Other·July 21, 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 4/25/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about quality of care. The facility failed to ensure Resident 1’s bed alarm (a physical or electronic device that monitors resident movement and alerts the staff when movement is detected while the resident is in bed) was functional and turned on as ordered by the physician and as indicated in the care plan. As a result, on 4/25/2022 Resident 1 fell and sustained an occipital (rear portion of the head) scalp hematoma (abnormal collection of blood outside of a blood vessel) and laceration (a deep cut or tear in the skin). A review of Resident 1's Admission Record indicated the resident was admitted into the facility on 5/29/2019, and was most recently readmitted on 11/11/2021, with diagnoses that included, but not limited to, end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), failure to thrive, and a history of transient ischemic attack (temporary blockage of blood flow to the brain) and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area without residual deficits). A review of the Physician’s Order for Resident 1, dated 11/15/2021, indicated to apply a sensor pad alarm (type of bed alarm) on bed, and to monitor for function and placement every shift. A review of Resident 1' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/25/2022, indicated the resident had the ability to make self-understood and has the ability to understand others. The MDS indicated Resident 1 requires one-person extensive assistance with bed mobility, transferring to or from bed, dressing, toilet use, and personal hygiene. The MDS further indicated the bed alarm was being used daily for the resident. A review of Resident 1' s Quarterly Risk Data Collection Tool, dated 3/1/2022, indicated the resident is at risk for falls. A review of Resident 1' s Care Plan for risk for falls, initiated on 11/12/2021 and revised on 3/15/2022, indicated a goal that the resident will be free of fall-related injuries. The care plan indicated an intervention, revised on 3/8/2022, for sensor pad alarm on bed and to monitor for function and placement every shift. A review of the nursing progress note, dated 4/21/2022 at 11:05 p.m., indicated resident was found lying on her right side on the landing pad (floor mat to protect residents from fall-related injuries). Certified Nursing Assistant 1 (CNA 1) called the charge nurse that resident was on the floor. Upon completing a body assessment, Resident 1 was found with a three-centimeter (cm) laceration to the back of her head with moderate bleeding. The physician was notified and ordered to transfer the resident to the hospital. A review of Resident 1' s computed tomography (CT - noninvasive diagnostic imaging procedure that produces images of the inside of the body) of the head without contrast (substance taken by mouth or injected into bloodstream that cause the particular organ or tissue to be seen clearly), taken at the hospital, indicated a result of an occipital scalp hematoma and laceration. During an interview, on 4/25/2022 at 4:33 p.m., Licensed Vocational Nurse 1 (LVN 1) stated CNA 1 had found Resident 1 on the floor during CNA 1’s initial rounds and notified her (LVN 1) of the fall. LVN 1 stated she found Resident 1 laying on her right side on the landing pad on the right side of the bed upon checking on her. LVN 1 stated a body assessment was completed and a laceration to the back of her head was noted with moderate bleeding. LVN 1 stated Resident 1 was identified as a high fall risk since the resident is confused and always tries to get out of bed and explained staff were performing frequent checks, ensured bed was in the lowest position, and landing pads and bed alarm were in place to prevent Resident 1 from falling. LVN 1 confirmed the bed alarm did not sound when she came to check on Resident 1. LVN 1 stated she was not sure if the bed alarm was not working or if CNA 1 had turned it off after the bed alarm went off. During an interview, on 5/10/2022 at 11:46 a.m., CNA 1 verified she was the first person to find Resident 1 on the floor at around 11 PM on 4/21/2022. CNA 1 stated she was making rounds in the beginning of her shift and passing by when she heard someone yelling for help. When CNA 1 looked inside Resident 1 ' s room, CNA 1 stated she found Resident 1 laying with her body on the landing pad and her head partially on the floor. CNA 1 stated Resident 1 sustained an injury to the back of her head and was bleeding. CNA 1 stated she immediately called for help. CNA 1 stated that she did not hear anything besides the resident yelling for help when she found Resident 1 on the floor. CNA 1 stated she saw the bed alarm on the resident ' s bed but confirmed the bed alarm did not go off. CNA 1 stated she would have heard it if the bed alarm was on. CNA 1 further stated she honestly did not see a green or red light on the bed alarm and explained that the light on the bed alarm should be blinking green if the bed alarm was working or turned on. During an interview, on 5/10/2022 at 4:12 p.m., Registered Nurse 1 (RN) 1 stated she was in Station 1 when LVN 1 notified her that Resident 1 had fallen. RN 1 stated she found Resident 1 in her room laying in her right side on the landing pad located on the floor to the right side of the bed. RN 1 verified she did not hear anything when she arrived at Resident 1 ' s room. RN 1 stated that if LVN 1 had not called her and gotten her attention, she would not have known that the resident had gotten out of bed and fallen. RN 1 further stated she was more concerned about Resident 1 ' s condition during that time and did not pay attention to see if Resident 1 had a bed alarm or not. During an interview and record review, on 5/10/2022 at 4:50 p.m., the Director of Nursing (DON) stated Resident 1 was identified as a high fall risk and verified Resident 1 had an order for sensor pad alarm in bed that was ordered on 11/15/2021. The DON stated Resident 1 was sleeping in bed prior to when she attempted to get out of bed and fell. The DON confirmed the bed alarm should have been on since the resident was in bed sleeping. When asked what it means if the interviewed staff (CNA 1, LVN 1, and RN 1) at the scene are saying that they did not hear any sound upon attending to Resident 1 while she was on the floor, the DON stated it means the bed alarm was not working. The DON explained the bed alarm is checked for function and placement every shift by staff and that the bed alarm has to be blinking a green light, indicating the alarm is on and functional. The DON stated staff should notify central supply immediately to replace the bed alarm sensor if it is not working. When asked if the facility did everything to prevent Resident 1 from falling, the DON answered no and confirmed the intervention for bed alarm was missed. The DON further stated it is possible the fall could have been avoidable if the bed alarm was working. The DON stated the purpose of the bed alarm is to remind residents not to get up by themselves and to alert staff. A review of the facility ' s policy and procedure titled, "Tab Alarms, Bed Alarm, Wanderguard System," last reviewed and updated on 4/12/2022, indicated tab alarms or bed alarms may be used on a resident who is deemed unsafe through the nursing assessment and documented on the resident ' s care plan that the resident is at risk for falls. The policy and procedure further indicated the bed alarm will be utilized on the resident while they are in bed and that after applying the tab alarm or bed alarms in place, a safety check to make sure they are in proper working condition must be done before leaving the resident. The facility failed to ensure Resident 1’s bed alarm was functional and turned on as ordered by the physician and as indicated in the care plan. As a result, on 4/25/2022 Resident 1 fell and sustained an occipital scalp hematoma and laceration. 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.