Other·May 5, 2021

T22 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. T22 § 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. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). F580 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). The facility failed to follow its policies for Fall and Change of Condition by failing to notify the physician for Resident 1 when the resident sustained an unwitnessed fall. On 2/2/20 at 6 a.m., Certified Nurse Assistant 1 (CNA 1) found Resident 1 on the floor next to the resident's bed with her legs bent to the right. CNA 1 and Housekeeper 1 (HK 1) transferred Resident 1 from the floor to the resident's bed without reporting the fall. As a result, Resident 1 experienced severe pain (pain that prevent the resident from performing daily living activities), and the resident did not receive timely treatment for the right hip fracture (broken hip bone). A review of Resident 1's Admission Record indicated the resident was a 68-year-old female who admitted to the facility on 11/26/17, and readmitted on 10/22/19, with diagnoses of diabetes (a condition that affects the way the body absorbs sugar/glucose an important source of fuel for the body), dementia (a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life) and anemia (a condition in which the blood does not have enough healthy red blood cells). A review of Resident 1's Care Plan for Dementia dated 10/22/19, indicated the resident was at high risk for further decline. The approached intervention was to notify the resident's physician on any significant changes in Resident 1's conditions. A review of Resident 1's History and Physical dated 10/23/19, indicated the resident had a fluctuating (continually change) capacity to understand and make decisions. A review of Resident 1’s Fall Risk Evaluation dated 1/22/20, indicated the resident was assessed as high risk for fall with a total score of 18 (total score of 10 or above represents high risk for fall). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 1/26/20, indicated the resident had severe impairment in cognitive skills (brain uses to think, read, learn, remember, reason, and pay attention) for daily decisions making. Resident 1 required extensive assistance for transfers and bed mobility with one-person physical assist. The MDS indicated the resident did not have limitations that interfered with daily functions to her lower extremities (hip, knee, ankle, and foot). A review of Resident 1's Fall Reduction Care Plan Fall dated 2/3/20, indicated the resident had a suspected fall. The care plan indicated that on 2/2/20, CNA 1 found Resident 1 on the floor. The care plan indicated CNA 1 and HK 1 transferred Resident 1 back to bed and CNA 1 did not communicate with a Licensed Nurse (unidentified) regarding Resident 1's fall. A review of Resident 1's Change of Condition Notes dated 2/3/20, timed at 7:40 a.m., indicated Resident 1 complained of pain (no pain level indicated on the notes), had discoloration on her right hip, and was unable to move her legs due to pain. The notes indicated a facility's staff (unidentified) notified Resident 1's physician on 2/3/20 at 9:26 a.m. (more than 27 hours after the resident sustained a fall on 2/2/20 at 6 a.m.) A review of Resident 1's Physician Telephone Orders dated 2/3/20, and timed at 11:27 a.m., indicated for the resident to receive an X-ray (a photographic/digital image of the internal part of the body) to the right hip due to right hip pain and discoloration. A review of Resident 1's Physician Telephone Orders dated 2/3/20, and timed at 10:41 p.m., indicated to transfer the resident to a General Acute Care Hospital (GACH) in the morning for further evaluation and treatment due to right hip pain and severe anemia. A review of Resident 1's Radiology Patient Report from the facility dated 2/3/20, and timed at 11:47 p.m., indicated the resident sustained an acute (sudden in onset) mildly displaced right intertrochanteric fracture (broken right hip bone). A review of Resident 1's Physician Order, dated 2/3/20 indicated for the resident to receive Ibuprofen (medication used to treat fever, swelling and pain) 200 milligrams (mg) 3 tablets by mouth every 12 hours as needed for mild to moderate pain. A Review of Resident 1's Right Hip Pain and Discoloration Change of Condition Notes, dated 2/4/20, untimed, indicated the resident complained of pain 6/10 (moderate pain) to her hip (unidentified side) and the resident received a warm compress for pain. The notes did not indicate Resident 1 receive the Ibuprofen to reduce her pain. A review of Resident 1's Nurses Progress Notes dated 2/4/20, timed at 8:30 a.m., (two days after the unwitnessed fall) indicated two paramedics transferred the resident to a GACH. A review of the facility's Final Investigation Report dated 2/9/20 indicated Resident 1's right hip fracture was a result of an unwitnessed fall that occurred on 2/2/20 at 6 a.m. The report indicated CNA 1 noted Resident 1 was sitting on the floor next to the bed with her legs bent and leaning on the right side. The report indicated CNA 1 and HK 1 transferred Resident 1 from the floor back to the bed and did not report the fall incident to the charge nurse. A review of Resident 1's GACH records, titled "Discharge Summary," with a discharge date of 2/23/20, indicated the GACH admitted the resident secondary to a right hip fracture after sustaining a fall and anemia. The discharge summary indicated the resident described her hip pain as aching, rated as 8/10 (severe pain-unable to perform daily living activities) and her symptoms were aggravated with movement. Resident 1 received an order for Motrin (pain reliever) 400 milligrams (mg), one tablet by mouth, four times a day for mild pain and an order for Norco [a non-opioid (nature or synthetic chemicals) pain reliever] 5-325 mg, one tablet, two time a day as needed for severe pain. The discharge summary indicated a two-view hip X-ray was done on 2/4/20 and revealed a fracture within the base of the right femur (thigh bone) with intertrochanteric extension (hip fracture) suspected. Resident 1 received orthopedics (a branch of medicine dealing with the correction of deformities of bones or muscles) consultation and was referred to Physical Therapist (movement experts who improve quality of life through prescribed exercise, hands-on care, and patient education). During a telephone interview on 4/16/20, at 2:30 p.m., HK 1 stated that on 2/2/20 at 6 a.m., Resident 1 was on the floor with her right knee bent and CNA 1 asked him to assist her (CNA 1) to move Resident 1 to the bed. HK 1 stated they (CNA 1 and HK 1) transferred Resident 1 from the floor back onto the resident's bed by holding the resident's armpits. During two telephone interviews on 4/16/20, at 3:22 p.m. and at 3:45 p.m., CNA 1 stated she was busy and discontinued the phone interviews. During a telephone interview on 6/4/20 at 10:44 a.m., the facility's Director of Staff Development (DSD) stated on 2/2/20, CNA 1 did not follow the facility's Fall policy and procedure. The DSD stated CNA 1 failed to notify Licensed Vocational Nurse 1 (LVN 1) after finding Resident 1 on the floor so LVN 1 could assess the resident and call the physician for further orders. The DSD stated CNA 1 and HK 1 did not need to transfer Resident 1 back to bed. A review of the facility's undated policy and procedure, titled "Falls," indicated for the first staff member who arrived at the scene when a resident has fallen to not move the resident unless directed by a licensed nurse or a physician. A review of the facility's undated policy and procedure, titled "Change of Condition," indicated for staff to notify the attending physician promptly when there was an accident involving residents, which resulted in injury and had the potential for requiring medical intervention. The policy indicated in emergency situations such as a fall with a possible fracture, the Registered Nurse would assess the resident and immediately call the attending physician. The facility failed to follow its policies for Fall and Change of Condition by failing to notify the physician for Resident 1 when the resident sustained an unwitnessed fall. On 2/2/20 at 6 a.m., CNA 1 found Resident 1 on the floor next to the resident's bed with her legs bent to the right. CNA 1 and HK 1 transferred Resident 1 from the floor to the resident's bed without reporting the fall. As a result, Resident 1 experienced severe pain, and the resident did not receive timely treatment for the right hip fracture. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious physical harm would result.