Health inspection·September 6, 2024

T22 § 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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. F689 Free of Accident Hazards/Supervision/Devices §483.25(d) Accidents. The facility must ensure that (1) The Patient environment remains as free of accident hazards as is possible; and (2) Each Patient receives adequate supervision and assistance devices to prevent accidents. On 7/23/2024 at 8:30AM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to conduct an annual recertification survey. As a result of the investigation, CDPH determined that the facility failed to ensure Patient 1 with history of falls was provided supervision, monitoring and assistance as indicated on the resident’s care plan (a document that outlines the facility’s plan to provide personalized care to a resident based on the resident’s needs) of high risk for falls and facility’s policy and procedure to prevent recurrent falls. The facility failed to: 1. Ensure Patient 1’s room was well lit and had adequate lighting and not kept dark, in accordance with the resident's care plan dated 6/8/2024, to prevent hazards and accidents. 2. Ensure Patient 1’s care plan addressed high-risk factors identified on the patient’s Fall Risk Evaluation dated 6/8/2024 to ensure an individualized care plan is developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the elements of the evaluation that put the patient at risk. 3. Implement IDT’s (Interdisciplinary Team, a team of staff that review and develop the patient's plan of care) recommendation and resident's care plan on 6/25/2024, to place Patient 1 on a Bowel and Bladder Schedule by offering the resident toilet use upon rising (the act of getting out of bed in the morning, or at some other time during the day) at mealtimes, at bedtimes and as needed. As a result, after the first fall in the facility on 6/25/2024, on 7/6/2024 at 4:20 AM, Patient 1 fell again on the floor with complaint of the right hip pain after the fall. An Xray (medical procedure that generate images of tissues and structures inside the body) was performed which revealed a right hip fracture. Patient 1 was transferred to General Acute Care Hospital (GACH)’s Emergency Department (ED) on 7/6/2024 at 10:33 PM (18 hours after the resident fell on 7/6/2024 at 4:20 AM) for further treatment and evaluation for severe, constant right hip pain. On 7/8/2024, Patient 1 had hemiarthroplasty (a surgical procedure that replaces only the ball portion of the hip joint, not the socket portion) right hip due to right femoral neck fracture (broken bone of the thigh bone near the hip joint). A review of Patient 1’s Admission Record, indicated Patient 1 was an 87 years old, female admitted to the facility on 6/8/2024 and readmitted on 7/11/2024 with diagnosis that included dementia (the loss of memory and impaired cognition [thinking, remembering, and reasoning] to such an extent that it interferes with a person's daily life and activities), right femur (thigh bone) fracture (broken bone), muscle weakness, abnormality of gait (a manner of walking) and mobility (ability to move freely), osteoporosis (a condition that causes bones to become weak and lose their strength, making them break more easily than normal bones), history of fall, fractures of lower end of right radius (one of two major bones in the forearm from the elbow to the wrist), fracture of right pubis (broken bones between the abdomen and thighs). A review of Patient 1’s “Fall Risk Evaluation,” dated 6/8/2024, indicated Patient 1 was high risk for fall due to “history of one (1) to two (2) falls in the past 3 months, and was regularly incontinent (no control of bladder to urinate and bowel to have bowel movement), and had balance problem. A review of Patient 1’s “Care Plan,” dated 6/8/2024, indicated Patient 1 was at risk for falls related to post (after) fall at home on 6/5/2024. The Care Plan indicated to ensure Patient 1 was free from falls and serious injury, the facility will anticipate the patient’s needs, by providing a safe environment with adequate lighting, and will keep personal items within reach. The interventions indicated the facility will review information about Patient 1’s past falls and will attempt to determine cause of falls, record possible root causes, and alter/remove any potential causes of fall if possible. The care plan did not address the patient being at high risk for fall as indicated in the Fall Risk Evaluation dated 6/8/2024 to ensure the care plan include measurable objectives and interventions that addressed risk factors to prevent falls. A review of Patient 1’s “Bowel and Bladder Evaluation,” dated 6/8/2024, indicated Patient 1 was a “likely candidate” for Bowel and Bladder re-training (a program for toileting schedule when the nurse promotes a patient’s toileting every two hours to avoid overfilling the bladder to decrease the chance of incontinence). A review of Patient 1’s “History and Physical (H&P)," dated 6/9/2024, indicated Patient 1 had fluctuating (changing) capacity to understand and make decisions. A review of Patient 1’s GACH record titled “Physician Discharge Summary,” dated 6/10/2024, indicated Patient 1 was admitted to GACH from 6/5/2024 to 6/8/2024 due to a fall at home that resulted in fractures of the right radius and the right pubis and received nonsurgical intervention for the right ramus (branch of the arm bone) fracture and, underwent an open reduction and internal fixation (ORIF, surgical procedure to fix a severe bone fracture. "Open reduction" means surgery is needed to realign the bone fracture into the normal position) of the right radius. A review of Patient 1’s “Minimum Data Set” (MDS, a comprehensive assessment and screening tool) dated 6/13/2024, indicated Patient 1’s cognitive skills (ability to think, remember and reason) were moderately impaired, was dependent (full staff performance, resident does none of the effort to complete activity) in toileting hygiene [ability to maintain perineal (relating to the area between the anus and genitals) hygiene, adjust clothes before and after voiding or having a bowel movement) and toilet transfer (ability to get on and off a toilet or commode). The MDS indicated, Patient 1 required moderate assistance (helper lifts, holds, or supports trunk or limbs but provides less than half the effort) in walking 10 feet in the room and walking at least 50 feet and make two turns. During further review of Patient 1’s MDS, dated 6/13/2024, indicated, Patient 1 was frequently incontinent (unable to control bladder to urinate and bowel to have a bowel movement), balance problem while standing/walking, and required the use of assistive devices (such as cane, walker, wheelchair) with urine and was on a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) to manage the resident’s urinary continence. The MDS assessment did not address Patient 1’s history of falling at home where the resident sustained a right radius and right pubis fracture on 6/5/2024 prior to admission to the facility on 6/8/2024. A review of Patient 1’s “SBAR (Situation, Background, Assessment, Recommendation) Communication Form,” (a form used for consistent process to facilitate concise, clear, focused communication in the facility), dated 6/25/2024 (no time indicated), indicated Patient 1 was found sitting on the floor outside of the bathroom and reported having pain at the level of 2/10 in pain scale (0 for no pain and 10 for severe pain) and Tylenol (pain medication) was given. A review of Patient 1’s “Progress Notes-Nursing,” dated 6/25/2024, documented by Licensed Vocational Nurse (LVN) 6 indicated on 6/25/2024 at approximately 1:45 AM, a Certified Nursing Assistant (CNA) (unspecified) found the resident sitting on the floor outside of bathroom. The record indicated Patient 1 stated she got up to use the bathroom without assistance and was given Tylenol (pain medication) for pain. A review of Patient 1’s “Progress Notes-Nursing,” dated 6/25/2024, documented by Registered Nurse (RN) 4, indicated on 6/25/2024 at 1:50 AM, a CNA (unspecified) found the resident sitting upright on the floor in front of the bathroom and one cm (centimeter, unit of length) skin tear was found on the resident’s left knuckle of the middle finger. A review of Patient 1’s “Fall Risk Evaluation,” dated 6/25/2024, indicated, RN 4 documented Patient 1 was at medium risk for fall due to history of 3 or more falls in the past 3 months. The record indicated Patient 1 had improved elimination status from regularly incontinent (no control bladder and bowel) to regularly continent and improved her gait/balance/ambulation that she no longer had balance problem. A review of Patient 1’s “Post-Event IDT Review,” dated 6/25/2024, indicated on 6/25/24 at around 1:50 AM, a facility’s staff (unspecified who) found Patient 1 sitting upright on the floor in front of the bathroom. The record indicated, IDT recommended for Patient 1 to be placed on bowel and bladder scheduling by offering toileting upon rising, at mealtimes, at bedtimes and as need and the care plan needed update to include new interventions. A review of Patient 1’s “Care Plan,” dated 6/25/2024, the care plan indicated, Patient 1 had an actual fall related to poor safety awareness and sustained a skin tear on left middle finger. The care plan interventions indicated Patient 1 will be placed on Bowel and Bladder Scheduling by offering toilet use upon rising in bed, at mealtimes, at bedtimes and as needed (PRN). A review of the facility’s “Fall Investigation,” dated 6/26/2024, indicated on 6/25/24 at 1:50 AM, a CNA (unspecified) reported to RN 4 that Patient 1 fell. RN 4 went to the resident’s room and found Patient 1 on the floor near the bathroom. The investigation report indicated Patient 1 was alert and oriented, able to verbalize when she needed to use the bathroom. The report indicated Patient 1 stated she was walking then lost her balance and fell. The investigation report also indicated the fall resulted in Patient 1’s sustained skin tear measuring one centimeter on the left knuckle of the middle finger after the fall, The IDT recommended for Patient 1 to be placed on bowel and bladder scheduling by offering to use the toilet upon rising in bed, at mealtimes, and at bedtimes and PRN. A review of Patient 1’s “SBAR Communication Form,” dated 7/6/2024, documented by LVN 6, the SBAR indicated on 7/6/2024 (unspecified time) Patient 1 had a fall that resulted in mild right hip pain. Tylenol (pain medication) was given. A review of Patient 1’s “Order Summary Report,” for July 2024, indicated the Patient 1’s primary physician ordered on 7/6/2024 (unspecified time) to obtain X-Rays of the resident’s bilateral (both sides) pelvis and hips post (after) fall. The order summary indicated to transfer the resident to General Acute Care Hospital for further evaluation. A review of Patient 1’s “Progress Notes-Nursing,” dated 7/6/2024, LVN 6 documented, Patient 1 “attempted to use the bathroom without assistance and sat down on the floor due to room being too dark.” A review of Patient 1’s “Progress Notes-Nursing,” dated 7/6/2024, RN 4 documented on 7/6/2024 at 4:20 AM, a CNA (unspecified) found Patient 1 sitting upright on the floor next to her bed in the dark. The progress notes indicated Patient 1 reported that she needed to use the bathroom and fell. The record indicated Patient 1 complained of 2/10 on the pain scale when performing both active (moving a part of your body without assistance), and passive (someone or something is creating the movement) range of motion (ROM) of the right lower extremity and refused to take pain medication. The record indicated, Patient 1’s primary physician was notified of incident and Xray was ordered. A review of Patient 1’s “Progress Notes-Nursing,” dated 7/6/2024, indicated on 7/6/2024 at approximately 6:25 PM, the Xray result showed right hip fracture after an unwitnessed fall. The progress notes indicated, Patient 1’s primary physician was notified and ordered to send Patient 1 to GACH. The record indicated Patient 1 was provided with her pain medication (Norco 5-325 mg) at approximately 9 PM on 7/6/24 and was transferred to GACH at 10:15 PM. A review of Patient 1’s “MAR,” dated 7/6/2024, indicated on 7/6/2024 at 8:49 PM, Patient 1 was experiencing a level of 5/10 pain with no identified location of pain and was given Norco to relieve pain as ordered. A review of Patient 1’s GACH record titled, “Physician History & Physical (H&P),” dated 7/7/2024, indicated Patient 1 was admitted to GACH with a chief complaint of right hip pain after an unwitnessed fall on 7/6/2024. The record indicated, Patient 1 landed on her right hip after a mechanical fall (fall caused by outside or environmental factors) and experienced severe pain at the right hip and unable to put weight on the right leg. The record also indicated Patient 1 had sharp, constant, severe right hip pain with more pain when the resident moved her right leg. A review of Patient 1’s GACH’s record titled, “ED Note,” dated 7/7/2024, indicated on 7/6/2023 at 10:33 PM, Patient 1 was admitted to GACH’s ED for complaint of right hip pain. The record indicated Patient 1 had a history of dementia and had unwitnessed fall and Patient 1 stated that she was trying to stand up, lost her footing and fell. The record indicated on 7/6/2024 at 11:37 PM, a hip X-ray was done that showed a result of the right femoral neck fracture. The record indicated, Patient 1 required admission to GACH with orthopedic (the medical specialty that focuses on injuries and diseases of the body's bones and muscles system) consult for closed right femoral neck fracture related to fall. A review of Patient 1’s GACH’s record titled, “Orthopedic Surgery Consult,” dated 7/7/2024, indicated on 7/6/2024, Patient 1 had a fall when she got up unsupervised injuring her right hip with immediate pain and unable to bear weight and get up. The record indicated Patient 1 needed hemiarthroplasty of the right hip due to right femoral neck fracture. A review of Patient 1’s GACH’s record titled, “Operative Report,” dated 7/8/2024, indicated, on 7/8/2024 at 3:44 PM, Patient 1 underwent a surgical procedure for right hip hemiarthroplasty procedure. A review of the facility’s “Written Investigation Summary Report (WISP),” dated 7/11/2024, signed by the Director of Nurses (DON), indicated CNA 4’s interview statement that on 7/6/2024, CNA 4 changed Patient 1’s brief around 2:30 AM, then at 4:20 AM, while finishing care with another resident, CNA 4 heard a sound from Patient 1’s room. CNA 4 quickly went inside the room and saw Patient 1 sitting on the floor next to her bed. CNA 4 instructed Patient 1 not to move as CNA 4 rushed to the nursing station and informed RN 4 of the resident’s fall incident. RN 4 immediately went to assess Patient 1 while the resident was still sitting on the floor. CNA 4 and RN 4 assisted Patient 1 back to bed. During the sam