Health inspection·September 16, 2022

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(a)(2) 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 6/21/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident about quality of care. The facility failed to ensure Resident 1 who had poor safety awareness, had a history of falls, and was admitted to the facility for rehabilitation after a fall at home resulting in a left hip fracture (break of a bone), was provided a safe environment and supervision as indicated in the facility’s policies and procedures. The facility failed to: 1. Review and revise the plan of care after Resident 1 fell on 5/23/2022 and on 6/9/2022. 2. Develop new interventions to prevent further falls after each unwitnessed fall on 5/23/2022 and on 6/9/2022. As a result, on 6/14/2022, less than a month after admission, Resident 1 sustained a third unwitnessed fall requiring transfer to General Acute Care Hospital 1 (GACH 1) where she was diagnosed with a right hip fracture. A review of Resident 1’s Admission Record indicated the facility admitted the resident on 5/19/2022, with diagnoses including left femur (hip) fracture, presence of left artificial hip (the hip joint is replaced by artificial implants made of ceramic or metal alloy) joint, history of falling, orthostatic hypotension (a drop in blood pressure that occurs when moving from a laying down position to a sitting or standing position), and osteoporosis (bone disease that causes bones to gradually thin and weaken, leaving them at greater risk of fractures). A review of the Physician’s Orders for Resident 1, dated 5/23/2022 (prior to the fall), indicated physical therapy evaluation and treatment, once a day five days a week for forty-five days for gait (manner of walking) training and group therapy. A review of Resident 1’s Physical Therapy Evaluation and Plan of Treatment, dated 5/20/2022-7/3/2022, indicated the need for skilled services due to balance deficits, strength impairments, unilateral weakness, gross motor coordination deficits, joint mobility/integrity deficits, decreased safety awareness and judgment. A review of Resident 1’s Care Plan developed on 5/21/2022 for the resident’s fall risk had a goal for the resident not to sustain serious injury. The intervention included making sure the resident’s call light was within reach and encouraging the resident to use it for assistance as needed and responding promptly to all requests for assistance. A review of Resident 1’s Situation, Background, Assessment, and Recommendation (SBAR - a tool to aid in facilitating and strengthening communication between health care staff) Communication form, dated 5/23/2022, timed at 9:30 p.m., indicated Resident 1 had an unwitnessed fall. The Charge Nurse heard the resident yelling for help inside her room. The resident was found lying on the floor mat (bedside high-impact foam to prevent injury from potential fall from the bed) next to the resident’s bed. A review of Resident 1’s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/24/2022, indicated the resident sometimes made herself-understood and sometimes understood others. Resident 1 had severe cognitive impairment (very hard time remembering things, making decisions, concentrating, or learning), needed extensive assistance with transfers from or to bed and wheelchair, walking with one or two-person assist, and was able to balance and stabilize during transitions and walking with staff assistance. Resident 1 used a walker and wheelchair to move around. A review of Resident 1’s Notification of Room Change, dated 6/2/2022, timed at 11 a.m., indicated Resident 1 was moved to a room near the Nurses’ Station due to high fall risk (for the nursing staff to be close to the resident). A review of Resident 1’s Care Plan Conference Summary, dated 6/3/2022, indicated the resident was alert (awake), occasionally incontinent (unable to control) of bowel and bladder function, had a history of falls, and a was a high fall risk. The physical therapist focused on her mobility. The resident was walking 20-30 feet with front wheel walker (FWW) with 25-50% assist focusing on her safety. The resident required 50-75% assist with toileting. A review of Resident 1’s SBAR Communication form, dated 6/9/2022, timed at 10 a.m., indicated Resident 1 was sitting in a wheelchair, in her room, and had an unwitnessed fall. The housekeeper saw the resident lying on the floor on the right side of her wheelchair. The resident told the nurses she was trying to use the bathroom. A review of Resident 1’s SBAR Communication form, dated 6/14/2022, timed at 6 p.m., indicated the resident was found on the floor inside her room next to her wheelchair. Resident 1 could not remember what she wanted to do. Four staff assisted Resident 1 back to the wheelchair and Resident 1 complained of severe pain on the right hip. The licensed nurse called 911 (emergency telephone number) for emergency medical services (EMS, paramedics) who took Resident 1 to the emergency room (ER) at GACH 1. A review of the facility’s Incident Investigation Report, dated 6/14/2022, indicated Resident 1 had a history of restlessness (inability to remain still or at rest) and anxiety (intense, excessive, and persistent worry and fear about everyday situations), was at risk for falls, did not have safety awareness, required maximum assistance with transfer and walking, was confused, forgetful, disoriented, and attempted to get up unassisted. The investigation conclusion indicated Resident 1’s fracture to the right hip was a result of the fall from the wheelchair. On 6/21/2022, at 10:26 a.m., during an interview, Registered Nurse Supervisor (RNS) stated Resident 1 had a fall at home and was admitted to the facility on 5/19/2022 for a left femur fracture. Resident 1’s first fall at the facility occurred on 5/23/2022, in her room when she tried to walk without assistance and did not call for assistance or use the call light. The facility moved Resident 1 to a room near the Nurses’ Station for frequent observation. On 6/9/2022, Resident 1 sustained a second fall in her room after attempting to walk without assistance and did not call for assistance or use the call light. On 6/14/2022, at around 6 p.m., Resident 1 sustained her third fall after attempting to walk without assistance and did not call for assistance or use the call light and was transferred to GACH 1. The following day the facility got a call from GACH 1 that Resident 1 sustained a right hip fracture. On 6/21/2022, at 11:00 a.m., during an interview, the Physical Therapist (PT) stated Resident 1 required extensive assistance with transfer, was forgetful, but followed simple commands. On 6/21/2022, at 11:12 a.m., during an interview, the Assistant Director of Nursing (ADON) stated Resident 1 was very restless, confused, and had no safety awareness. The resident did not call when getting out of bed or wheelchair. The ADON stated that they did not think of using a chair alarm (an alarm systems designed to activate audible and/or visual signals when a patient attempts to move from the wheelchair) or 1:1 supervision (a staff assigned to be with the resident at all times) because they thought placing the resident near the nurses’ station was enough to keep the resident from getting out of her bed or wheelchair. The ADON agreed that a chair alarm or a 1:1 care companion could have prevented further falls. The ADON further stated they forgot to update the care plan for the 5/23/2022 fall and 6/9/2022 fall incidents of the resident. During an interview on 6/21/2022, at 3 p.m., the ADON and MDS Coordinator, both stated that Resident 1’s Care Plan should have been reviewed and updated on 5/23/2022 and 6/9/2022 after each fall incident to include new interventions. A review of the facility's policy and procedure titled, "Safety and Supervision of Residents," revised 7/2017, indicated that monitoring the effectiveness of interventions shall include the following: (a) ensuring that interventions are implemented correctly and consistently; (b) evaluating the effectiveness of interventions; (c) modifying or replacing interventions as needed; and (d) evaluating the effectiveness of new or revised interventions. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment or if there is a change in the resident's condition. A review of the facility's policy and procedure titled, "Safety for Residents," dated 7/2015, indicated that residents should be visualized for safety during rounds and per care plan for individual residents. A review of the facility’s policy and procedure titled, “Falls Management Policy,” last revised 2/2022, indicated when a fall occurs, the resident’s care plan is reviewed and updated as necessary. A review of the facility’s policy and procedure titled, “Comprehensive Care Plan Policy,” dated 11/2017, indicated care plans will be revised as information about the resident and the resident’s condition changes. The facility failed to ensure Resident 1 who had poor safety awareness, had a history of falls, and was admitted to the facility for rehabilitation after a fall at home resulting in a left hip fracture, was provided a safe environment and supervision as indicated in the facility’s policies and procedures. The facility failed to: 1. Review and revise the plan of care after Resident 1 fell on 5/23/2022 and on 6/9/2022. 2. Develop new interventions to prevent further falls after each unwitnessed fall on 5/23/2022 and on 6/9/2022. As a result, on 6/14/2022, less than a month after admission, Resident 1 sustained a third unwitnessed fall requiring transfer to GACH 1 where she was diagnosed with a right hip fracture. 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 Residents 1.