Health inspection·August 25, 2023

F726 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 72501 (e)Licensee-General Duties The licensee shall employ an adequate number of qualified personnel to carry out all the functions of the facility and shall provide for initial orientation of all new employees, a continuing in-service training program and competent supervision. 72533(a)(1)(E) Employee Personnel Records (a) Each facility shall maintain current complete and accurate personnel records for all employees (1) The record shall include (E) Information as to past employment and qualifications On 6/30/2023, the California Department of Public Health (CDPH) received a complaint regarding employee to resident abuse. On 7/11/2023, an unannounced visit was made to the facility to investigate the allegation of abuse. No deficient practice was identified as a result of investigation of alleged abuse. However, the investigation determined Resident 1 did not receive full active range of motion ([AROM] movement at a given joint when the person moves voluntarily) exercises to his upper extremities (upper arm, forearm, wrist, hand and fingers and thumb) and restorative nursing assistants ([RNA 1, 2 and 3] a nurse trained to provide rehabilitative care to individuals recovering from illnesses or injuries) did not provide training as prescribed by the physician, and did not have documentation indicating they were competent to conduct ROM exercises to the residents. The facility failed to: 1. Ensure Resident 1 was provided AROM exercises to his left and right upper extremities from 3/28/2022 through 7/11/2023. 2. Ensure RNAs had required skill to provide AROM to Resident 1's left and right upper extremities. 3. Ensure Resident 1 did not sustain a decline in ROM to the 1st, 3rd, 4th, and 5th fingers of his left hand. 4. Ensure the facility followed their policy and procedure (P/P), titled "Limitations in Range of Motion and Mobility and Referrals for Therapy," that stipulated residents who enter the facility without limited ROM does not experience a reduction in ROM. These failures resulted in Resident 1 developing a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, leading to deformity and rigidity of joints) to his left hand, pain upon movement of his left hand, and inability to fully straighten the 1st, 3rd, 4th, and 5th fingers of his left hand, and to use his left hand to complete activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting). A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on 2/12/2022 with diagnoses including cellulitis (bacterial infection of the skin) and chronic pain syndrome. A review of the facility's undated Resident Census (record of hospitalizations, room changes, and payer source changes), indicated Resident 1 resided in the facility from his admission on 2/12/2022 with no hospitalizations. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 2/12/2022, indicated Resident 1 was able to make independent decisions that were reasonable and consistent. The MDS indicated Resident 1 required extensive one-person physical assist for bed mobility, transfers, locomotion on the unit (how a resident moves between locations in his/her room and adjacent), dressing, toilet use and personal hygiene and limited one-person physical assist when bathing. The MDS indicated Resident 1 had no functional limitations in the ROM (the direction a joint can move to its full potential) to both of his arms. A review of the Resident 1's History and Physical (H&P), dated 2/9/2023, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Nursing Admission Assessment (NAA), dated 2/12/2022, indicated Resident 1's joints (part of the body where two or more bones meet to allow movement) were normal and did not present with contractures. A review of Resident 1's Physical Therapy Evaluation and Plan of Treatment (PTEPC) dated 2/14/2022 indicated Resident 1 did not present with contractures. A review of Resident 1's undated Restorative Orders (RNO) indicated Resident 1 to receive AROM to both his upper extremities, every day, five times a week or as tolerated beginning 3/23/2022. A review of Resident 1's Occupational Discharge Summary Evaluation (ODSE), dated 3/26/2022, indicated the restorative nursing program's (RNP) goal was to facilitate Resident 1 to maintain his current level of function and prevent decline. A review of Resident 1's Physician's Telephone Order (PTO) dated 7/27/2022 indicated Resident 1 was to receive AROM to his bilateral (both) upper extremities (BUE) every day, five times a week or as tolerated, by the RNA. During an observation on 7/11/2023, at 3:10 p.m., Resident 1 was observed in bed with his left hand closed in a fist. During an interview on 7/11/2023, at 3:10 p.m., Resident 1 stated he was currently bedridden (weak and unable to get out of bed) and needed help to get dressed and to pick up items because he could not straighten his fingers (1st, 3rd, 4th, and 5th fingers) or grasp things with his left hand. Resident 1 stated, when he was admitted to the facility in 2022, he did not have any problems with his left hand but sometime last year (2022) he could no longer straighten his fingers on his left hand without using his right hand to straighten his fingers. Resident 1 stated, he felt frustrated because he could not use his left hand anymore like he used to. Resident 1 stated it was painful whenever he tried to straighten the fingers in his left hand and the staff did not help him exercise his hands. During a concurrent observation and interview on 7/12/2023, at 12 p.m., with Resident 1, in the facility's dining room, Resident 1's left hand was observed resting on top of the dining room table. The fingers on Resident 1's left hand could not be seen because Resident 1's hand was in a fist; Resident 1 was observed using only his right hand to eat. Resident 1 stated, he eats slower because he could only use his right hand and was unable to use his left hand to grasp the utensils, steady his plate or assist in anyway. A review of Resident 1's MDS, dated 5/17/2023, indicated Resident 1's functional limitation in ROM was "0" (indicating no decline) for his upper extremities. A review of Resident 1's Occupational Therapist Evaluation and Plan of Treatment (OTEPT), dated 7/12/2023, indicated Resident 1 had a left-hand contracture. The OTEPT indicated Resident 1's ROM assessment of his left upper extremity indicated his left hand was impaired (moderate flexion [bent joint, cannot be straightened] with a contracture at the proximal interphalangeal ([PIP] finger joint) at the joints of his 3rd, 4th, and 5th fingers of his left hand and with a mild flexion contracture at PIP joint of the 1st finger of his left hand. A review of Resident 1's SBAR ([Situation Background Assessment Recommendation] a form of communication between members of a health care team, created after the concern was brought to the attention of the facility), dated 7/12/2023, indicated Resident 1's left hand could not fully flex ([contract] to shorten, become reduced in size) and extend (to straighten out). The SBAR indicated Resident 1 was unable to grasp objects easily with his left hand and experienced pain upon exercising his left hand. The SBAR indicated Resident 1's physician was notified and an order for Hydrocodone -Acetaminophen (a narcotic [a drug or other substance that affects mood or behavior] used to relieve moderate to severe pain) 10-325 milligrams ([mg] a unit of measurement), by mouth once a day 30 minutes prior to RNA exercises was obtained. A review of Resident 1's Restorative Nursing Weekly Summaries (RNWS) indicated there was no documentation to show Resident 1 received ROM therapy to his right and left hands, including his fingers, from 3/28/2023 through 7/11/2023. A review of Resident 1's Joint Mobility Screening (JMS) indicated Resident 1's last screening was completed on 5/18/2022. A review of Resident 1's Rehabilitation Screening Form (RSF) indicated Resident 1's last screening was completed on 8/26/2022. During an interview on 7/13/2023, at 9 a.m., the Director of Staff Development (DSD) stated, the RNA program falls under the direction of the nursing department. The DSD stated she and the Director of Nursing (DON) were responsible for RNA skills training and ensuring RNA staff competencies were completed through a competency checklist. The DSD stated, the therapy department provides additional training to RNAs, but the facility does not maintain records of the RNAs competencies. During an interview on 7/13/2023, at 9:35 a.m., RNA 2 stated, she does not perform ROM exercises on any residents' hands unless there was a specific order from the doctor to do so or the residents had a splint (an appliance made of different materials for the fixation [the action of making something firm or stable], union or protection of an injured part of the body). RNA 2 stated, Resident 1 had orders for AROM to his BUEs but "that did not include his hands." During an interview on 7/13/2023, at 9:57 a.m., RNA 1 stated, AROM exercises to the upper extremities meant for them (RNAs) to direct and observe the resident while they (the residents) exercised their shoulders, elbows, and forearms independently. RNA 1 stated, AROM does not include hands exercise, unless there was an order specifically to exercises the hands. RNA 1 stated, if there was a change in residents' ROM, they (RNAs) were instructed to inform the charge nurse and staff in the therapy department. During a concurrent record review and interview, on 7/13/2023 at 10:30 a.m., with the DSD, a Certified Nursing Assistant Skills, and Competency Validation (CV) for RNA 1, dated 9/1/2015, RNA 2, dated 7/22/2021, and RNA 3, dated 7/29/2019 were reviewed. The DSD stated, the skills list did not indicate ROM exercises were completed by the RNA 1, 2, and 3 or that RNA 1, 2 and 3 were competent in performing ROM exercises. The DSD stated not ensuring RNAs were competent in ROM skills could result in residents not receiving the proper ROM exercises which could cause a decline in function. During a concurrent record review and interview on 7/14/2023, at 11:46 a.m., with the Physical Therapy Regional Director (PTRD), Resident 1's Restorative Nursing Program Referral Care Plan (RNP-CP), dated 3/23/2022 was reviewed. The PTRD stated, the RNA-CP indicated Resident 1 was discharged from physical and occupational therapy on 3/23/2022 and was at risk for weakness to his BUEs. The PTRD stated the RNP-CP's goal was for Resident 1 to maintain ROM and strength to all of his extremities and orders on the RNP-CP indicated that Resident 1 was to receive AROM exercises to his BUEs, daily, five times per week or as tolerated. The PTRD stated AROM means Resident 1 would perform ROM exercises independently without physical assistance from the RNA, but the RNA would direct and observe Resident 1 for any pain, discomfort, or limitations as he (Resident 1) performed the ROM exercises. The PTRD stated, BUEs are defined as shoulders, arms, elbows, wrists, hands, and all fingers to both left and right side of the body. The PTRD stated, if AROM exercises were not performed as ordered, the RNAs might not observe a decline in the resident's function and the resident would be at risk for a decline in their ROM. During an interview on 7/14/2023, at 1:30 p.m., RNA 3 stated, during AROM exercises to resident's upper extremities he directs and observes as they (the resident) exercise their shoulders, elbows, and forearms. RNA 3 stated, AROM of the upper extremities does not include hands and fingers, unless there was an order from the physician that indicated to exercise the resident's hands and fingers. RNA 3 stated he received training from RNA 1 and sometimes a physical therapist would train him during resident hand off (when a resident is discharged from physical and/or occupational therapy and received by the RNP). During a concurrent record review and interview on 7/14/2023, at 4 p.m., with the Registered Occupational Therapist (ROT), Resident 1's Occupational Therapy Evaluation and Plan of Treatment (OTEPT), dated 2/14/2022, was reviewed. The ROT stated Resident 1's OTEPT indicated Resident 1's left hand's ROM was within functional limits ([WFL] within what is considered normal movement for that joint), meaning Resident 1 was able to use his left hand to pick up items and accomplish daily tasks at that time. The ROT stated, Resident 1's current OTEPT, dated 7/12/2023, indicated a moderate contracture (26-50% loss in ROM) to his 3rd, 4th, 5th PIP joint and a mild flexion contracture at his 1st finger PIP joint. The ROT stated, she was the therapist who performed Resident 1's OT evaluation on 7/12/2023 and Resident 1 could not straighten the fingers (1st, 3rd, 4th, and 5th fingers) on his left hand which demonstrated a decline in Resident 1's ROM in comparison to the OT evaluation conducted on 7/14/2022. A review of the facility's job description (JD) for RNAs, dated 11/2014, indicated the RNA is delegated the administrative authority, responsibility, and accountability necessary for carrying out assigned duties. The RNAs JD included following general duties and responsibilities, recording on flow sheets, notes and charts when applicable, reporting significant changes in the resident's condition to the licensed vocational nurse (LVN)/registered nurse (RN) as soon as practical, providing range of motion and general strengthening exercises, documenting daily and weekly on residents in the restorative program, reports, charts, and communicates to occupation therapy any observed problems or any changes in the residents condition, motivation level, mobility level and resident complaints of pain. A review of the facility's P/P titled, "Limitations in R