Health inspection·March 24, 2021

F684 § 483.25 Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. § 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. The Department received a facility reported incident (FRI) on 9/30/19 indicating a resident (Resident 1) was attempting to self-transfer and slid from her wheelchair, landing on her right side. Resident 1 verbalized right arm pain and received pain management. An x-ray revealed an oblique fracture (broken bone) of the right proximal humeral diaphysis (shoulder). On 10/10/19 an unannounced investigation was conducted at the facility. The facility failed to: 1. Develop a resident-centered comprehensive care plan with documented staff interventions to prevent falls for Resident 1 who was at high risk for falls, in accordance with the facility’s policy and procedure (P/P). 2. Adhere to the facility’s P/P for baseline care plans, which indicated the resident's immediate care needs would be met and maintained. As a result, Resident 1, who was admitted to the facility for rehabilitation status post ([s/p] after) fall and kyphoplasty (a medical procedure to stabilize and reduce pain associated with a spinal compression fracture), had a fall 16 days after admission, sustained a shoulder fracture, and required a transfer to a general acute care hospital (GACH). During a review of Resident 1's Admission Face Sheet dated 9/11/19, the Face Sheet indicated Resident 1, a 93-year-old female, was admitted to the facility on 9/11/19. Resident 1's diagnoses included fractures of the lower and middle back spine, abnormalities of gait (walk) and mobility (the ability to move or be moved freely and easily), age-related osteoporosis (disorder characterized by low bone mass [brittle bones]), and spinal stenosis (narrowed spine). During a review of Resident 1's Fall Risk Observation/Assessment dated 9/11/19, the assessment indicated Resident 1 was at high risk for falls. During a review of Resident 1's Admission/Readmission Assessment dated 9/11/19, the assessment indicated Resident 1 was admitted s/p fall with fractures and kyphoplasty. Resident 1's assessment was incomplete and did not include documented staff interventions for Resident 1's ambulation, transferring, and activities of daily living ([ADLs] everyday activities such as grooming, eating, and toileting.). During a review of Resident 1's Baseline Care Plan Person-Centered Care Planning, dated 9/11/19, the care plan indicated Resident 1 was at risk for falls due to history of falls. The goal was to manage the resident's pain after laminectomy surgery (a surgical removal of the bony arch of the spine which covers the nerve). The plan of care did not have any documented staff interventions to prevent Resident 1 from further falls. During a review of Resident 1's untimed Nursing Progress Note (NPN) dated 9/11/19, the NPN indicated Resident 1 used a wheelchair for mobility. During a review of Resident 1's History and Physical (H/P) dated 9/12/19, the H/P indicated Resident 1 was admitted to the facility following a fall with fractures. The H/P physical examination indicated Resident 1 was elderly and frail (weak), had resting tremors (shakiness) and generalized weakness. The H/P indicated Resident 1's diagnoses included fracture and spinal stenosis. During a review of Resident 1's Physical Therapy ([PT] treatment used to restore normal physical functioning) Progress Reports, dated from 9/12/19 to 9/18/19, the PT progress notes indicated Resident 1 had a fall risk and had spinal precautions (efforts to prevent movement of the spine in those with a risk of a spine injury). The PT reports indicated Resident 1 was receiving therapy due to a recent fall and was status post hospitalization and kyphoplasty. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/18/19, the MDS indicated Resident 1 had the ability to understand others. The MDS indicated Resident 1 required extensive one-person physical assist with transferring between surfaces. The MDS indicated Resident 1 was not steady when moving from a seated to standing position, walking, and turning around, and could only stabilize with assistance. The MDS indicated Resident 1 had a fall within the last month and within the last two to six months prior to her admission to the facility. According to the MDS, Resident 1 had a fracture related to her fall in the last six months and was receiving opioid medications (narcotic medication used to treat pain) seven days a week. During a review of Resident 1's Physician's Progress Record dated 9/19/19, the physician progress record indicated Resident 1 had mild confusion. The record indicated Resident 1 had a fracture and generalized weakness. During a review of Resident 1's Nursing Progress Note (NPN) dated 9/27/19 and timed at 10:15 a.m., the NPN indicated Resident 1 had a fall, was unable to move her right arm, and complained of pain. The NPN indicated Resident 1's x-ray showed a right humeral surgical neck (shoulder bone) fracture. During a review of Resident 1's Physician's Order dated 9/27/19, the physician's order indicated Resident 1 had orders to be transferred to a GACH for evaluation of the right arm fracture. During a review of NPN dated 9/27/19 and timed at 6:50 p.m., the NPN indicated Resident 1 was transferred to the GACH for further evaluation of her right arm fracture. During a review of Resident 1's GACH Emergency Department (ED) note dated 9/27/19, the ED note indicated Resident 1 complained of pain in the right upper arm. The ED note indicated Resident 1 reported she slipped and fell out of her wheelchair and hit her right shoulder during the fall. The ED note indicated Resident 1's x-ray revealed a right humeral surgical neck fracture and Resident 1 was discharged with a right shoulder immobilizer (medical device used to immobilize for healing). During a review of Resident 1's Licensed Nurse Report dated 9/30/19, titled "Following a Fall," the report indicated Resident 1 had a fractured arm and osteoporosis, and was forgetful at times. The report indicated Resident 1's fall was attributed to the following: wheelchair brakes not being locked, history of one to two falls within the last six months, and an unsteady gait. According to the report, as a result of the fall with a fracture, Resident 1 had reduced or loss of use in arms with a decline in function. During an interview on 10/10/19 at 4:05 p.m., Resident 1 stated she had a fall before she was admitted to the facility and had broken several bones. Resident 1 stated she had a fall in the facility and broke her arm because the wheelchair brakes were not locked. During an interview on 10/10/19 at 4:35 p.m., Certified Nurse Assistant 1 (CNA 1) stated Resident 1 can no longer participate in her care as she did prior to the fall incident on 9/27/19. During an interview on 1/23/2020 at 7:45 a.m., Housekeeper 1 stated on 9/27/19, she entered Resident 1's room to clean and saw Resident 1 sitting in the wheelchair. Housekeeping 1 stated she walked out of the room to grab her cleaning supplies and heard a noise and saw Resident 1 sitting on the floor. During an interview on 1/23/2020 at 8:15 a.m., CNA 2 stated the brakes on Resident 1's wheelchair had to be locked to prevent the resident from falling. CNA 2 stated she locked Resident 1's wheelchair ten minutes prior to the fall. CNA 2 stated on 9/27/19, when she arrived in Resident 1's room the resident was on the floor. CNA 2 stated she thought Resident 1 fell trying to go back to bed on her own. CNA 2 stated Resident 1 required one-person assistance with all her ADLs before she fell but now requires two-person physical assist with her ADLs because she has an arm immobilizer. During an interview and concurrent review of Resident 1’s care plans on 1/23/2020 at 8:28 a.m., Licensed Vocational Nurse 1 (LVN 1) stated residents were assessed for fall risk upon admission and interventions were tailored to each resident's needs. LVN 1 stated the facility developed a care plan upon admission for Resident 1’s fall risk because residents who had a history of falls were at greater risk for falls. LVN 1 stated she was called to assess Resident 1 after she fell. LVN 1 stated when she entered Resident 1's room, Resident 1 was sitting on the floor holding her right arm and complaining of pain. LVN 1 stated Resident 1 told her she fell when she tried to move, and that the wheelchair moved with her because the wheels were not locked. LVN 1 stated she noticed something was wrong with Resident 1's right arm. LVN 1 stated Resident 1's x-ray showed a fracture of the right arm and the resident was transferred to a GACH. LVN 1 stated Resident 1 returned from the GACH with orders for an arm immobilizer with limited right arm movement. LVN 1 reviewed the Fall Risk Observation/Assessment dated 9/11/19 and stated Resident 1 had a score of 22 on the fall risk assessment, which indicated the resident was at high risk for falls. During an interview and concurrent review of Resident 1's care plans with LVN 2 on 1/23/2020 at 9:50 a.m., she stated Resident 1 should have had a plan of care with staff interventions to prevent falls. LVN 2 was unable to find any documentation of staff interventions to prevent Resident 1 from falling prior to the resident’s fall on 9/27/19. LVN 2 stated the comprehensive care plan was developed within 14 to 21 days from admission. LVN 2 reviewed Resident 1's care plan dated 9/27/19 that indicated the resident had a fall. The care plan interventions indicated to continue the interventions on the at-risk care plan, but LVN 2 stated she was unable to find an "At Risk for Fall" care plan with staff interventions for Resident 1. During an interview and concurrent review of Resident 1’ care plans on 1/23/2020 at 10:22 a.m., LVN 1 stated Resident 1's baseline care plan dated 9/11/19 identified Resident 1 was at risk for falls after laminectomy surgery. LVN 1 stated she was unable to find any documentation of staff interventions to prevent Resident 1 from falling. LVN 1 stated it was important to develop staff interventions for Resident 1 to prevent her from falling. During a subsequent interview and review of Resident 1's care plans on 1/23/2020 at 10:50 a.m., the Director of Nurses (DON) stated Resident 1 was at risk for falls but there was no care plan with staff's interventions documented to prevent falls prior to 9/27/19. During a review of the facility's P/P, revised in 12/2016 and titled "Care Plans, Comprehensive Person-Centered," the P/P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs would be developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident, would develop and implement a comprehensive person-centered care plan for each resident. The care plan process would include an assessment of the residents' strengths and needs. The comprehensive person-centered care plan would include measurable objectives and timeframes, describe services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being, incorporate identified problem areas, incorporate risk factors associated with identified problems, and aid in preventing or reducing decline in the resident's functional status and/or functional levels. During a review of the facility's P/P, revised in 12/2016 and titled "Care Plans-Baseline," the P/P indicated a baseline plan of care would meet the residents' immediate needs. The policy interpretation and implementation indicated the care plan would assure that the resident's immediate care needs were met and maintained. The IDT team would review the health care practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs. The comprehensive, person-centered care plan would be developed within seven days of the completion of the required comprehensive assessment (MDS). The facility failed to: 1. Develop a resident-centered comprehensive care plan with documented staff interventions to prevent falls for Resident 1 who was at high risk for falls, in accordance with the facility’s policy and procedure (P/P). 2. Adhere to the facility’s P/P for baseline care plans, which indicated the resident's immediate care needs would be met and maintained. As a result, Resident 1, who was admitted to the facility for rehabilitation status post fall and kyphoplasty, had a fall 16 days after admission, sustained a shoulder fracture, and required a transfer to a general acute care hospital (GACH). These violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result.