Other·January 10, 2024

42 CFR §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following — i. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and ii. Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). 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. 42CFR §483.25: 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: (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 11/27/2023 the California Department of Public Health made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about quality of care. Resident 1 experienced four unwitnessed falls at the facility within a period of approximately eight months. The facility failed to ensure Resident 1, who required moderate assistance (helper lifts, hold, or supports trunk or limbs and provides less than half the effort) while walking between 10 to 50 feet and supervision or touching assistance with transfers from or to bed, and as indicated in the comprehensive assessment and plan of care, was provided with the necessary assistance and supervision to prevent repeated unwitnessed falls and injury. As a result, on 11/16/2023, at around 10 a.m., Resident 1 fell for the fourth time, while walking in the hallway unassisted and unsupervised sustaining pain to the right hip. The next day, on 11/17/2023, Resident 1’s pain worsened and required transfer to General Acute Care Hospital 1 (GACH 1), where he was diagnosed with an acute fracture (sudden break of a bone) of the femoral component (generally made of metal, and curves around the end of the femur [thigh bone]) of the right total hip arthroplasty (damaged femoral head is removed and replaced with a metal stem that is placed into the hollow center of the femur). A review of Resident 1’s Admission Record indicated the facility admitted the resident, an 84-year-old male, on 1/6/2023 with diagnoses including essential (primary) hypertension (high blood pressure that does not have a known cause), muscle weakness, history of fall, personal history of (healed) fractures, bilateral hip replacement, cancer of the throat and lungs, and Alzheimer’s. A review of Resident 1’s History and Physical exam, dated 3/23/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/3/2023, indicated Resident 1’s cognitive skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort; helper lifts, hold, or supports trunk or limbs and provides more than half the effort while walking between 10 to 50 feet). The MDS also indicated resident had one episode of fall with injury since admission and had a bed alarm (device that contains sensors that trigger an alarm or warning light when they detect a change in pressure). The MDS also indicated Resident 1 was receiving active (resident participated) range of motion (ROM, moving the joints) exercises and walking exercises by restorative nursing assistant (RNA). The MDS indicate Resident 1 did not use assistive devices with walking (cane or walker). A review of Resident 1’s Care Plan developed for the resident’s fall risk, dated 1/11/2023, included in the interventions assisting Resident 1 with activities of daily living (ADL- such as walking, dressing and personal hygiene), providing a safe environment, observing / anticipating / intervening for factors causing prior falls (e.g., bowel and bladder urgency, mobility problem (standing, transferring, walking); ROM exercises or assist with ambulation if ordered. A review of Resident 1’s Situation-Background-Assessment-Recommendation (SBAR) Communication Form and Progress Note (communication form between members of the health care team about a resident’s condition), dated 1/13/2023, indicated Resident 1 claimed he fell on 1/13/2023 at noon. The SBAR indicated resident was assessed with yellowish to bluish discoloration to right hand. A review of Resident 1’s SBAR, dated 3/17/2023, indicated that around 4:45 p.m., Resident 1 was found on the floor, by his bed, lying on his left side with a bump on the left forehead. A review of the Physician’s Order for Resident 1, dated 3/22/2023, indicated to apply a bed alarm to remind Resident 1 to ask for assistance when getting out of bed. A review of Resident 1’s SBAR, dated 9/22/2023, indicated Resident 1 was found at 7 a.m. lying on the floor, near the foot of the bed. Resident 1 had redness and scratched skin to back. The SBAR documentation did not indicate whether the bed alarm was in place and functioning. A review of Resident 1’s Care Plan for the actual fall sustained on 9/22/2023, included in the interventions monitoring effectiveness / response to the plan of care. A review of Resident 1’s Fall Risk Evaluation, dated 11/3/2023, indicated resident had one to two episodes of fall in the past three months. A review of Resident 1’s SBAR, dated 11/16/2023 and timed at 10:35 a.m., indicated Certified Nursing Assistant 2 (CNA 2) reported to Registered Nurse 1 (RN 1) that resident was found lying on the floor, in the hallway, and was complaining of right hip pain. The exact time of the fall was not specified. Resident 1’s vital signs were checked at 9:38 a.m. The SBAR indicated the attending physician was notified at 9:56 a.m. and ordered X-rays (type of radiation used to create a picture of the inside of the body) of both hips. The results were negative for fractures. A review of Resident 1’s SBAR, dated 11/17/2023, indicated resident had worsening right hip pain, the severity was six of ten (on a pain scale where zero means no pain and 10 the worst pain possible). The Nurse Practitioner (NP) ordered to transfer Resident 1 to GACH 1. A review of Resident 1’s Progress Note, dated 11/18/2023, indicated RN 3 from General Acute Care Hospital 1 (GACH 1) notified the Director of Nursing (DON) Resident 1 was diagnosed with a right femur fracture (break in the thigh bone). A review of Resident 1’s GACH 1 History and Physical Reports, dated 11/20/2023, indicated Resident 11 was admitted because of a right hip fracture after a fall and the orthopedic surgeon (doctor who specializes in surgery of bones, joints, and muscles) was consulted and determined no surgery was indicated. A review of Resident 1’s GACH 1 Final Report, dated 11/20/2023, indicated a Computed Tomography (CT scan - an imaging procedure that uses special x-ray equipment to create detailed pictures, or scans, of areas inside the body) of the right hip showed acute fracture of the femoral component of the right total hip arthroplasty with multiple fractures involving the greater trochanter (a four-sided bony prominence located at the upper part of the femur) and extending inferiorly (lower part). Resident 1 was discharged back to the facility on 11/20/2023. During an interview on 11/27/2023 at 8:10 a.m., RN 1 stated Resident 1 was ambulatory with unsteady gait (unstable pattern of walking) and had previous history of fall. RN 1 stated on 11/16/2023 he worked in the unit for residents with Coronavirus Disease – 2019, which had 40 residents including Resident 1. RN 1 stated that around 9:30 a.m. to 10 a.m., he was at the end of the hallway in front of Room A about to give medications when he saw Resident 1 falling on his right side while walking in the hallway by himself using a straight cane. RN 1 confirmed that he did not document in the SBAR dated 11/16/2023 that he witnessed Resident 1's fall, but he observed when Resident 1 fell in front of Room F while CNA 2 was coming out of Room E. RN 1 stated that CNA 2 informed RN 1 that she went to Resident 1’s room to retrieve his eyeglasses and left Resident 1 alone, walking in the hallway. RN 1 stated Resident 1’s fall could have been avoided if CNA 2 stayed with the resident while he (Resident 1) was walking in the hallway. RN 1 stated CNA 2 should have asked another staff to look for the resident’s eyeglasses instead of leaving him by himself. During a concurrent interview and record review on 11/27/2023 at 10:32 a.m., with the Director of Nursing (DON), Resident 1’s MDS, dated 11/3/2023, and SBARs, dated 1/13/2023, 3/17/2023, 9/22/2023 and 11/16/2023, were reviewed. The MDS dated 11/3/2023 and the four SBAR forms for Resident 1’s episodes of fall indicated resident needed moderate assistance. The DON stated moderate assistance meant the resident should walk with a staff beside him. The DON stated CNA 2 should have stayed with him while Resident 1 was walking in the hallway but left the resident in the hallway while returning to Resident 1’s room to retrieve his glasses. During a concurrent interview and record review on 11/27/2023 at 11:12 a.m., with Physical Therapist 1 (PT 1), Resident 1’s Physical Therapist Discharge Summary (DC Summary) from the therapy provided from 3/23/2023 to 4/20/2023, was reviewed. The DC Summary indicated on 4/20/2023 resident was able to ambulate 150 feet with standby assist (SBA) from staff using a single point cane (SPC). PT 1 stated SBA meant staff should be next to the resident while walking. During an interview on 11/27/2023 at 11:44 a.m., the Administrator (ADM) stated fall was avoidable if CNA 2 stayed with Resident 1 while he was walking in the hallway. A review of facility’s policy and procedure titled, “Safety and Supervision of Residents,” dated 7/2017 and reviewed on 3/9/2023, indicated “Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Employees shall be trained on potential accidents hazards and demonstrate competency on how to identify and report accidents hazards and try to prevent avoidable accidents. Resident supervision is a core component of the systems approach to safety. They type and frequency of resident supervision is determined by the individual residents assessed needs and identified hazards in the environment.” Resident 1 experienced four unwitnessed falls at the facility within a period of approximately eight months. The facility failed to ensure Resident 1, who required moderate assistance while walking between 10 to 50 feet and supervision or touching assistance with transfers from or to bed, and as indicated in the comprehensive assessment and plan of care, was provided with the necessary assistance and supervision to prevent repeated unwitnessed falls and injury. As a result, on 11/16/2023, at around 10 a.m., Resident 1 fell for the fourth time, while walking in the hallway unassisted and unsupervised sustaining pain to the right hip. The next day, on 11/17/2023, Resident 1’s pain worsened and required transfer to GACH 1, where he was diagnosed with an acute fracture of the femoral component of the right total hip arthroplasty. 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 to Resident 1.