Health inspection·July 8, 2022

§ 72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require § 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 10/19/2021, the Department received a facility reported incident (FRI)alleging Resident A was admitted on 10/11/2021 with generalized body rash, scaly and crusty in appearance. Skin scrapping done and Resident A was positive for scabies (an infestation of the skin by the human itch mite). On 10/20/2021, an unannounced investigation was conducted at the facility to investigate Resident A’s diagnosis of scabies. The non-compliance unrelated to the original FRI allegation was identified related to Resident A fall on 10/13/2021 and death within six hours of the fall. The facility failed to: 1. Report Resident A’ death to the Licensing and Certification (L&C) State agency as an unusual occurrence in accordance with the facility’s policy and procedure (P/P) titled, "Unusual Occurrence Reporting." 2. Thoroughly investigate Resident A’s fall as per the facility’s P/P titled, "Falls by a Resident and Post Fall," to identify factors that contributed to the resident’s fall and to implement interventions to prevent repeated fall unless the fall was unavoidable. This deficient practice resulted in the L&C Department not being made aware of resident A’s unwitnessed fall with death within six hours after the fall as an injury of unknow origin and delaying the Department’s investigation regarding the resident’s fall and death. During a review of Resident A's Admission Record (AR), the AR indicated Resident A, a 69 year-old male, was admitted to the facility on 10/11/2021. Resident A had a diagnosis including but not limited dementia (progressive loss of memory). During a review of a Situation Background Assessment Recommendation ([SBAR] an internal communication form), dated 10/13/2021 and timed at 1:40 p.m., the SBAR indicated Resident A was found on the floor. The SBAR indicated at 1:30 p.m., the writer, Registered Nurse 1 (RN 1) was called to Resident A's room by a certified nursing assistant (CNA 1). The SBAR indicated Resident A's body was halfway on the floor with both legs on the bed. The SBAR indicated Resident A's trunk did not hit the floor. Resident A was able to move his upper and lower extremities with no difficulty or pain, there was no apparent injuries. The SBAR indicated Resident A's physician was called and an x-ray of the resident shoulders were ordered. During a review of Resident A's Licensed Nurses Progress (LNP) Note, dated 10/13/2021 and timed at 7:25 p.m., the LNP indicated Licensed Vocational Nurse 1 (LVN 1) and an x-ray technician went to Resident A's room and found the resident unresponsive and his vital signs were unappreciated (not recognized). During a telephone interview on 11/1/2021 at 1:05 p.m., LVN 1 stated he had never taken care of Resident A prior to the night of his death (10/13/2021) and did not know Resident A had fallen earlier that day. LVN 1 stated he was covering for another nurse (LVN 2) when the x-ray technician approached him saying he could not do Resident A's x-ray because the resident was on the floor. LVN 1 stated he asked the x-ray technician, "What do you mean?" and the x-ray technician replied, "The resident (Resident A) is not breathing." LVN 1 stated he and the x-ray technician went to Resident A's room and he (LVN 1) could tell immediately Resident A was dead because of the way he looked. LVN 1 stated Resident A was lying on his back, his mouth and eyes were open, his arms were down, his elbows were tucked with the forearms almost resting on his abdomen. LVN 1 stated he shook Resident A and got no response. LVN 1 stated he tried to get a pulse and respiration and there was none. LVN 1 stated Resident A was cold to touch and stiff, Resident A's extremities were not easily movable. LVN 1 stated Resident A was not totally in rigor mortis (stiffing of the joints and muscles of a body a few hours after death). During a telephone interview on 11/1/2021 at 2:05 p.m., the Director of Nursing (DON) stated the facility does not typically report the death of a resident when death was expected. The DON stated Resident A was refusing food, medication, and fluids and his condition was worsening. The DON stated Resident A had only been in the facility for two days and the DON stated the resident refusing care did not mean the resident's death was imminent (happening soon). During a review of the facility's policy and procedure (P/P) titled, "Unusual Occurrence Reporting," dated 2/2018, the P/P indicated it was the policy of the facility to report unusual occurrences or other reportable events which affect the health, safety or welfare of residents, employees, and/or visitors. According to the P/P, the facility would report the following events to the appropriate agency, including L&C State agency: death of a resident by suicide, homicide, or accidents. The P/P indicated unusual occurrences shall be reported via telephone to appropriate agencies within 24-hours of such incident. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the State agency (and other appropriate agencies) within forty-eight hours of reporting the event. During a review of the facility's investigation report of Resident A's fall, the report indicated there were only two staff statements, which did not include Resident A's charge nurse (LVN 2) nor did it include the circumstances surrounding the fall and the environment when Resident A was found. In addition, Resident A's death, six hours after falling, there was no investigation to determine his cause of death. During a review of the facility's policy and procedure (P/P) titled, "Falls by a Resident," dated 2/2017, the P/P indicated a post-fall assessment should be completed to identify factors that may have contributed to the fall. The purpose of a post-fall assessment was to identify possible causative factors that could have contributed to a fall. According to the P/P, the information was then used to formulate a plan of care to prevent further falls or accidents. During a review a facility's P/P titled, "Post Fall," dated 1/2017, the P/P indicated it was the facility's policy to assess and investigate resident falls to implement approaches to prevent repeated falls unless the falls are unavoidable. The facility failed: 1. Report Resident A’ death to the Licensing and Certification (L&C) State agency as an unusual occurrence in accordance with the facility’s policy and procedure (P/P) titled, "Unusual Occurrence Reporting." 2. Thoroughly investigate Resident A’s fall as per the facility’s P/P titled, "Falls by a Resident and Post Fall," to identify factors that contributed to the resident’s fall and to implement interventions to prevent repeated fall unless the fall was unavoidable. This deficient practice resulted in the L&C Department not being made aware of resident A’s unwitnessed fall with death within six hours after the fall as an injury of unknow origin and delaying the Department’s investigation regarding the resident’s fall and death. These violations had a direct or immediate relationship to the health, safety, or security for Resident A.