Other·July 14, 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 - (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: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 5/25/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate two complaints about quality of care. The facility failed to ensure Resident 1, who had history of falls in the facility, was confused, and needed supervision and assistance to prevent falls and injuries, was provided with supervision while Resident 1’s assigned one-to-one sitter (one caregiver is assigned to continuously stay with the resident to monitor and prevent accidents or falls) was away from the resident on break. The facility failed to: 1. Supervise Resident 1 when the resident’s one-to-one sitter went on break. 2. Develop and implement a policy and procedure for one-to-one sitters, including how to handle a one-to-one sitter’s break. As a result, on 5/19/2023 at 1:30 a.m., Resident 1 had an unwitnessed fall from bed sustaining a laceration (a deep cut or tear in the skin) on the right side of the head above the eyebrow, a skin tear on the left thumb and a laceration on the right cheek below the eye. Resident 1 required transfer to General Acute Care Hospital 1 (GACH 1) where he received six sutures (row of stitches holding together the edges of a wound) on the left thumb and three sutures above the right eyebrow. Resident 1 sustained a right frontotemporoparietal (area of the brain above the ear) subdural hematoma (bleed inside the head within the skull and outside the brain) measuring up to 11 millimeters (mm) deep. A review of Resident 1`s Admission Record indicated the facility originally admitted the resident, a 77-year-old male, on 3/29/2023 and readmitted the resident on 5/8/2023 with diagnoses including end stage renal disease (ESRD - when the kidneys permanently fail to work) on hemodialysis (process of purifying the blood of a person whose kidneys are not working) treatment, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and chronic respiratory failure (a condition that occurs when not enough oxygen travels from the lungs into the blood or when too much carbon dioxide [colorless, odorless gas] remains in the blood) with hypoxia (happens when there is not enough oxygen in the blood). A review of Resident 1’s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/10/2023, indicated the resident's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision-making was impaired. The MDS indicated Resident 1 required limited assistance from staff with bed mobility, transfer, dressing, eating, toilet use, and required extensive assistance with personal hygiene and bathing. A review of Resident 1’s Fall Risk Observation/Assessment form dated 3/29/2023, indicated Resident 1 was a high fall risk. A review of Resident 1’s licensed nursing Progress Notes and Interdisciplinary (IDT - group of professionals from different disciplines who provide care to the resident) Notes indicated Resident 1 had four falls since admission to the facility: on 4/4/2023 at 3:30 p.m.; on 4/26/2023 at 4:00 a.m. sustaining a skin tear on the left arm; on 5/15/2023 at 12:15 p.m. sustaining a skin tear on the right forearm and a skin tear on the left hand, and on 5/18/2023 at 3:30 p.m. A review of Resident 1’s Care Plan titled “At risk for falls” related to cerebral infarction with left side weakness, neuropathy (a condition that affects the nerves and may include prickling, burning or numb sensation), osteoarthritis (a condition that causes joints to become painful and stiff) of the knee, and gets in and out of bed and wheelchair without calling for assistance, developed on 4/7/2023 had a goal for Resident 1 to be free of falls. The interventions included providing a one-to-one sitter from 7:00 p.m. to 7:00 a.m. for two weeks pending discharge to home and provide a safe environment. A review of Resident 1’s Change of Condition (COC) Evaluation form, dated 5/19/2023 timed at 1:39 a.m., indicated that at 1:30 a.m., Licensed Vocational Nurse 1 (LVN 1) heard yelling from Resident 1’s room. LVN 1 went to Resident 1’s room and found the resident on the floor while Resident 1’s one-to-one sitter was away on break. The COC form further indicated that Resident 1 was noted with a skin laceration on the right side of the head above the eyebrow with bleeding, a skin tear on the left thumb and a skin tear on the right cheek below the eye with bleeding. The COC form further indicated that Registered Nurse Supervisor 1 (RNS 1) called 911 (a telephone number to use in emergency to obtain immediate assistance from paramedics) and that paramedics arrived and transferred Resident 1 to GACH 1. A review of Resident 1’s IDT Notes, dated 5/22/2023, indicated on 5/19/2023 at around 1:39 a.m., staff found Resident 1 lying on the floor mat next to his bed on his right side. Staff called Registered Nurse Supervisor 1 (RNS 1) who assessed Resident 1 to have a 2.5 centimeters (cm – unit of measure) laceration on the right side of the resident’s head above the eyebrow, a 1.5 cm skin tear on the left thumb, and a 1.0 cm laceration to the resident’s right cheek with small amount of bleeding. The IDT notes indicated Resident 1’s one-to-one sitter went on break. The IDT Notes further indicated Certified Nurse Assistant 1 (CNA 1) checked Resident 1 around 1:15 a.m. and the resident was awake, the bed was in a low position with landing pads (cushion mats placed by the bed to minimize injuries if the resident falls out of bed). CNA 1 then proceeded to attend to another resident. On 5/30/2023, at 1:43 p.m., during an interview, the Assistant Director of Nursing (ADON) stated the facility contracted a one-to-one sitter to be with Resident 1 from 7:00 p.m. to 7:00 a.m. since there are less staff during the evenings and nights. On 5/31/2023 at 7:43 a.m., during an interview, CNA 1 stated she works the 11:00 p.m. to 7:00 a.m. shift and was working on 5/19/2023. CNA 1 stated LVN 1 informed her that Resident 1’s one-to-one sitter would be taking a break from 1:00 a.m. to 2:00 a.m. CNA 1 went to Resident 1’s room around 1:05 a.m., and the one-to-one sitter was no longer in the room. CNA 1 observed Resident 1 in bed. CNA 1 stated she stayed in the room for about two to three minutes, and then left to go and check on another resident who had their call light (a device used by residents to signal to staff that assistance is needed) on. CNA 1 stated that she informed LVN 1 that she needed to attend to the call light in another room. CNA 1 stated that after leaving Resident 1’s room to provide care to another resident, approximately 20 minutes later, she was informed by LVN 1 that Resident 1 had fallen. CNA 1 stated that if she had waited for Resident 1’s one-to-one sitter to return from his break the fall could have been prevented. On 5/31/2023 at 8:09 a.m., during an interview, LVN 1 stated she was working the 11:00 p.m. to 7:00 a.m. shift on 5/19/2023. LVN 1 stated Resident 1 was a fall risk, confused, and did not use the call light to ask for help. LVN 1 stated that on 5/19/2023 at 1:00 a.m., Resident 1’s one-to-one sitter had informed LVN 1 that he was going to take his break and that Resident 1 was awake at the time. LVN 1 stated she had then informed CNA 1 to cover for Resident 1’s one-to-one sitter and watch Resident 1. LVN 1 stated that she should have stayed with the resident after CNA 1 had informed her that CNA 1 was leaving to respond to the call light of another resident. LVN 1 stated the fall incident could have been prevented. LVN 1 stated there was no guidance provided to staff regarding Resident 1’s one-to-one sitter’s break periods. LVN 1 stated that moving forward she would ensure that Resident 1 is supervised by staff while Resident 1’s one-to-one sitter was away on break. On 6/1/2023 at 9:30 a.m., during an interview, the Director of Nursing (DON) stated since admission they have identified Resident 1 as a high risk for fall. A one-to-one sitter from 7:00 p.m. to 7:00 a.m. started on 5/10/2023 for Resident 1. The DON stated that when Resident 1’s one-to-one sitter is away on break, the staff should alternate in monitoring the resident until the one-to-one sitter returns from break. The DON further stated the purpose of the one-to-one sitter was to provide constant supervision and prevent occurrence of fall. The DON stated if someone was watching Resident 1 at that time, the fall could have been prevented. A review of Resident 1’s GACH 1 Consultation Report, dated 5/19/2023, indicated Resident 1 had a computed tomography scan (CT scan - medical imaging technique used to obtain detailed internal images of the body) and was found to have a frontotemporoparietal subdural hematoma measuring up to 11 mm deep. Resident 1 required six sutures on the left thumb and three sutures to the laceration above the right eyebrow. A review of the facility’s policy and procedure titled, “Falls and Fall Risk, Managing,” dated 10/2022, indicated “Based on previous evaluations and current data, the staff will identify interventions related to the resident`s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling…if falling recurs despite initial interventions, staff will implement additional interventions, or indicate why the current approach remains relevant…” The facility failed to ensure Resident 1, who had history of falls in the facility, was confused, and needed supervision and assistance to prevent falls and injuries, was provided with supervision while Resident 1’s assigned one-to-one sitter was away from the resident on break. The facility failed to: 1. Supervise Resident 1 when the resident’s one-to-one sitter went on break. 2. Develop and implement a policy and procedure for one-to-one sitters, including how to handle a one-to-one sitter’s break. As a result, on 5/19/2023 at 1:30 a.m., Resident 1 sustained an unwitnessed fall from bed sustaining a laceration to the right side of the head above the eyebrow, a skin tear on the left thumb and a laceration on the right cheek below the eye. Resident 1 required transfer to GACH 1 where he received six sutures on the left thumb and three sutures to the laceration above the right eyebrow. Resident 1 sustained a right frontotemporoparietal subdural hematoma measuring up to 11 mm deep. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result Resident 1.