Health inspection·December 22, 2022

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. 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 § 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 10/24/2022, the California Department of Public Health made an unannounced visit to the facility to investigate a Facility-Reported Incident (FRI) and a complaint about quality of care. The facility failed to provide Resident 1 with care and services based on the comprehensive assessment, care needs, professional standards of practice, and facility’s policy to ensure supervision and assistive devices to prevent accident and injury. For Resident 1, who was assessed as high fall risk and had a history of falls, the tab alarm (a safety device consisting of a pull-string that attaches magnetically to the alarm [placed on the bed or the wheelchair] and to the resident with a garment clip; it alerts the staff when movement [attempting to get up without assistance] is detected while the resident is in bed and chair; staff in the area could respond immediately and may prevent falls) was not applied as ordered by the physician. As a result, on 10/10/2022, at 1:40 a.m., Resident 1 got out of bed unnoticed by staff, fell, and sustained a fracture (broken bone) on the left hip. Resident 1 required transfer to General Acute Care Hospital 1 (GACH 1) where he underwent surgery on 10/11/2022 to repair the fracture. A review of Resident 1’s Admission Record indicated the facility admitted the resident, a 49-year-old male, on 12/27/2021, with diagnoses including pedestrian injured in a traffic accident involving unspecified motor vehicle, traumatic brain injury, dysphonia (impairment of the voice), and anxiety disorder (uncontrollable feelings of nervousness and fear such that it affects a person's daily life). A review of Resident 1’s Care Plan developed on 3/23/2022 for the resident’s high fall risk secondary to poor balance, restlessness with constant movements, poor safety awareness, and history of falls included the goal for Resident 1 not to have falls with injuries by the target date of 10/30/2022. The care plan indicated Resident 1 fell on 1/14/2022 and 3/22/2022. The interventions included to observe the resident frequently (frequency not specified) and provide a safe environment. A review of the Physician’s Order for Resident 1, dated 3/25/2022, indicated to apply a tab alarm every shift when in bed and wheelchair to alert and remind resident to ask for assistance when transferring. A review of Resident 1’s Fall Risk Assessment, dated 5/1/2022, indicated the resident’s score was 24. A score of 18 or above indicated high risk for falls. A review of Resident 1’s Care Plan developed on admission and revised on 5/22/2022 for the resident’s high fall risk, had a goal to reduce the resident’s fall and injury occurrences by the target date of 10/30/2022. The interventions included to observe the resident frequently (frequency not specified) and ensure a safe environment. The interventions did not include the use of the tab alarm. A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care- screening tool), dated 8/1/2022, indicated the resident sometimes could make self-understood and understood others and required one-person extensive assistance with bed mobility, transferring to or from bed, walking, dressing, toilet use, and personal hygiene. Resident 1’s balance during surface-to-surface transitions, walking with staff assistance, moving on and off toilet, and moving from sitting to standing, was not steady, and could only stabilize with staff assistance. Resident 1 was a high fall risk, had a history of falls, and used a tab alarm in the bed and chair daily. The MDS also indicated Resident 1 used a walker and wheelchair as mobility devices. A review of Resident 1’s interdisciplinary team (IDT, group of healthcare staff from different disciplines involved in the care of the resident), dated 8/1/2022, indicated the resident had two falls in the facility, the resident’s bed was kept in the lowest position, the resident had a floor mat (or landing mat, hard floor covering placed by the bed to help prevent injury from potential falls) at his bedside, and the resident used a tab alarm in bed and wheelchair. A review of Resident 1’s Changes of Condition (COC) documentation dated 10/10/2022 and timed at 1:40 a.m., indicated Certified Nursing Assistant 2 (CNA 2) reported to Licensed Vocational Nurse 1 (LVN 1) that CNA 2 found Resident 1 lying on the resident’s floor mat (at his bedside). LVN 1 went to Resident 1’s room and the resident was lying on the floor mat leaning onto another resident’s bed with his head up high. Resident 1 nodded his head when asked if he had pain on his hip area. The physician ordered X-rays (painless test that produces images of the bones inside the body) of both hips immediately upon notification. The COC documentation did not include information about if the tab alarm went off or if it was in use. A review of the Physician’s Orders for Resident 1, dated 10/10/2022 and timed at 1:16 p.m., indicated to transfer the resident to GACH 1 due to a left hip fracture (identified in the X-rays). A review of Resident 1’s GACH 1 Operative Report dated 10/11/2022, indicated the resident underwent an open reduction and internal fixation (ORIF, type of surgery to fix broken bones) of the left hip fracture. A review of Resident 1’s Admission Record indicated the resident returned to the facility on 10/12/2022. A review of Resident 1’s re-admission orders included the use of the tab alarm in bed and wheelchair for safety. On 10/24/2022, at 11:40 a.m., Resident 1 was observed in his room lying in bed, leaning on his right, with half of the side rail of the bed up. Resident 1 was moving repeatedly (restless), trying to sit up. There was no tab alarm or other safety device attached to Resident 1. Resident 1 did not respond to questions. CNA 1, present in the room, was asked if Resident 1 had any safety devices to prevent falls. CNA 1 responded she had been assigned to care for Resident 1 three days in a row during the day shift (7 a.m. to 3 p.m.) from 10/22/2022 to 10/24/2022, and she was not aware that the resident needed a tab alarm or other safety device. On 10/24/2022, at 11:52 a.m., during an interview with Registered Nurse 1 (RN 1) in Resident 1’s room, RN 1 stated she was busy that morning and did not check if Resident 1 needed safety devices. On 10/24/2022, at 12:30 p.m., during an interview with the Director of Nursing (DON) and concurrent review of Resident 1’s COC dated 10/10/2022, the DON confirmed there was no documentation of the tab alarm sounding off or not when the resident fell. The DON stated Resident 1 used the tab alarm as a safety device. On 10/24/2022, at 1:10 p.m., during an interview with LVN 3 and concurrent review of Resident 1’s care plans prior to the fall and fracture incident dated 10/10/2022, LVN 3 stated the care plans related to fall risk did not address the use of a tab alarm. On 10/24/2022, at 2:30 p.m., during an interview, CNA 1 stated she did not hear any alarm sound when she found Resident 1 on the floor on 10/10/2022. During an interview, on 10/24/2022, at 5:15 p.m., the DON stated Resident 1 had an order for the tab alarm when in bed and wheelchair to alert staff of the resident’s movements to reduce the fall risks. Resident 1 still had the tab alarm order as an active order, and it had not been changed. The DON could not provide documentation about the tab alarm on the day Resident 1 fell, whether it had gone off or was not in use. A review of the undated facility’s policy and procedure titled, “Personal Alarm” indicated “This facility will use, as indicated, a sensor pad that conveniently sounds an audible alarm when the sensor detects a patient rising out of the bed/wheelchair reminding the resident to return to a safe position while alerting the staff to a possible fall.” “Licensed nurses and therapists will assess the resident for potential safety issues. Residents at risk will demonstrate neuro muscular impairment/weakness, decrease mobility, poor safety and judgement, and frequent falls…. Check alarm system every day for proper functioning. Attend resident promptly when alarm sounds and provide appropriate assistance…. Nursing will monitor proper functioning and positioning of personal alarm…. Care plan will be developed.” The facility failed to provide Resident 1 with care and services based on the comprehensive assessment, care needs, professional standards of practice, and facility’s policy to ensure supervision and assistive devices to prevent accident and injury. For Resident 1, who was assessed as high fall risk and had a history of falls, the tab alarm was not applied as ordered by the physician. As a result, on 10/10/2022, at 1:40 a.m., Resident 1 got out of bed unnoticed by staff, fell and sustained a fracture on the left hip. Resident 1 required transfer to GACH 1 where he underwent surgery on 10/11/2022 to repair the fracture. 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 Resident 1.