Other·May 16, 2023

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 - §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. (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. 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 3/10/2023, the California Department of Public Health made an unannounced visit to the facility to investigate a Facility-Reported Incident (FRI) about death and quality of care. As a result of the investigation, CDPH determined that the facility failed to: 1. Accurately assess Resident 1’s Fall Risk Assessment (FRA) upon readmission to the facility on 1/28/2023 in accordance with the facility’s policies and procedures (P&P) titled “Initial Fall Risk Assessment,” “Promoting Safety, Reducing Falls,” reviewed on 11/17/2022, and “The Resident Care Plan,”. The resident’s history of seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain) were not considered on the assessment. The facility identified Resident 1 as a low fall risk when the resident should have been identified as a high fall risk. 2. Ensure that the facility conducted a Fall Risk Interdisciplinary Team (IDT-team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meeting for Resident 1 who was a high risk for falls. 3. Ensure Resident 1’s care plan, initiated 2/27/2023, for restlessness (unable to stay still) as evidenced by trying to sit on the bed, and restlessness as evidenced by Resident 1 hanging their feet on the bed, initiated 3/1/2023, included interventions to address safety concerns when the resident was found on two occasions to be sitting up in bed despite being identified as needing maximum assistance from two staff for mobility and transfer (moving from one place to another). As a result, Resident 1 fell on the floor and sustained a laceration (a cut or tear in the skin) to the back of their head on 3/9/2023. The facility staff found Resident 1 unresponsive at 7:11 p.m. and called 911 (contact number to request emergency assistance). The paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) pronounced Resident 1’s death at the facility on 3/9/2023 at 7:46 p.m. A review of Resident 1’s Admission Record indicated the facility admitted the resident, a 70-year-old female, on 12/16/2022 and was readmitted on 1/27/2023 with diagnoses including chronic obstructive pulmonary disease (COPD - inflammatory lung disease that causes obstructed airflow from the lungs), seizures, and anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities). A review of Resident 1’s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/3/2023, indicated the resident had memory problems and could understand and be understood. Resident 1 required total assistance with two-person physical assist with bed mobility, transfer, and to walk in room. The MDS indicated Resident 1’s balance during transitions and walking was not steady and was only stabilized with staff assistance when moving from sitting to standing position, walking, and surface-to-surface transfer. A review of the General Acute Care Hospital 1’s (GACH 1) Discharge Summary dated 1/23/2023 indicated that Resident 1 had multiple episodes of seizures while in the emergency room (ER). A review of the GACH 1’s Discharge Instructions dated 1/27/2023 indicated that Resident 1’s medical problems included a new onset of seizures. A review of Resident 1’s Fall Risk Assessment (FRA) dated 1/28/2023, indicated. that a total score of 18 or more would identify a resident as a high risk for fall. The FRA indicated that Resident 1 was scored a 16 by Registered Nurse 1 (RN 1), identifying the resident as a low fall risk. Noted on the FRA under predisposing factors (conditions and activities that can lead to the development of falls), the diagnosis of seizure was not selected. Identification of a predisposing factor such as seizures would have accounted for four (4) additional points towards Resident 1’s total fall risk score. The FRA indicated that for any residents scoring 18 or more, the facility was to implement the following interventions: • Complete Fall Risk IDT • Initiate Falling Star/Super Star Care Plan • Complete Rehab Fall Risk Assessment • Assess for Environmental Hazards • Implement Useful Interventions A review of Resident 1’s Change of conditions (COC- a deterioration in health) dated 3/9/2023, indicated, at 7:11 p.m., Resident 1 was found on the floor, parallel (lying in the same direction) to their bed. Resident 1 was facing upwards with the back of her head on the floor, and her upper back down to her thigh (upper leg) on the floormat. The COC further indicated that on the back of Resident 1’s head was a skin tear with minimal bleeding. The COC indicated that Resident 1 was found unresponsive with no pulse (heartbeat), cardiopulmonary resuscitation (CPR, any medical intervention used to restart a person’s heartbeat and breathing after one or both have stopped) was initiated and 911 was called at approximately 7:12 p.m. Paramedics arrived at 7:20 p.m., and CPR was continued. Resident 1 was pronounced dead at 7:46 p.m. A review of the paramedic’s narrative report dated 3/9/2023 indicated Resident 1 was pronounced dead at 7:46 p.m. and CPR was ordered to stop. A review of Resident 1’s Care Plan developed on 2/27/2023, indicated Resident 1 had an episode of restlessness as evidenced by trying to sit on the bed by Resident 1 placing her foot hanging on bed and moving a lot in bed. On 3/29/2023 at 1:13 p.m., during a concurrent interview with the Director of Nursing (DON) and a review of Resident 1’s FRA, dated 1/28/2023, the DON stated the assessment was done incorrectly because RN 1 failed to account for Resident 1’s diagnosis of seizures. The DON stated had RN 1 accounted for Resident 1’s diagnosis of seizures that would change the resident’s total score from 16 to 20, and Resident 1 should have been identified as a high risk. The DON stated that for high fall risk residents, the facility should conduct a Fall Risk IDT meeting. After reviewing Resident 1’s medical records dated 1/27/2023 to 3/9/2023, the DON stated there was no Fall Risk IDT meeting held for Resident 1. DON stated that a Fall Risk IDT should have been done for Resident 1. On 3/29/2023 at 2:56 p.m. during a concurrent interview with the MDS Coordinator (MDSC) and a review of Resident 1’s care plans for the two episodes of restlessness dated 2/27/2023 and 3/1/2023, the MDSC stated, there were no safety interventions (a set of actions to reduce the risk of falls for all patients and focus on keeping the environment safe and comfortable) in the care plan for the resident’s restlessness to prevent the resident from falling out of bed. The MDSC stated that after having reviewed the interventions listed in Resident 1’s care plans for the two episodes of restlessness dated 2/27/2023 and 3/1/2023, Resident 1 required an individualized care plan that included safety measures to reduce the risk for falls. On 3/30/2023 at 3:11 p.m., during a concurrent interview with the Assistant Director of Nursing (ADON) and a review of Resident 1’s FRA dated 1/28/2023 and the care plans, the ADON stated the FRA was inaccurate because it did not reflect Resident 1’s diagnosis of seizure. The ADON stated that the facility could have possibly tried additional interventions being that Resident 1 was a high fall risk. ADON stated interventions could have included things such as one to one care (one facility staff assigned to always remain with one resident), or an alarm device could have been utilized to alert staff if Resident 1 attempted to get out of bed. The ADON stated Resident 1’s care plans for the two episodes of restlessness did not address fall risk or safety issues. On 3/31/2023 at 9:23 a.m. during an interview with RN 1 and a concurrent review of Resident 1’s FRA dated 1/28/2023, RN 1 stated she was the staff completing the FRA, and she incorrectly did not include Resident 1’s diagnosis of seizure on the FRA. RN 1 stated that because she did not include Resident 1’s diagnosis of seizure, the resident was incorrectly identified as a low fall risk. A review of the facility’s undated P&P titled, “Initial Fall Risk Assessment,” indicated, a fall risk assessment will be completed within 72 hours for all new admissions and readmissions to prevent or reduce the episode of fall…. Each resident will be given a score, if the score is 18 or above, the resident will be considered as a high risk for fall and a plan of care will be established immediately for implementation of interventions to attempt prevention. The plan of care will be reviewed by the IDT quarterly and as needed for update of the resident’s current needs. A review of facility’s P&P titled, “Promoting Safety, Reducing Falls,” reviewed on 11/17/2022, indicated if caregivers are to prevent the falls, they must first have a working knowledge of the key factors that determine which residents are most at risk. A review of the facility’s undated P&P titled, “The Resident Care Plan,” indicated care plans are considered comprehensive in nature, and should be reviewed in its entirety. Problems, goals, and approaches can be addressed in more than one or different areas of the plan of care. As a result of the investigation, CDPH determined that the facility failed to: 1. Accurately assess Resident 1’s Fall Risk Assessment (FRA) upon readmission to the facility on 1/28/2023 in accordance with the facility’s policies and procedures titled “Initial Fall Risk Assessment,” “Promoting Safety, Reducing Falls,” reviewed on 11/17/2022, and “The Resident Care Plan,”. The resident’s history of seizures was not considered on the assessment. The facility identified Resident 1 as a low fall risk when the resident should have been identified as a high fall risk. 2. Ensure that the facility conducted a Fall Risk Interdisciplinary Team meeting for Resident 1 who was a high risk for falls. 3. Ensure Resident 1’s care plan, initiated 2/27/2023, for restlessness as evidenced by trying to sit on the bed, and restlessness as evidenced by Resident 1 hanging their feet on the bed, initiated 3/1/2023, included interventions to address safety concerns when the resident was found on two occasions to be sitting up in bed despite being identified as needing maximum assistance from two staff for mobility and transfer. As a result, Resident 1 fell on the floor and sustained a laceration to the back of their head on 3/9/2023. The facility staff found Resident 1 unresponsive at 7:11 p.m. and called 911. The paramedics pronounced Resident 1’s death at the facility on 3/9/2023 at 7:46 p.m. These violations, jointly, separately or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and were a substantial factor in the death of Resident 1.