Health inspection·August 19, 2022

42CFR §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 4/5/2021, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident about an injury of unknown origin. The facility failed to ensure Resident 1, who was at risk for fractures (break of bones), was provided with an environment free of accident hazards. As a result, on 4/1/2021 at 7:30 p.m., expressed being in pain after Certified Nursing Assistant 1 (CNA 1) took the resident in the resident’s wheelchair to use the toilet. The resident’s left leg appeared red and swollen, and an x-ray (radiation called electromagnetic waves which create pictures of the inside of the body) indicated Resident 1 sustained a left femur (thighbone) fracture. Resident 1 and required transfer to General Acute Care Hospital 1 (GACH 1), where she underwent surgery to repair the fracture on 4/2/2021. A review of Resident 1's Admission Record indicated the facility originally admitted the resident on 8/28/2019 with a readmission date of 11/7/2019. Resident 1's diagnoses included type 2 diabetes mellitus (a long-term chronic condition in which there is an impairment in the way the body regulates and uses sugar [glucose] as a fuel), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), age-related osteoporosis (a condition that makes the bones thin and brittle posing a greater risk for sudden and unexpected bone fractures), unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbance (such as agitation, restlessness, and aggressiveness). A review of Resident 1's Care Plan developed on 8/28/2019 for the resident's risk of injuries, deformities, fractures, and pain related to osteoporosis, included in the interventions maintaining a safe and hazard free environment, handling gently the resident during care especially when moving, turning, and repositioning. A review of Resident 1's History and Physical exam, dated 2/8/2020, by the attending physician indicated the resident did not have capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/30/2021, indicated the resident had memory problems, was able to make self-understood and understands others. Resident 1 needed extensive assistance with two-person physical assist with transfers, one-person physical assist with dressing, toilet use, and personal hygiene. Resident 1's balance was unsteady for surface-to-surface transfer (transfer between bed and chair). Resident 1 used a wheelchair as a mobility device. A review of Resident 1's Situation, Background, Assessment, Recommendations (SBAR - a tool that provides a framework for communication between members of the health care team about a patient's condition) form, dated 4/1/2021 timed at 7:32 p.m., by Licensed Vocational Nurse 1 (LVN 1), indicated the resident was sitting in the wheelchair and stated the left leg was in a lot of pain with visible swelling to the left thigh. LVN 1 notified the physician who ordered STAT (immediately) X-rays of the left leg and hip. A review of Resident 1's Radiology Results Report, dated 4/1/2021 and timed at 8:42 p.m., indicated the resident had a fracture of the left femur. A review of the Physician's Order for Resident 1, dated 4/1/2021 timed at 11:13 p.m., indicated to send the resident to GACH 1 due to the left femur fracture. A review of GACH 1 Operative Report for Resident 1, dated 4/2/2021, indicated Resident 1 underwent a left femur fracture retrograde nailing (left thighbone shaft fracture fixation). A record review of the facility's Final Investigation Summary indicated a day after Resident 1's injury, on 4/2/2021 at 10:45 a.m., Family Member 1 (FM 1) reported the resident said a staff wheeled her against the wall and that was the reason she sustained the injury. On 4/9/2021 at 10:01 a.m., during a telephone interview, LVN 1 stated that on 4/1/2021 at 7:30 p.m., she heard Resident 1 screaming from the room. LVN 1 entered Resident 1's room and saw CNA 1 wheeling the resident from the restroom to the bed and Resident 1 was screaming in pain on the left leg. LVN 1 checked it and noticed the knee was swollen. LVN 1 asked Resident 1 what happened but the resident did not answer but kept saying she was in pain. LVN 1 asked CNA 1 what happened, and CNA 1 stated nothing had happened but Resident 1 started screaming in pain. On 5/7/2021 at 5:17 p.m., during a telephone interview, CNA 1 stated that on 4/1/2021 Resident 1 complained of pain on the left leg from the beginning of the shift (3 p.m.) and at 7:30 p.m., she had just taken her to the restroom when Resident 1 started screaming in pain. CNA 1 stated there was no fall and the resident did not hit or bump into a wall or a door. CNA 1 stated she had not notified LVN 1 the resident was complaining of left leg pain since the beginning of her shift. On 5/20/2021 at 10:12 a.m., during an interview, the Director of Nursing (DON) stated the incident was investigated and concluded Resident 1 could have bumped onto the wall accidently and CNA 1 did not realize it. The DON stated Resident 1 had the pre-existing condition of osteoporosis and was susceptible to sustaining fractures. A review of the facility's policy and procedure titled, "Activity of Daily Living (ADL), Supporting" revised 3/2018, indicated that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). A review of the facility's policy and procedure titled, "Safety and Supervision of Residents" revised 7/2017 indicated that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The facility failed to ensure Resident 1, who was at risk for fractures (break of bones), was provided with an environment free of accident hazards. As a result, on 4/1/2021 at 7:30 p.m., expressed being in pain after CNA 1 took the resident in the resident’s wheelchair to use the toilet. The resident’s left leg appeared red and swollen, and an x-ray indicated Resident 1 sustained a left femur fracture. Resident 1 and required transfer to GACH 1, where she underwent surgery to repair the fracture on 4/2/2021. The facility failed to ensure Resident 1, who had risk for fractures, was provided with an environment free of accident hazards and was gently assisted by CNA 1 to use the toilet as indicated in the plan of care and facility's policies. As a result, on 4/1/2021 at 7:30 p.m., Resident 1 sustained a left femur fracture and required transfer to GACH 1 where she underwent surgery to repair the fracture on 4/2/2021. The above violation 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.