Other·May 3, 2024

§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. §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 22 CCR § 72311. 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: (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(a) Patient Care Policies and Procedure. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 3/8/2024, the California Department of Public Health (CDPH) received a complaint alleging Resident 1 had a fall at a Skilled Nursing Facility (SNF) which resulted in Resident 1 requiring hospitalization in the general acute care hospital (GACH) Intensive Care Unit ([ICU] an area in the hospital which handles severe, potentially life-threatening cases) due to the injuries sustained from the fall. On 3/13/2024, CDPH conducted an unannounced visit to the facility to investigate the allegations. Upon investigation, the CDPH determined the facility failed to ensure that Residents 1, who was assessed as a high risk for falls, had measures implemented to prevent falls and injuries. The facility failed to: 1. Ensure Resident 1 was provided with a landing mats ([floor mats] a high-impact foam pads which are placed adjacent to the bed on the floor to help reduce the impact of falls and help prevent injury from potential falls and a bed alarm (device that signals staff when a resident is trying to get out of bed) as care plan to minimize an impact from a fall and prevent injury. Resident 1 had a history of falls on 10/24/2023 and 11/20/2023 and was assessed as a high fall risk. 2. Ensure the Licensed Vocational Nurse (LVN 1) had knowledge of the facility's fall protocol, Resident 1's assessment as a high risk for falls, how to access Resident 1's care plans for falls, and to implement Resident 1's care plan for falls to safeguard Resident 1 from falls and injuries. 3. Ensure a Certified Nurse Assistant (CNA 2) had knowledge of Resident 1's high risk for falls or what interventions to implement if a resident is a high fall risk. 4. Follow the facility's policy and procedure (P&P) titled, "Fall Management System," by implementing Resident 1's care plan interventions who was identified as high fall risks. These failures resulted in Resident 1 fall from the bed to the floor on 3/4/2024 and having an altered level of consciousness ([ALOC] a change in a person's state of awareness [ability to relate to self and the environment] and arousal [alertness]) on 3/5/2024. Resident 1 was transferred to a GACH on 3/5/2024 and subsequently admitted to the ICU with diagnoses including head trauma (any injury to the scalp, skull, or brain caused by injury), abrasions (a superficial rub or wearing off of the skin) to the right forehead, intracranial (within the skull) hemorrhage (bleeding) with thick subdural hematoma ([SDH] a collection of blood between the covering of the brain and the surface of the brain which develops after an injury to the head) over the right cerebral hemisphere (the part of the brain that controls muscle functions and also controls speech, thought, emotions, reading, writing, and learning) secondary to fall. Resident 1 required immediate endotracheal ([ET] placed within the trachea [windpipe]) intubation (a medical procedure in which a tube is placed into the windpipe through the mouth or nose to assist breathing), emergent right temporal (area of the brain located behind the ears) parietal (area of the brain at the top rear of the head) craniotomy (a medical procedure in which a piece of bone from the skull is removed to access the brain for surgical repair) and subdural hematoma evacuation (a surgical procedure which is done to remove a pooling of blood in the brain) with subdural drainage placement due to a high probability of clinically significant, life-threatening deterioration. While in the ICU, Resident 1 later required a tracheostomy (a surgically created hole in the windpipe which provides an alternative airway for breathing) due to a total dependence on ventilator (a machine used to help a person breathe when they can no longer breathe on their own) for breathing and gastrostomy tube ([GT] a tube which is inserted through the wall of the abdomen directly into the stomach which is used to give medications, fluid, and liquid food to a patient) for nutrition and medication administration. A review of Resident 1 Admission Record indicated Resident 1, a 69-year-old male, was originally admitted to the facility on 11/24/2020 and readmitted to the facility on 1/13/2024 with diagnoses including epilepsy (a disorder of the brain characterized by repeat seizures, lack of coordination (not able to move different parts of the body together with intention), need for assistance with personal care, unspecified dementia (the impaired ability to remember, think, or make decisions which interfere with doing everyday activities), and hemiplegia (total or partial loss of the ability to move one side of the body) affecting the left nondominant (part of the body which is not used as much) side. A review of Resident 1's History and Physical (H&P), dated 1/16/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS]- a standardized assessment and care screening tool) dated 1/17/2024, indicated Resident 1's cognitive (a person's ability to think, learn, remember, use judgement, and make decisions skills for daily living) skills for daily decision making were severely impaired. The MDS indicated Resident 1 was totally dependent on staff for eating, personal hygiene, toileting, bathing, upper and lower body dressing and rolling left to right in bed. A review of Resident 1's Fall Risk Evaluation, dated 6/17/2023, indicated Resident 1 was assessed as a high fall risk. A review of Resident 1's untitled Care Plan, initiated on 6/17/2023, indicated Resident 1 was identified to be at risk for falls related to left sided weakness, unsteady gait (manner of walking) /balance, generalized muscle weakness, and hypertension (high blood pressure). The care plan goal indicated Resident 1 would be free of falls through review date of 3/8/2024. The care plan interventions for Resident 1 included placing landing mats at bedside. A review of Resident 1's Fall Risk Evaluation dated 10/24/2023 and timed at 9:52 p.m., indicated Resident 1 was assessed as a high fall risk after sustaining a fall from the bed to the floor on 10/24/2023. A review of Resident 1's Fall Risk Evaluation dated 11/20/2023, indicated Resident 1 was assessed as a high fall risk after sustaining a second fall from the bed to the floor on 11/20/2023. A review of Resident 1's untitled care plan dated 11/22/2023, indicated Resident 1 utilizes bed and wheelchair alarms to alert staff when he gets up unassisted. The care plan goal indicated Resident 1 will remain free of complications related to alarm-use through review date of 3/8/2024. The care plan interventions included to apply a sensor pad (a weight sensitive alarm device) as ordered. A review of Resident 1's quarterly Fall Risk Evaluation dated 12/14/2023, indicated Resident 1 was assessed as a high fall risk. A review of Resident 1's Readmission Note dated 1/19/2024 and timed at 10:30 p.m., indicated Resident 1 was readmitted from a GACH where he had been transferred to on 1/17/2024 due to syncope (fainting or passing out) during hemodialysis (a mechanical procedure to remove waste products and excess fluid from the blood when the kidneys [a pair of organs which remove waste and extra water from the blood and keep chemicals balanced in the body] stop working). A review of Resident 1's readmission Fall Risk Evaluation dated 1/13/2024, indicated Resident 1 was assessed as a high fall risk. A review of Resident 1's Change of Condition ([COC] a document indicating a sudden deterioration or improvement in a resident's physical or behavioral health which may require a modification in the resident's treatment) dated 3/4/2024 and timed at 8:09 p.m., indicated Resident 1 had an unwitnessed fall from the bed to the floor. The COC indicated Resident 1 sustained redness to the right side of his forehead. The COC indicated to initiate neurological checks (identifying and assessing the functions of the vital portions of the system that transmit signals between the brain and the rest of the body and controls the ability to move, breathe, think, and see) for 72 hours. A review of Resident 1's COC dated 3/5/2024 and timed at 2:34 a.m., indicated Resident 1 was vomiting and had ALOC. The COC indicated Resident 1 was awake and alert but unable to maintain eye contact or verbalize his needs. A review of Resident 1's Incident Report (a documentation tool used by emergency medical responders ([EMRs] provide immediate lifesaving care to critical patients who are not in the hospital) to record patient data when arriving on the scene) dated 3/5/2024, indicated Emergency Medical Services ([EMS] a system which provides emergency medical care) were called to the SNF. The Incident Report indicated Resident 1's level of consciousness (being awake and aware of surroundings) was an 11 based on the Glasgow Coma Scale ([GCS] clinical scale used to objectively describe the extent of impaired consciousness in all types of acute [sudden]medical and trauma patients which is scored between 3 and 15, with 3 being the worst and 15 the best). The Incident Report indicated Resident 1 was found with an abrasion to the right temple area. On 3/5/2024, Resident 1 was subsequently transported to a GACH due to ALOC and traumatic injury (physical injuries of sudden onset and severity which require immediate medical attention). A review of Resident 1's GACH Admission Record indicated Resident 1 was admitted to the GACH on 3/5/2024 under trauma services (a hospital equipped and staffed to provide care for patients suffering from major traumatic injuries such as falls, motor vehicle collisions, or gunshot wounds). A review of Resident 1's GACH Trauma/Resuscitation Flowsheet dated 3/5/2024 and timed at 3:31 a.m., indicated Resident 1 had an abrasion and a hematoma to the right forehead. A review of Resident 1's Physician's Emergency Documentation dated 3/5/2024 and timed at 3:42 a.m., indicated Resident 1 was brought in by EMS from the SNF after an unwitnessed fall with evidence of head trauma and a trauma alert was activated. The Physician's Emergency Documentation indicated Resident 1 normally had a GCS of 13 and presented to the GACH with a GCS of 11. The Physician's Emergency Documentation indicated Resident 1 presented in critical condition, with concern for acute decompensation (failure of an organ) and possible cardiopulmonary arrest (sudden, unexpected loss of heart function, breathing and consciousness). A review of Resident 1's Computed Tomography (CT) scan dated 3/5/2024 and timed at 4:04 a.m., indicated Resident 1 had a 1.7 centimeter (cm) thick acute subdural hematoma over the right cerebral hemisphere and a 1.1 cm midline shift (when the natural centerline of the brain is pushed to the to the right or left following traumatic brain injury associated with a hematoma) from right to left. A review of Resident 1's GACH Neurosurgery Operative and Procedural Report dated 3/5/2024 and timed at 8 a.m., indicated Resident 1 underwent a right sided frontotemporal (the areas behind the forehead and behind the ears) craniotomy for evacuation of acute subdural hematoma and resection (surgery to remove tissue or part or all an organ) of membranes (layer which protect the brain), and externalized drain placement (tube which drains excess fluid or blood from the brain and stops the fluid building up). The Neurosurgery Operative and Procedural Report indicated Resident 1 was then transferred to the ICU post-operatively (the period following a surgical [a procedure to remove or repair a part of the body] operation). A review of Resident 1's GACH Operative and Procedure Report dated 3/13/2024 and timed at 1:16 p.m., indicated Resident 1 underwent a GT insertion due to oropharyngeal (the middle part of the throat behind the mouth) dysphagia (difficulty swallowing) and tracheostomy due to acute respiratory failure (not enough oxygen in the body to sustain life) requiring long term mechanical ventilation (a machine which takes over the work of breathing when a person is not able to breathe enough on their own). During an interview on 3/14/2024 at 4:37 p.m., Registered Nurse (RN 1) stated that on 3/4/2024, LVN 1 informed her of Resident 1's fall from the bed to the floor. RN 1 stated when she went to assess Resident 1 after the fall, there were no landing mats noted on the floor. RN 1 stated because of Resident 1's high risk for falls with a history of previous falls, there should have been landing mats on the floor to prevent or lessened the injury from the fall. During an interview on 3/14/2024 at 5:34 p.m., LVN 1 stated she was assigned to Resident 1 on 3/4/2024. LVN 1 stated at around 8 p.m., CNA 1 informed her of Resident 1's fall from the bed to the floor. LVN 1 stated upon arrival to Resident 1's room, she found Resident 1 on the floor. LVN 1 stated Resident 1 was on the bare floor and there were no landing pads underneath him, nor were there any activated bed alarm alerts. LVN 1 stated she was not aware of Resident 1's care plan and interventions which included bed alarm, and landing (floor) mats. LVN 1 stated it was her second day working on the unit and was not aware on how to access residents' care plans. LVN 1 stated she was not aware that Resident 1 was a high risk for falls because the outgoing nurse did not report it to her during shift report, and it was not mentioned during the huddle at the beginning of the shift. LVN 1 stated she was not aware of what interventions should be implemented for residents who are a high fall risk. LVN 1 stated she should have looked at Resident 1's care plan prior to assuming care of Resident 1 since she was not familiar with the resident. LVN 1 stated the purpose of a care plan is to prevent accidents and incidents from occurring or reoccurring. LVN 1 stated she does not know what the facility's protocol for falls and fall prevention are. During an interview on 3/14/2024 at 6:22 p.m., CNA 1 stated on 3/4/2024 at around 8 p.m., she was walking by Resident 1's room and saw Resident 1 laying on the bare floor. CNA 1 stated she did not see any landing mats underneath Resident 1, nor did she hear a bed alarm sound. During an interview on 3/15/2024 at 11:45 a.m., Resident 1's Responsible Party (RP) 1 stated on 3/4/2024 at approximately 8:52 p.m., she received a call from the SNF indicating Resident 1 had an unwitnessed fall from the bed to the floor. RP 1 stated in the early morning of 3/5/2024 she received a second call from the SNF indicating Resident 1 vomited and had ALOC which required the resident's transfer to the GACH. RP 1 stated this was Resident 1's third fall since 10/2023. RP 1 stated after Resident 1's second fall in 11/2023 she requested a bed alarm, landing mats, two siderails up, and bed bolsters (air filled raised pads placed at the edge of the bed to prevent residents from rolling out of the bed) implemented in Resident 1's care. RP 1 stated in 2/2024, when Family Member (FM) 2 went to visit Resident 1 in the fac