Health inspection·September 17, 2021

Title 22 72311(a)(2) 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. § 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. F689 §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. On 7/2/2021, an unannounced visit was made to the facility to investigate a complaint and an Entity-Reported Incident (ERI) about quality of care. The facility failed to ensure Resident 1 was free from accident and injury by not providing two-person physical assist during surface-to-surface transfers as indicated in the assessment and Care Plan, and as per policies and procedures. As a result, on 6/19/2021, at 9:57 a.m., while Certified Nursing Assistant 1 (CNA 1) was transferring Resident 1 on her own (without another staff assistance) from a shower chair to bed, Resident 1 fell onto the floor sustaining a right hip fracture (broken bone) requiring immediate transfer to General Acute Care Hospital 1 (GACH 1). On 6/23/2021, Resident 1 underwent surgery to repair the right hip fracture. A review of Resident 1's Admission Record indicated the facility originally admitted the resident on 10/4/2020 with a re-admission dated 2/24/2021. Resident 1’s diagnoses included spina bifida (a defect of the spine in which part of the spinal cord and its meninges [layers of tissue that cover and protect the spinal cord] are exposed through a gap in the backbone. It often causes paralysis [loss of the ability to move and feel] of the lower limbs and sometimes mental handicap), major depressive disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily life), history of fall with right hip fracture and orthostatic hypotension (low blood pressure caused when changing position from lying to sitting or sitting to standing). A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 4/1/2021, indicated the resident was able to remember, communicate needs, make decisions, and required two-person physical assist for transfers. A review of Resident 1's Care Plan developed on 2/25/2021 for the resident’s use of a low air loss mattress (pressure relieving mattress that provides airflow to help keep skin dry, as well as to relieve pressure and prevent or assist with healing pressure sores [also known as bed sores, are skin injuries from pressure due to lack of mobility]), indicated Resident 1 was at risk of falling from bed due to being large and heavy. The interventions included providing two-person physical assist with transfers, repositioning, and daily care. A review of Resident 1's Care Plan, developed on 2/25/2021, for the resident’s fall risk included in the interventions providing the resident with a safe environment. A review of Resident 1's Change of Condition / Interact Assessment form, dated 6/19/2021, time at 9:57 a.m., indicated the resident fell from the shower chair while transferring to bed. Resident 1 complained of right hip pain and was transferred GACH 1 by paramedics (911 called for emergency response). A review of Resident 1's GACH 1’s Emergency Department documentation, dated 6/19/2021, indicated X-rays (test that produces images of the structures inside the body such as bones) results showed a right femoral (thighbone) subcapital (just below the head of the thighbone) fracture (right hip fracture). A review of Resident 1's GACH 1’s Progress Notes, dated 6/23/2021, indicated the resident underwent surgery to repair the right hip fracture. On 7/2/2021 at 2:36 p.m., during an interview, CNA 1 stated on 6/19/2021 that Resident 1 was being impulsive and impatient, and after showering Resident 1 (while sitting in the shower chair) and returning to the room, Resident 1 attempted to transfer himself from the shower chair to bed and CNA 1 tried to assist him to get back in bed. CNA 1 stated Resident 1 required two-person physical assist during transfers for the Resident 1’s and staff's safety. CNA 1 stated that she not having another staff member present at the time of Resident 1's fall. CNA 1 stated, "The safe thing to do was to have had someone else there to help already, but we have to get lucky to have another staff available." CNA 1 explained that during the mornings, other staff are too busy administering medications, taking breaks, or providing showers to other residents. On 7/2/2021 at 3:25 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was to receive assistance from two staff during transfers. On 7/9/2021 at 3:07 p.m., during an interview, Resident 1 stated that on the day he fell and broke his hip (6/19/20210), only one staff assisted him when transferring back to bed after receiving a shower. Resident 1 stated, "After the fall, it was painful, crazy painful for my hips." On 8/6/2021 at 1:35 p.m., during an interview, Registered Nurse 1 (RN 1) stated Resident 1 had a history of previous falls and a healed traumatic fracture. RN 1 stated two-person physical assist was required for Resident 1 to prevent re-occurrence of a fracture. RN 1 stated, "Knowing the resident is aggressive and impulsive, the CNA should have called someone to assist before going in the room to transfer the resident. This was preventable if the CNA had called for assistance." On 8/10/2021 at 3:30 p.m., during an interview, Director of Staff Development (DSD) stated if a resident requires the assistance from two staff, another qualified staff should be informed in advance to provide assistance within the next 10 minutes. A review of the undated facility’s policy and procedure titled "Accident/Incident Prevention" indicated, "This facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accident/incidents and the provision of adequate care plans with procedures to prevent accidents". The facility failed to ensure Resident 1 was free from accident and injury by not providing two-person physical assist during surface-to-surface transfers as indicated in the assessment and Care Plan and as per policies and procedures. As a result, on 6/19/2021, at 9:57 a.m., while CNA 1 was transferring Resident 1 on her own (without another staff assistance) from a shower chair to bed, Resident 1 fell onto the floor sustaining a right hip fracture (broken bone) requiring immediate transfer to GACH 1. On 6/23/2021, Resident 1 underwent surgery to repair the right hip fracture. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.