Other·May 17, 2023

F689 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 Services - 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. On 4/4/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) and one complaint. The facility failed to provide Resident 1, who had history of falls before admission, and was confused, with the needed supervision and assistance to prevent further falls and injuries. The facility failed to ensure: 1. Resident 1’s fall risk care plan interventions were evaluated (reviewed and revised) for effectiveness and failed to identify and develop new interventions based on the individual needs of the resident such as toileting. 2. The Interdisciplinary Team (IDT, group of professionals from different health care disciplines who participate in the care of the resident) including the attending physician, met to identify causative factors for Resident 1’s repeated incidents of falls while attempting to use the bathroom. As a result, Resident 1 fell a total of five times from admission on 12/27/2023 to discharge dated 3/17/2023 while attempting to go to the restroom., After the 4th fall on 3/2/2023, an X-ray of the right hip taken the same day, with the result dated 3/5/2023, indicated Resident 1 sustained a right hip fracture. On 3/5/2023, the physician ordered a computerized tomography (CT) scan (combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross-sectional images [slices] of the bones, blood vessels and soft tissues inside the body; CT scan images provide more-detailed information than plain X-rays) which was done 3/16/2023 and the result received on 3/20/2023 confirmed the right hip fracture. A review of Resident 1’s Admission Record indicated the facility admitted the resident, an 88-year-old female, on 12/27/2022, from an acute hospital after falling at the assisted living facility (ALF) where the resident resided. Resident 1’s diagnoses included parkinsonism (a disorder of the central nervous system that affects movement, often including tremors [shaking movements in one or more parts of the body, most often in the hands]) and dementia (a loss of mental ability severe enough to interfere with normal activities of daily living). A review of Resident 1’s History and Physical (H&P) exam by the attending physician, dated 12/28/2022, indicated the resident had a history of frequent falls at the ALF. A review of the Physician’s Orders for Resident 1, dated 12/27/2022, indicated Physical Therapy (PT) evaluation and treatment as indicated; another order was for the use of a landing mat (floor mat, cushioned mat placed at the bedside to reduce the impact and injury risk). A review of Resident 1’ s PT Evaluation and Plan of Treatment dated 12/29/2022 indicated Resident 1 was referred to PT due to new onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely walk, reduced balance, reduced functional activity tolerance, decreased coordination, decreased judgment, cognitive deficits (problems with a person's ability to think, learn, remember, use judgement, and make decisions), increased need for assistance from others, and reduced participation in activities of daily living (ADLs, refers to resident's daily self-care activities) and skilled PT services were warranted. A review of Resident 1’s Morse Fall Risk (a rapid and simple method of assessing a patient's likelihood of falling) Screen, dated 12/27/2022, indicated the resident as high risk for falling (a score of 45 or higher). Resident 1’s Morse Fall Risk score was 65. A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 12/31/2022, indicated the resident had severe cognitive impairment (unable to understand, remember and make decisions), was able to communicate but confused. Resident 1 needed one-person physical assist with bed mobility, transfer, walk in room and in corridor, locomotion on and off unit, dressing, toilet use, and personal hygiene. The MDS indicated the resident was not steady and only able to stabilize with staff assistance for moving from seated to standing position, walking, moving on and off toilet, moving on and off toilet, and for surface-to-surface transfer (transfer between bed and chair or wheelchair). Resident 1 used a wheelchair to move around. A review of Resident 1’s Care Plan developed on 1/10/2023 for the resident’s fall risk related to diagnoses, had a goal for Resident 1 to be free of falls through the next review on 3/27/2023. The interventions included anticipating and meeting the resident’s needs, making sure the call light was within reach and encouraging its use for assistance, encouraging the resident to participate in activities, responding promptly to all Resident 1’s requests for assistance, and provide a safe environment. A review of Resident 1’s Care Plan developed on 1/24/2023, for the resident’s high fall and injury risk, indicated as one of the goals to prevent falls and injury until next review 3/27/2023. Another goal was to manage Resident 1’s risk factors to minimize falls and injuries. The care plan interventions included using landing mats to both sides of the bed, keeping the bed in a low position, assisting with activities of daily living (ADLs, walking, personal hygiene, toilet use, transfer, and bathing), and check surfaces for sharp edges. A review of Resident 1' s SBAR (Situation, Background, Assessment, and Recommendation, a tool to aid in facilitating and strengthening communication between health care staff) Communication Form dated 2/1/2023, indicated that at 7:55 a.m. CNA 1 reported finding Resident 1 lying on the floor in front of the restroom when CNA 1 entered the room to serve breakfast to the resident. A review of Resident 1’s Post Fall Assessment, dated 2/1/2023, indicated that around 7:55 a.m., resident had redness and a bump on the back of the head and ice pack was applied. Resident 1’s attending physician was notified and gave an order to send the resident to a hospital for further evaluation. A review of Resident 1’s Care Plan for fall risk, dated 1/24/2023, indicated an added intervention, to keep bed in low position. A review of Resident 1’s Admission Record indicated the facility re-admitted the resident on 2/7/2023, with no other injuries from the fall. A review of Resident 1’s x-ray of the right hip, dated 2/16/2023, indicated normal hip with no evidence of fracture. A review of Resident 1’s SBAR Communication Form, on 2/20/2023, timed at 2:41 p.m., indicated the resident was found on the restroom floor at 2:40 p.m. accompanied by Family Member 1 (FM 1, her husband and roommate) and sustained a laceration (wound that is produced by the tearing of soft body tissue) on the back of the left arm and on the left elbow. The SBAR indicated FM 1 brought Resident 1 to the restroom without informing staff. Resident 1 was transferred to a hospital via emergency medical services (EMS or paramedics). Resident 1 returned the same day with no new injuries identified. A review of Resident 1’s Post Fall Assessment/IDT, dated 2/20/2023, indicated FM 1 brought Resident 1 to the restroom without informing staff. A review of Resident 1’s Care Plan for Actual Falls on 2/1/2023 and 2/20/2023, included as a new intervention to conduct a review of the resident’s medication regimen. A review of Resident 1’s SBAR Communication Form, dated 3/2/2023, indicated the resident was found lying on the floor on her back at 7:30 p.m. Resident 1 did not complain of pain and was able to move joints. Resident 1 could not recall what happened. The physician when notified ordered x-rays of spine (neck and chest areas), skull, both wrists, and both hips. A review of Resident 1’s Post Fall Assessment dated 3/2/2023, indicated that at 7:30 p.m., the resident was found in her room on the floor. Resident 1 stated she was trying to walk. A review of Resident 1’s X-rays results taken on 3/2/2023 with the results dated 3/5/2023, indicated the left hip had hardware (history of left hip fracture surgery) intact with no acute fracture. The right hip impression suggested a right acetabular fracture (a break in the socket portion of the "ball-and-socket" hip joint). This result was correlated to the X-ray dated 2/16/2023. The physician was notified of the X-ray results on 3/5/2023. A review of the Physician’s Order for Resident 1, dated 3/5/2023, indicated to do a CT scan of the hips. A review of Resident 1’s Care Plan developed on 1/24/2023 and revised on 3/7/2023, had the same goals and additional interventions were developed: the use of a bedside commode portable (toilet that look like a chair and have a bucket-like receptacle beneath it which can be removed for cleaning) and the use of sensor pad alarms (the alarm go off when the pressure is released as a result of the resident standing up or getting off the bed) while in bed and wheelchair to remind the resident not to stand up initiated on 3/7/2023. A review of Resident 1’s SBAR Communication Form, dated 3/8/2023, timed at 8:00 a.m., indicated the resident had been getting out of bed and assigned CNA 2 to monitor the resident all through the night. The SBAR indicated around 5:00 a.m. when CNA 2 was called to help another resident in another room, the chair alarm sounded and when CNA 2 ran back to the resident’s room, Resident 1 was on the floor. RN 1assessed Resident 1 and found no obvious injury. A review of Resident 1’s Post Fall Assessment/IDT, dated 3/8/2023, indicated the resident was seen sitting on the wheelchair, the alarm was heard, and Resident 1 was found sitting on the floor. A review of Resident 1’s SBAR Communication Form, on 3/16/2023, timed at 4:45 a.m., indicated FM 1 went to the Nursing Station requesting help with Resident 1. Licensed Vocational Nurse 1 (LVN 1) found the resident lying on the safety pad (also known as a landing mattress, a cushioned device placed by the bedside to protect from injury if the resident falls out of bed). LVN 2 and the RN supervisor assessed Resident 1 and a skin tear was identified on the right lateral arm. A review of Resident 1’s Post Fall Assessment/IDT, dated 3/16/2023, indicated the alarm was heard, the resident was on the landing pad, lying on her left side with right lateral arm side skin tear. Resident stated she was trying to use the bathroom/commode. A review of Resident 1’s Fall Care Plan interventions, dated 3/16/2023, indicated to anticipate the resident’s needs and offer fluids. A review of Resident 1’s PT Discharge Summary dated 3/16/2023 for PT sessions from 2/8/2023 to 3/16/2023 indicated the resident was returning to the ALF and PT recommended home health PT. A review of Resident 1’s nursing Progress Notes, dated 3/17/2023, indicated the resident was transferred to the ALF and the result of the CT scan of hips was not received. Resident 1’s attending physician was informed and approved the discharge. On 4/5/2023 at 1:35 p.m., during an interview, the Assistant Director of Nursing (DON) stated Resident 1 was non-compliant with calling for assistance before trying to walk alone. The ADON stated the facility could not provide Resident 1 with a 1:1 caregiver (a staff to be always with the resident) and it was discussed with FM 2, but FM 2 declined because it had to be paid out of pocket. On 4/5/2023 at 1:59 p.m., during an interview, the ADON stated he could not provide documentation the IDT met to conduct a root cause analysis for Resident 1’s repeated falls. The ADON stated Post Fall Assessments were conducted by the interdisciplinary team attended by him, the Director of Nursing, and the Rehab Director. The attending physician did not participate in the IDT teams. There was no documentation to indicate a scheduled toileting program was attempted. A review of the facility’s policy and procedures titled, “Fall Risk Assessment,” reviewed on 9/29/2022, indicated that upon admission, the nursing staff and the physician will review a resident’s record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. A review of the facility’s policy and procedures titled, “Fall Management,” reviewed on 9/29/2022, indicated if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the physician will help the staff reconsider possible causes that may not previously been identified. Staff would 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 A review of the facility’s policy and procedures titled, “Care Planning” dated 9/12/2019 indicated the comprehensive care plan must describe services that are furnished to maintain the resident’s highest practicable physical, mental, and psychological well-being. The resident’s goals for admission and desired outcomes. The planning process must facilitate the inclusion of the resident and/or resident representative. Include an assessment of the resident’s strengths and needs. The facility failed to provide Resident 1, who had history of falls before admission, and was confused, with the needed supervision and assistance to prevent further falls and injuries. The facility failed to ensure: 1. Resident 1’s fall risk care plan interventions were evaluated (reviewed and revised) for effectiveness and failed to identify and develop new interventions based on the individual needs of the resident such as toileting. 2. The IDT including the attending physician, met to identify causative factors for Resident 1’s repeated incidents of falls while attempting to use the bathroom. As a result, Resident 1 fell a total of five times from admission on 12/27/2023 to discharge dated 3/17/2023 while attempting to go to the restroom., After the 4th fall on 3/2/2023, an X-ray of the right hip was taken the same day, with the result dated 3/5/2023, indicated Resident 1 sustained a right hip fracture. On 3/5/2023, the physician ordered a CT scan which was done 3/16/2023 and the result received on 3/20/2023 confirmed the 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 to Resident 1.