Other·March 17, 2023

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 § 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: (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 2/3/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a recertification survey. The facility failed to provide an environment free of accident hazards and adequate supervision and assistance to prevent falls and injury to Resident 18 by failing to: 1. Ensure the Interdisciplinary Team (IDT, group of healthcare staff from different disciplines involved in the care of the resident) met, reviewed, and revised Resident 18’s care plans after each fall to develop and implement resident-centered interventions with measurable goals to prevent falls. 2. Monitor the use and effectiveness of Resident 18’s sensor pad alarm (a device used to detect movement of a resident to mitigate falls). As a result, Resident 18 sustained a total of 19 falls from 11/22/2019 to 2/3/2022 and was identified with injuries on eight falls as follows: - On 11/22/2019, Resident 18 fell and sustained a head laceration (a deep cut or tear in skin or flesh). - On 1/17/2020, Resident 18 fell and sustained a scratch on the right lower back. - On 6/18/2021, Resident 18 fell and sustained a skin tear on the right elbow. - On 7/19/2021, Resident 18 fell and sustained abrasions (an area damaged by scraping or wearing away) on the right and left knees. - On 10/18/2021, Resident 18 fell and sustained bruising (occurs when small blood vessels break and leak their contents into the soft tissue beneath the skin) and swelling (occurs when a part of the body increases in size, typically because of injury, inflammation, or fluid retention) of the left side of the hip area. - On 11/15/2021, Resident 18 fell and sustained pain on the side of the right knee. - On 12/20/2021, Resident 18 fell and sustained a superficial (on the surface) abrasion on the left knee. - On 1/17/2022, Resident 18 fell and sustained a purplish discoloration to the left occipital (back of the head) area and the left mid-back and left scapular (shoulder) region reddish discolorations. On 1/31/2023 at 10 a.m., during an observation and interview, Resident 18 was sitting in a wheelchair (WC) and stated he had fallen while in the facility because he forgot to lock the wheels on his WC. A review of Resident 18’s Admission Record indicated the facility admitted the 77-year-old male resident on 6/24/2019 with diagnoses including muscle weakness, lack of coordination, unsteady on the feet (unable to stand or walk easily), history of falls, and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 18’s Morse Fall Scale form (a rapid and simple method of assessing a patient’s likelihood of falling), dated 1/5/2023, indicated the resident was a high risk for falling with a history of falls, impaired gait, and the resident overestimated or forgot limits of his ability to ambulate safely. A review of Resident 18’s Minimum Data Set (MDS, an assessment and screening tool), dated 2/1/2023, indicated the resident was usually able to understand others and make himself understood; and the resident required supervision with bed mobility, transfer, walking in the room, dressing, toilet use, and personal hygiene. The MDS further indicated the resident had two or more falls with injury and two or more falls with no injury since admission. On 2/1/2023 at 3:17 p.m., during an interview with the Director of Nursing (DON) and a concurrent review of Resident 18’s clinical records, the DON stated the resident had a fall on 11/22/2019 that resulted in a laceration on the resident’s forehead requiring transfer to a general acute care hospital (GACH). The review of Resident 18’s clinical records indicated the resident’s Care Plan (CP) titled, “At risk for recurrent falls or injuries related to impaired cognition related to dementia, impaired mobility secondary to muscle weakness, unsteadiness on feet, and hypertension (high blood pressure),” initiated 7/4/2019 and last revised 12/20/2021, indicated the resident fell on 7/19/2021, 11/15/2021, 11/22/2021, 12/13/2021, and 12/20/2021. The CP indicated a goal that the resident would be free from falls through the review date with a target date of 11/1/2022. The CP further indicated to have a floor pad (a cushioned mat designed to help prevent injury from falls out of the bed) at bedside, initiated 2/28/2021. A review of Resident 18’s CP titled, “The Resident had had actual fall with poor balance, unsteady gait,” initiated on 11/12/2019 and last revised on 10/31/2022, indicated the resident fell on 11/12/2019, 1/17/2020, 2/21/2021, 6/18/2021, 6/30/2021, 8/4/2021, 8/17/2021, 9/9/2021, 10/18/2021, 11/15/2021, 11/22/2021, 12/13/2021, 12/20/2021, 1/17/2022, 7/12/2022, and 10/31/2022. The CP indicated goals that Resident 18 would remain free from injuries by the target date of 11/1/2022. On 2/2/2023 at 9:40 a.m., during an interview with the Director of Staff Development (DSD) and concurrent review of Resident 18’s clinical records, the DSD stated Resident 18 was a high fall risk and had fallen in the facility. The DSD stated when a resident has a fall there is a change of condition (COC) reported to the physician and the resident’s representative (RP), treatment is ordered as appropriate, and the care plan is reviewed and updated by the IDT with new interventions. The DSD reviewed Resident 18’s COC notes, CPs, and IDT meeting notes and stated the following: - On 11/22/2019 at 3:30 p.m., Resident 18 had a witnessed fall, sustained a deep laceration to the top of the head measuring approximately 4 centimeters (cm, unit of measure) long by (x) 1 cm, 911 was called (emergency telephone number) for emergency medical services (EMS, paramedics) who took Resident 18 to an emergency room (ER) due to persistent bleeding. Resident 18 returned to the facility the same day with staples to repair the scalp laceration. The DSD stated there was no documented evidence the resident’s CP was updated after the fall. - On 1/17/2020 at 9:49 a.m., Resident 18 had an unwitnessed fall in the bathroom and was noted with a scratch on the right lower back. - On 2/21/2021 at 5:45 a.m., Resident 18 had an unwitnessed fall, with no injuries. - On 6/18/2021 at 10:20 p.m., Resident 18 had an unwitnessed fall and sustained a skin tear in the right elbow. - On 6/30/2021 at 12:30 a.m., Resident 18 had witnessed fall with no injuries. - On 7/19/2021 at 10:07 p.m., Resident 18 had unwitnessed fall and sustained abrasions on both right and left knees. - On 8/4/2021 at 1:51 a.m., Resident 18 had unwitnessed fall with no injuries. - On 8/17/2021 at 8:30 p.m., Resident 18 had unwitnessed fall with no injuries. - On 9/9/2021 at 11:30 p.m.., Resident 18 had unwitnessed fall with no injuries. - On 10/18/2021 at 3:04 p.m., Resident 18 claimed he fell on 10/17/2021, sustained injuries of bruising, discoloration and swelling of left side of hip area. - On 11/15/2021 at 4:10 a.m., Resident 18 had unwitnessed fall and complained of right lateral knee pain. - On 11/22/2021 at 6:30 p.m., Resident 18 had unwitnessed fall with no injuries. - On 12/13/2021 at 10:00 a.m., Resident 18 had witnessed fall with no injuries. - On 12/20/2021 at 1:50 p.m., Resident 18 had unwitnessed fall and sustained superficial abrasion on the left knee. - On 1/17/2022 at 6:50 p.m., Resident 18 had unwitnessed fall and was noted to have purplish discoloration to left occipital part of head. Also noted with left mid-back and left scapular region reddish discolorations. - On 7/11/2022 at 8:10 p.m., Resident 18 had unwitnessed fall with no injuries. - On 10/18/2022, Resident 18 reported fall with no injuries. - On 10/31/2022, Resident 18 had unwitnessed fall with no injuries. - On 1/5/2023, Resident 18 had unwitnessed fall with no injuries. The DSD stated there was no documented evidence the IDT met, or the CP was updated after each fall, and the last CP update was on 10/31/2022. The DSD stated there should have been new CP interventions to prevent further falls as per the facility’s policy on fall mitigation. On 2/2/2023 at 11:10 a.m., during an interview with the Medical Records Designee (MRD) and concurrent review of Resident 18’s clinical record, the MRD confirmed there was no documented evidence the resident’s CPs were reviewed or updated after the resident fell on 11/22/2019 and 1/5/2023. On 2/2/2023 at 11:45 a.m., during an interview with the DON and concurrent review of Resident 18’s IDT and CPs, the DON stated the IDT should update CPs after every fall to include a review of and put in place new interventions. The DON stated there were no CP updates after the resident fell on 11/22/2019 and 1/5/2023, but there should have been updates per the facility’s policy. The DON stated the importance of updating CPs was to develop new recommendations and interventions to decrease the episodes of falls and injuries. The DON stated interventions should be reviewed after each fall to determine if they are still current and appropriate. The DON stated Resident 18’s fall CPs were also outdated because the target date for the CP goals was for 11/1/2022 and it was 2/2/2023. The DON stated the target date should be in the future. The DON stated the CP goals are updated annually, quarterly, and as needed. The DON stated it was important to have current goals so there was a measurable timeframe for the interventions in place. The DON stated Resident 18’s short-term goals and interventions indicated in the CPs should be resolved but were not. The DON stated the CP indicated an intervention for a floor pad at bedside, but the order had been discontinued because it was no longer appropriate. The DON stated the CP interventions were current for Resident 18 and the MDS Nurse was responsible for ensuring CPs were updated, but she must have gotten behind. During an interview and record review on 2/3/2023 at 9 a.m., the DON reviewed Resident 18’s CPs and physician orders and stated the order to place a fall mat at bedside was discontinued on 4/30/2021 and it was not removed from the resident’s CP. The DON stated the importance of the CP is that it guides the staff in the appropriate care to minimize injury. The DON stated by looking at the CP it looks like all the interventions are current because nothing has been discontinued. The DON stated the CP was not updated based on physician’s order and the IDT recommendations. The DON stated the risk of having the CP not reflect a person-centered CP would result in inadequate interventions to prevent falls and the interventions would not reflect the current care for the resident. During an interview on 2/3/2023 at 2:30 p.m., the MDS Nurse stated CPs are used as a guide to care for the resident and they should be specific, measurable, current, and applicable to the resident’s current condition. The MDS Nurse reviewed Resident 18’s CPs related to falls and stated they were not updated because she got behind and missed them. The MDS Nurse further stated for Resident 18, if the CPs were not all those things (specific, measurable, current, and applicable to the resident’s current condition), the resident could fall resulting in injury. A review of Resident 18’s Physician’s Order, dated 8/27/2021, indicated to apply a sensor pad alarm in bed or WC to alert staff of unassisted transfers, getting up, or walking every shift for fall risk. The order was dated 8/27/2021 and was discontinued 1/30/2023. During an interview and record review on 2/3/2023 at 8 a.m., Registered Nurse 1 (RN 1) stated Resident 18 had fallen multiple times and forgets to call for assistance. RN 1 stated the resident had a sensor pad alarm to alert staff if he got up unassisted. RN 1 stated the resident had a history of non-compliance and removing the alarm and it was important to monitor the alarm for placement and document in the Medication Administration Record (MAR). RN 1 stated the documenting licensed nurse should indicate each shift (day, evening, and night) in the MAR “Y” for yes, the alarm was in place, or an “N” for no, the alarm was not in place. RN 1 stated a “- (dash)” did not indicate if a sensor pad alarm was in place or not and stated she did not know what a dash indicated. RN 1 reviewed Resident 18’s MAR for sensor pad alarm monitoring and stated the following: - For the month of 11/2022: all day, evening, and night shifts indicated a dash. - For the month of 12/2022: all day, evening, and night shifts (except 12/14/2023 and 12/23/2023 evening shifts), indicated a dash. - For the month of 1/2023 (up to 1/30/2023, date the order was discontinued): all day, evening, and night shifts (except 1/15/2023, 1/25/2023, and 1/26/2023 evening shifts), indicated a dash. RN 1 stated the dash did not indicate if the sensor pad alarm was in place or not and was not appropriate documentation. RN 1 stated the importance of appropriate documentation was to ensure accuracy and to communicate if the sensor was present or not. RN 1 further stated the importance of knowing if the sensor was in place or not was to see if the intervention was effective because Resident 18 frequently removed the alarm and had many falls in the facility. During an interview on 2/3/2023 at 9 a.m., the DON reviewed Resident 18’s MAR and stated she did not know what the dash meant, and “Y” or “N” should have been documented. The DON stated the importance was to ensure the alarm was in place and the accuracy of the collection of information to ensure if the order should be kept in place and that it was appropriate for the resident. The DON further stated the IDT would review the MAR post-fall when the team reviewed interventions to prevent falls. A review of the facility’s current policy and procedure titled, “Documentation Principles,” last reviewed 2/24/2022, indicated all health information regarding a resident’s stay shall be centralized in the resident’s health record. Resident’s health record shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each resident. The following principles shall be used for documenting: entries must accurate, specific, concise, and clear. A review of the facility’s current policy and procedure titled, “Fall/Accident Mitigation and Intervention,” last reviewed 2/24/2022, indicated it was the policy of the facility to minimize the risk of falls or accidents, and minimize the risk of serious injury associated with fall or accidents. Residents at risk for falls shall have a CP that identifies the risk factors for that individual resident and appropriate interventions based on the risk factors. After a fall or similar accident or occurrence, the resident shall have a physical assessment documented in the nursing notes in accordance with the facility documentation policy. The attending physician and legal representative or interested family member shall be notified of the event. The facility nursing staff or the IDT shall update the resident’s plan of care accordingly to reduce the risk of further occurrences of a fall or other event. A review of the facility’s current policy and procedure titled, “Comprehensive Care Plans – Section III -39,” last reviewed 2/24/2022, indicated the IDT shall develop and implement a comprehensive person-centered CP for each resident that inclu