Health inspection·September 12, 2024

F656 §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

F689 § 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 resident's choices, including but not limited to the following: § 483.25 (d) Accidents. The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 8/1/20204, at 10:02 AM the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint and a facility reported incident regarding patient safety and quality of care. As a result, CDPH determined, facility endangered Patient 1’s safety, who had severely impaired cognition (thought process) and severe contractures (a permanent tightening of the muscle, tendon, skin, and nearby tissues that cause the joints to shorten and become very stiff) to the upper and lower extremities, by failing to: 1. Follow facility policy and procedure, including but not limited to ensuring Licensed Vocational Nurse [LVN] 1 and Registered Nurse (RN) 1 provided report and informed Certified Nurse Assistant (CNA) 1 on potential accident hazards concerning Patient 1’s activities of daily living [ADL- fundamental skills that people need to do every day to care for themselves independently], including transfers from bed to chair and bathing, in accordance with the facility’s policies and procedures [P&P] titled, “Activity of Daily Living.” 2. Ensure a care plan was developed and implemented to address Patient 1’s specific needs for ADL assistance to monitor interventions and mitigate [make less severe] accident hazards identified for Patient 1’s bathing and transfer needs, and develop and implement care plan in accordance with the facility’s P&P “Safety and Supervision of Patients,” and “Care Plans, Comprehensive Person-Centered.” 3. Ensure CNA 1 identify and report to LVN 1 and RN 1 potential accident hazards to prevent avoidable accidents on 7/17/2024, after observing Patient 1 had severe contractures to both upper and lower extremities and stiffness [tightness or pain in the muscles, which can make it difficult to move] between the legs, prior to showering the patient on 7/17/2024. As a result of these failures, Patient 1 sustained serious injury to the lower extremities which included closed displaced fracture of left acetabulum, multiple pelvic fractures and hematoma to the abdomen requiring an emergency transfer to a General Acute Care Hospital (GACH). As detailed below, on 7/17/2024, CNA 1 placed Patient 1 from the bed to the shower chair (movable chairs designed to be used for bathing and placed inside the shower stall) without proper assistance and washed between the patient’s legs by stretching the patient’s lower extremities, despite Patient 1’s documented mobility limitations. As a result, and as further described below, Patient 1 complained of severe pain on 7/17/2024 after the shower. The facility transferred Patient 1 to the General Acute Care Hospital 2 via 911 emergency services and was treated in GACH 2 Intensive Care Unit (ICU - specialized unit and treatment given to individuals who are acutely unwell and require critical medical care). Patient 1 sustained injuries to the lower extremities which included closed displaced fracture [a type of bone fracture where the bone breaks completely and moves out of alignment, creating a gap, but the skin does not break] of left acetabulum (socket of the hipbone [large bone between the waist and your legs], into which the head of the femur [thigh bone] fits), multiple pelvic fractures (break or crack open in one or more of the bones that make up the pelvis [(basin-shaped complex of the bones between the hips that connects the trunk and the leg]), marked widening of the pubic symphysis [a joint that connects the left and right pelvic bones], and hematoma [a pool of mostly clotted blood that forms in an organ, tissue, or body space caused by a broken blood vessel damaged by an injury] to the abdomen. A review of Patient 1's Face Sheet (admission record), the Face Sheet indicated the facility admitted the Patient on 1/15/2024 with diagnoses including contractures, and inactivity. A review of Patient 1's History and Physical (H&P - a formal assessment of a patient and their medical condition performed by a healthcare provider, usually during an initial visit) dated 7/15/2024, indicated Patient 1 did not have the capacity to understand and make decisions. A review of Patient 1's General Acute Care Hospital (GACH) 1 H&P dated 1/9/2024, indicated that prior to admission to the facility, Patient 1 was bed to wheelchair bound with pre-existing contractures to all joints. The GACH 1 H&P indicated Patient 1 had “Decrease mobility due to severe bilateral [both] upper and lower extremities contractures and wound, severe disability [significantly limits your ability to perform basic work activities], bedridden [confined to bed], incontinent (having no or insufficient control over urination or defecation), and required constant nursing care and attention...” A review of Patient 1's Minimum Data Set (MDS, a standardized Patient assessment and care screening tool) dated 7/12/2024, the MDS indicated the Patient’s cognition (thought process) was severely impaired [a condition that significantly limits the individual's physical or mental abilities, so that he or she is unable to perform basic work activities]. The MDS indicated Patient 1 had unclear speech (slurred or mumble words). Patient 1 has rarely/never has ability to express ideas and wants and ability to understanding others. The MDS indicated Patient 1’s functional limitation in range of motion (ROM- capacity for movement at a given joint) was impaired to both sides for upper and lower extremity. The MDS indicated Patient 1 was dependent (helper does all the effort. and Patient does none of the effort to complete the activity, requiring assistance of two or more helper is required for the Patient to complete the activity) to facility staff for shower/bathing (including washing, rinsing ,and drying self), upper body dressing, lower body dressing, personal hygiene, rolling to the left and right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed-to-chair transfer, and toilet transfers (the ability to get on and off the toilet). The MDS further indicated for tub/shower transfers (the ability to get in and out of a tub/shower), Patient 1’s assist level was “Not applicable (not attempted and the Patient did not perform the activity prior to the current illness). A review of Patient 1’s Physical Therapy (PT) record, titled “Joint Mobility Assessment” dated 1/17/2024 signed by Physical Therapist (PT) 1 indicated Patient 1’s joint mobility limitations. The facility’s Joint Mobility Assessment indicated the appropriate percentage (%) description for each Patient’s joint mobility limitation indicating “Moderate limitation (50% to 75%), and severe (75% to 100%) limitation. Patient 1’s Joint Mobility Assessment indicated Patient 1’s left, and right shoulder had moderate joint mobility limitation, left and right elbow had moderate joint mobility limitation, left and right hip had severe joint mobility limitation, left and right knee had severe joint mobility limitation. A review of Patient 1’s facility records titled, “Physical Therapy Discharge Summary” dated 3/26/2024 indicated Patient 1 had contracted muscle to the right and left lower leg, required maximum assistance for wheelchair mobility, bed to wheelchair transfers, sit to stand, but stand to sitting position was “Not applicable.” A review of a facility document titled “Nursing Service Assignment” dated 7/17/2024, indicated Certified Nursing Assistant (CNA) 1 was assigned to Patient 1 on 7/17/2024 (7 AM to 3 PM). A review of a facility document titled “Nursing Care Shower Schedule” indicated Patient 1’s shower days were scheduled for Wednesdays and Saturdays. A review of Patient 1’s Activities of Daily Living [ADL] worksheet under the “Task Shower/Bathe Self” indicated a check mark for 7/3/2024, 7/5/2024, 7/6/2024, 7/10/2024, 7/12/2024, 7/13/2024, and 7/17/2024. The ADL worksheet indicated Patient 1 was totally dependent with staff during showering/bathing. The ADL worksheet did not indicate the type of shower or bath provided to Patient 1. A review of Patient 1’s Progress Notes dated 7/17/2024 and timed at 1:40 PM, documented by License Vocational Nurse (LVN) 1, indicated CNA [1] gave Patient 1 a shower (no time indicated). The Progress Notes indicated at 12:55 PM, Patient 1 was observed sweating and pale... The Progress Notes indicated a vital signs [V/S- clinical measurements of a person’s essential body functions] 90/62 [blood pressure-BP], 97 beats/minute [heart rate -HR], 95.6 degrees Fahrenheit [temperature], and oxygen saturation [amount of oxygen in the blood] of 90 to 91 % [normal levels between 95 to 100%] on room air [the normal air we breathe in everyday environment]. The Progress Notes indicated Patient 1 stated “I have chest pain" when asked for pain or discomfort and was moving his head and up and down [nodding]. The Progress Notes indicated at 1 :02 PM, Registered Nurse (RN) 1 called 911 emergency services and Patient 1 was transferred to the general acute care hospital (GACH 2) on 7/17/2024. A review of Patient 1's “Nursing Home to hospital transfer Form” dated 7/17/2024 and timed at 12:04 PM, indicated that RN 1, who was the charge nurse for Patient 1 on 7/17/2024 wrote that at around 12: 55 PM, Patient 1 was noted sweating and pale... The Nursing Home to hospital transfer form indicated RN 1 asked Patient 1 if he has pain or chest pain in the Patient’s native language to move his head up and down. The Nursing Home to hospital transfer form indicated Patient 1 responded by moving his head up and down... A review of the facility’s typewritten investigation report dated 7/22/2024, authored by the Director of Nursing (DON), the investigation report indicated Patient 1 was alert and oriented to self and able to understand simple phrases and follow simple instructions. The investigation report indicated LVN 1 was alerted by the “CNA” to Patient 1's room around 12:55 PM on 7/17/2024, because Patient 1 was pale and the scrotum (a part of the male reproductive system. It is a sac-like structure located behind the penis and contains the testicles) was swollen. The investigation report indicated the physician ordered the Patient be transferred to GACH 2 for further evaluation via 911 emergency services. The investigation report indicated that facility staff was later notified by GACH 2 staff that Patient 1’s x-ray (XR- a type of electromagnetic radiation used for imaging the inside of objects, including the human body) result indicated a fracture of the pelvis. A review of the facility’s undated handwritten investigation by the DON, indicated a telephone interview was conducted with CNA 1 on 7/18/2024. The handwritten investigation indicated that on 7/17/2024, LVN 1 informed CNA 1 that “Wednesdays (7/17/2024)” was Patient 1’s shower day. The handwritten investigation indicated CNA 1 reported having “Another CNA (CNA 2) assist him.” The handwritten investigation indicated CNA 1 “Attempted to wash between the Patient 1 legs with towel and there was resistance, so he did not try any harder.” The handwritten investigation indicated that “Patient [1] started to clench (close tightly) his legs/thighs, then put a diaper on the Patient.” The handwritten investigation further indicated “He (CNA 1) needed assistance when putting diaper on Patient 1.” The handwritten investigation indicated that at “Approximately 12:55 PM, he (CNA 1) called LVN 1 because Patient [1] was pale, holding on his chest and sweating...” The handwritten investigation indicated “Later that evening [GACH 2 staff] notified [the] charge nurse that Patient [1] had sustained a pelvic fracture.” A review of Patient 1's GACH 2 records titled, “Reason for Visit” dated 7/17/2024, indicated the Patient sustained a “Closed displaced fracture [a type of bone fracture where the bone breaks completely and moves out of alignment, creating a gap, but the skin does not break] of left acetabulum (socket of the hipbone, into which the head of the femur [thigh bone] fits), contracture of joint of multiple sites, multiple pelvic fractures, nonverbal, severe dementia [the loss of cognitive (relating to the mental processes of perception, memory, judgment, and reasoning) functioning — thinking, remembering, and reasoning]. A review of Patient 1's GACH 2 records titled, “Physical Exam” dated 7/17/2024, indicated [Patient 1] “Appears in pain. In fetal position [the body lies curled up on one side with the arms and legs drawn up and the head bowed forward]. Initial concern for sepsis [a serious condition in which the body responds improperly to an infection (invasion and growth of germs in the body)], suspect likely intraabdominal [within the belly] source given abdominal pain.” A review of Patient 1's GACH 2 records and titled “ED [Emergency Department] management” dated 7/17/2024, indicated “No history reported from [facility] of fall...Patient's (Patient 1) primary issue is open book pelvic [a type of fracture when the front of the pelvis breaks and separates into two or more pieces, often caused by trauma such as in an elderly fall] fracture. The orthopedic surgeons [doctors who specialize in surg