floor sustaining injury to his right eye. Resident 1 required emergent transfer to a general acute care hospital 1 (GACH 1) via ambulance. GACH 1 diagnosed Resident 1 with right orbital (bony cavity that contains the eyeball) displaced fracture (two or more breaks in the bone surrounding the eye causing improper alignment), right retrobulbar hematoma (a collection of blood within the bony orbit and behind the eyeball) with proptosis (bulging) and right periorbital (around the eye) hematoma (clotted blood usually caused by broken blood vessel). On 2/25/2024 Resident 1 was transferred to GACH 2, a trauma center (higher level of care) for emergent consult. GACH 2 performed canthotomy (a surgical procedure where the lateral corner of the eye is cut to relive the fluid pressure inside or behind the eye) to Resident 1's right eye. A review of Resident 1's Admission Record indicated the facility admitted the 91 year-old male resident on 2/2/2024 with diagnoses including dementia (progressive loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Parkinson's disease without dyskinesia (movement disorder), with fluctuations, open angle glaucoma of the left eye (ongoing progressive and irreversible increased pressure in the eye causing progressive visual loss) stage unspecified, osteoarthritis (condition of the breakdown of joint cartilage and the underlying bone causing pain and stiffness especially to hips, knees and thumb joint), and history of falling. A review of Resident 1's "Prior Stay Assessment- V2" form dated 2/2/2024, indicated Resident 1 was authorized for respite care (short term) at the facility from 2/2/2024 to 2/23/2024. A review of Resident 1's Physician Orders dated 2/2/2024, indicated the physician ordered the physical therapy (PT - the care provided to a patient promote, maintain, or restore health through patient education, physical intervention, disease prevention, and health promotion) and occupational therapy departments (OT - the use of occupation and meaningful activities with specific goals to help people of all ages prevent, lessen, or adapt to disabilities) to evaluate Resident 1. A review of Resident 1's Lift Transfer Resposition-V2 form dated 2/3/2024, indicated Resident 1 was not able to transfer independently or without supervision. The Lift Transfer Reposition form indicated Resident 1 was not able to bear weight on both legs. The Lift Transfer Reposition form indicated Resident 1 required a total lift (machine used when a resident needs complete assistance to transfer between surfaces) and required two staff to perform lift transfers and to reposition Resident 1in bed. A review of Resident 1's "Nursing Documentation Evaluation x V2" document dated 2/3/2024 at 1:32 p.m., indicated Resident 1 was dependent on staff for transfers and required two persons for transfers. A review of Resident 1's Medication Administration Record (MAR) for 2/2024, indicated Resident 1 received Melatonin (sleep aid) 3 milligrams (mg) every night from 2/1/2024 through 2/24/2024 at bedtime for sleep. The MAR did not indicate whether Resident 1 was on blood thinners. A review of Resident 1's care plan titled "Resident is at risk for fall/injury r/t (related to) poor balance, Parkinson's disease, hx (history) of fall, use of medications such as (psychotropic [medications that affect the nervous system], analgesic [medications that treat pain and inflammation])," initiated on 2/5/2024, indicated interventions included staff to prevent falls by anticipating and meeting Resident 1's needs. The care plan was not individualized to Resident 1's specific needs. A review of Resident 1's Minimum Data Set (MDS- standardized data collection tool used to assess cognitive and functional status, and care needs) dated 2/9/2024, indicated Resident 1's cognition was not intact. The MDS indicated Resident 1 had not attempted to move from sitting to lying position in bed, lying to sitting on side of the bed, and sitting to standing position due to medical condition or safety concerns. The MDS indicated Resident 1 was dependent on two or more staff to transfer from chair to bed and vice versa. The MDS indicated Resident 1 used a WC for mobility. A review of Resident 1's care plan revised on 2/12/2025 titled "Resident is at risk for fall/injury r/t to poor balance, Parkinson's disease, hx of fall, use of medications such as (psychotropic, analgesic)", indicated Resident 1 was at risk for fall/injury. The care plan interventions included to ensure staff followed facility's fall protocol (the care plan did not indicate what the protocol was). However, the care plan did not include the facility's fall protocol. A review of Resident 1's Change in Condition (COC - a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domain that without intervention, the deviation could lead to significant complications including death) Evaluation form dated 2/25/2024 at 8:00 p.m., indicated that on 2/25/2024 at 7:40 p.m., Licensed Vocational Nurse 1 (LVN 1), CNA 1, and CNA 2 entered Resident 1's room and saw Resident 1 on the floor face down between a window and a bed. The COC indicated LVN 1 observed Resident 1's right eyebrow was cut, and bleeding and the resident's right eyelid was bruised and swollen. The COC indicated LVN 1 asked Resident 1, "are you ok" and Resident 1 stated, "yes." The COC indicated LVN 1 called 911, Resident 1 was transported to GACH 1, and resident's family member 1 (FM 1) was notified. A review of Los Angeles Fire Department (LAFD) Patient Care Report (form emergency transport uses to document assessment and care) dated 2/25/2024 at 7:51 p.m., indicated Resident 1 had shortness of breath (SOB), dizziness, slurred speech, neck, and back pain (pain level not indicated). Resident 1 had hematoma over the right eye. Resident 1 was transported to GACH 1 after a mechanical (external force and or no underlying cause) fall while staff was assisting Resident 1 back to bed. A review of GACH 1 Emergency Department (ED) Summary Report dated 2/25/2024, indicated Resident 1 presented with a large right periorbital hematoma. A review of GACH 1's Computerized Tomography Scan (CT - medical imaging technique used to obtain detailed internal images of the body) of maxillofacial (portion of the face from the upper jaw) structures dated 2/25/2024, indicated Resident 1 had, "markedly displaced fracture of the right inferior (lower) orbital (eye socket) wall with protrusion of extraconal (sticking out of eye socket) fat through the orbital floor defect. Large right periorbital hematoma with retrobulbar (behind the eyeball) hemorrhage and severe proptosis (bulging from natural position) of the right globe (eye eyeball) and stretching of the right optic nerve (relays messages from your eyes to the brain to create visual images), frontal scalp contusion (injured tissue or skin in which blood capillaries have been ruptured), and extraocular (outside the eye) muscles. Urgent surgical assessment recommended for further management." A review of Resident 1's "ED Course" report" dated 2/25/2024 at 9:24 p.m., indicated, the ED attending physician documented that, "I received a call of CT results informed me there is retrobulbar hematoma with proptosis of the right eye." The ED physician placed a transfer order to transport Resident 1 to GACH 2 trauma center on 2/25/2024 at 11:44 p.m. for immediate consultation with ophthalmology for possible lateral canthotomy and facial surgeons. Resident 1 was accepted and transferred to GACH 2 on 2/26/2024 at 12:00 a.m. A review of Resident 1's "ED (emergency department) Summary Report" dated 2/26/2024 (no time), indicated a call was placed to GACH 2 trauma center on 2/25/2024 at 11:44 p.m. for immediate consultation with ophthalmology for possible lateral canthotomy and facial surgeons. The ED summary report prepared by the ED Physician under, "medical decision making" indicated, "After evaluation, it is my medical judgement that given patient's medical history, current needs, the medical predictability, and concern that something adverse is going to happen to the patient given the results of his work up, if they (Resident 1) are not admitted. The complexity required for the (Resident 1's) care, the time requirement for diagnostic procedure and services needed for the patient [Resident 1], the patient will need at least two midnight stays." The ED summary report indicated Resident 1 was treated with Tylenol for pain, administered an updated tetanus injection (vaccine to prevent lock jaw/painful muscle contractions), and ice packs were applied to the right eye. Resident 1 received Unasyn (antibiotic - medication to prevent/treat infections)) intravenous. A review of Resident 1's GACH 1 "ED Laboratory Results" completed on 2/25/2024 at 11:06 p.m., indicated Resident 1's hemoglobin (hgb - a protein containing iron that facilitates the transport of oxygen in red blood cells) was 13.1 (reference [RR] 12.5 to 16.3) range grams per deciliter (g/dl- unit of measurement) and hematocrit (hct - is the volume percentage of red blood cells in blood) was 39.8 percent (% - RR 36.7 % to 47.1%). A review of Resident 1's GACH 2 "Trauma Consult" dated 2/26/2024 at 12:16 a.m., indicated Resident 1 had a witnessed fall from a WC at Resident 1's nursing facility and it was unclear if Resident 1 was on aspirin/Plavix (medications to prevent blood clots) regularly. Resident 1 had obvious right orbital trauma status post lateral canthotomy in the ED. Resident 1 had significant bleeding from canthotomy site with associated hgb drop from 12.8 g/dl to 7.9 g/dl. Resident 1 was on serial CBC with associated hypotension (BP - low blood pressure) to the 80s. Resident 1 received 2 units of packed red blood cells (UPRB - blood transfusion) with response in BP. A review of Resident 1's GACH 2 ED Course (no date), indicated on exam, Resident 1, "with proptotic right eye, chemosis (swelling of the eye surface membranes), and 3-millimeter (mm) pupil nonreactive to light and significant periorbital ecchymosis with lid swelling." Resident 1 had emergent lateral right eye canthotomy performed prior to CT scans in ED given clinical exam and increased intraocular pressure (IOP- increase pressure in the eye) of 96 (normal IOP is 12 Mmhg to 22 Mmhg). GACH 2 ED course note indicated that repeat IOP was 25 Mmhg and that upon two hours reassessment Resident 1 had significant improvement in swelling and proptosis. A review of Resident 1's GACH 2 "Inpatient Progress Note" under lab (no date) the last four charted values, indicated Resident 1's hgb was 7.9 g/dl, 10.3 g/dl, and 12.8 g/dl on 2/26/2024. The inpatient progress notes under CT face, indicated Resident 1 had, "acute blowout fracture of the right orbital floor with associated retrobulbar hematoma, proptosis, and extensive periorbital soft tissue swelling." The inpatient progress under CT Neck indicated, ... "recommend correlation with ophthalmological exam for inferior rectus muscle (one of eye muscles responsible for eye movement) entrapment." The inpatient note indicated Resident 1 was not able to state if Resident 1 had diplopia (double vision) and that Resident 1 was on ASA. The inpatient progress note indicated, "Considering extent of inferior orbital floor involvement, patient [Resident 1] may develop a cosmetic defect or diplopia." During an interview on 2/27/2024 at 8:44 a.m., FM 1 stated the skilled nursing facility (SNF) admitted Resident 1 for respite care for three weeks. FM 1 stated, "I was in shock when I got the call (telephone) Sunday night (2/25/2024) that [Resident 1] fell, had a lot of bleeding, and was taken by 911 to the hospital." FM 1 stated, FM 1 contacted the SNF for clarification about Resident 1's fall. FM 1 stated that a nurse (unidentified) told FM 1 that Resident 1 fell when the aide (CNA 1) was transferring Resident 1 from the WC to bed. FM 1 stated, "we went to the hospital (GACH 1), and [Resident 1's] right eye was getting larger. The doctor told us they (GACH 1) needed to transfer [Resident 1] to a higher level of care trauma center stat (immediately)." FM 1 stated GACH 1 transferred Resident 1 to GACH 2, a trauma center, on 2/25/2024. FM 1 stated, "they had to drain blood from [Resident 1] eye" and GACH 2 was deciding whether to proceed with reconstructive surgery Resident 1's right eye. FM 1 stated GACH 2 admitted Resident 1 to the intensive care unit (ICU - a unit in a hospital that provides critical care and life support for acutely ill and injured patients), and that Resident 1 received blood transfusion. FM 1 stated Resident 1, "is unable to see out of the right eye" and that GACH was trying to save the right eyeball. FM 1 stated Resident 1's eyeball detached and was on the side as opposed to being in the right eye socket. FM 1 stated Resident 1 was not able to remember what happened regarding the fall. A review of Resident 2 (Resident 1's roommate) admission record indicated the facility admitted Resident 2 on 2/23/2024 with diagnoses including lumbar vertebra fracture (broken lower back bone), abdominal aortic aneurysm (enlargement of the aorta, the main blood vessel that delivers blood to the body), hyponatremia (low sodium), hypertension (high blood pressure), difficulty walking, and generalized weakness. A review of Resident 2's MDS dated 3/1/2024, indicated Resident 2's cognition was intact. During an interview on 2/27/2024 at 1:05 p.m. Resident 2 stated he recalled a nurse (did not state which nurse) was wheeling Resident 1 to the left side of the room next to the sliding glass door when all of the sudden Resident 2 heard the nurse howl (loud cry) and saw Resident 1 lying on t