Other·June 23, 2023

42 CFR § 483.25(d) Accidents The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 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: (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. 22 CCR § 72637 General Maintenance (a) The facility, including the grounds, shall be always maintained in a clean and sanitary condition and in good repair to ensure safety and well-being of patients, staff, and visitors. (b) Buildings and grounds shall be free of environmental pollutants and such nuisances as may adversely affect the health or welfare of patients to the extent that such conditions are within the reasonable control of the facility. (c) All buildings, fixtures, equipment, and spaces shall be maintained in operable condition. On 5/4/2023, the California Department of Public Health (CDPH) received a complaint regarding allegations of neglect and quality of care. On 5/8/2023, CDPH made an unannounced visit to the facility to investigate the complaint allegation. The facility failed to: 1. Ensure Resident 1, a 74-year-old female, who had a history of falls, did not fall and sustain a fracture (a break in a bone) of the right foot, fifth metatarsal bone (the bone connecting a person's ankle to the little toe). The facility failed to: 1. Offer Resident 1 assistance and assist the resident in going to the restroom as indicated in Resident 1's untitled Care Plan ([CP] a document that outlines a resident's health conditions, specific care needs, current treatments, and goals) to prevent the resident from falling again after the resident's first fall on 3/21/2023 at 6:00 a.m. 2. Accurately assess Resident 1 for the risk of falls to implement necessary fall prevention measures based on the fall risk assessment, including placement of a sign on Resident 1's room door indicating "High Fall Risk" and a soft fall mat by the bed. As a result, Resident 1 sustained a fall with a fracture to the right fifth metatarsal toe which led to swelling and discoloration of the resident's right foot and absence of pedal (an arterial [a measurement of the heart's contraction]) pulse (which can be felt on top of the foot in front of the ankle) that required a left femoral (related to a thigh) popliteal vein (related to the back of the knee) bypass surgery (a procedure that creates a new route for blood flow to the right lower leg by using a healthy vein from the left leg). A record review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was initially admitted to the facility on 3/2/2023, with readmission on 3/25/2023, and last re-admission on 4/13/2023, with diagnoses including muscle weakness, anemia (condition in which the blood does not have enough healthy red blood cells), anxiety (a feeling of fear, dread, and uneasiness), disorientation (a state of mental confusion), atrial fibrillation (irregular heartbeat), hypertension (high blood pressure), and diabetes mellitus (a chronic condition where the body is unable to absorb sugar from the blood stream without medication). A record review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 3/8/2023, indicated Resident 1 had moderately impaired cognitive (ability to make decisions for daily living) skills for daily living and required supervision from one staff for bed mobility, transfers, walking in room, locomotion on unit, eating, and limited assistance from one staff for personal hygiene, and getting dressed. A review of Resident 1's Medication Administration Record (MAR), dated 3/1/2023 to 3/31/2023, indicated Resident 1 was receiving medications that could increase Resident 1's risk for falls. The MAR indicated Resident 1 was receiving Insulin Lispro (medication for lowering high blood sugar) on a sliding-scale (amount given depends on the blood sugar level), Metoprolol Tartrate (a medication for lowering high blood pressure), 100 milligrams ([mg] a unit of measure) one tablet twice a day by mouth, Lisinopril (medication for lowering high blood pressure) 20 mg one tablet once a day by mouth, Furosemide (medication for removal of fluid excess from the body to lower blood pressure) 40 mg one tablet by mouth two times a day, Spironolactone (a medication to lower blood pressure) 25 mg one tablet by mouth one time a day, and Buspirone HCL (medication to reduce anxiety) 5 mg one tablet by mouth twice a day. According to https://www.drugs.com (a comprehensive and up-to-date source of drug information), Lispro could cause side effects such as, dizziness, fast heart rate, and feeling anxious or shaky. Metoprolol Tartrate, Lisinopril, Furosemide and Spironolactone have a potential side effect of very low blood pressure and causing dizziness. Buspirone HCL has potential side effects of dizziness, confusion, fatigue, and nervousness. These medications' side effects are a contributing factor to a resident's risk for falls. A review of Nursing Progress Note (NPN), dated 3/21/2023 and timed at 6:00 a.m., indicated staff found Resident 1 sitting on the floor on the left side of the bed. The NPN indicated Resident 1 was alert and denied discomfort or pain. The NPN indicated Resident 1's skin was intact. The NPN indicated Resident 1 stated she wanted to go to the restroom and lost her balance. The NPN indicated staff notified the resident's physician. A review of NPN, dated 3/21/2023 and timed at 10:00 a.m., indicated staff found Resident 1 sitting on the floor (for the second time on 3/21/2023) leaning back on the wall of her room near the door. The NPN indicated Resident 1 stated she was trying to stand up and fell. The NPN indicated Resident 1 had right hip skin discoloration and excoriation (lesions on the surface of the skin). The NPN indicated Nurse Practitioner (NP) ordered an X -ray (a type of medical imaging that creates pictures of bones and soft tissues) of the right foot on 3/21/2023 and reviewed the X-ray report which indicated an acute (new onset) fracture of the fifth metatarsal bone on 3/21/2023. The NPN indicated NP ordered to transfer Resident 1 to a general acute care hospital (GACH 1) on 3/21/2023 for further evaluation due to Resident 1's fall and resulting fracture. On 3/25/2023, the facility readmitted Resident 1 with a diagnosis of cerebro-vascular incident ([CVA] a loss of blood flow to part of the brain) with no treatment done to the fracture. On 3/30/2023, the facility transferred Resident 1 out to GACH 2 due to a change in condition (COC). A review of COC form dated 3/30/2023 at 3:00 p.m., indicated Resident 1's right lower extremity had mottled (marked with spots of discoloration) skin, cold to the touch with decreased sensation and a weak pulse. On 4/13/2023, the facility readmitted Resident 1. A review of the NPN dated 4/13/2023 at 1:30 p.m., indicated staff informed Resident 1's responsible party (RP) of the resident's current condition with a recommendation, by the physician, for the above knee amputation ([AKA] surgical removal of part of the right leg starting at the knee and below). The NPN indicated RP declined the right AKA recommended by the physician from GACH 2. The RP stated that Resident 1 had previously requested for no amputation or aggressive treatment. The NPN indicated Resident 1's right lower extremity ischemia (lack of blood flow to a part of the body) leading to tissue necrosis (irreversible cell death) and gangrene (tissue death due to some form of interrupted blood supply). On 4/15/2023, the facility transferred Resident 1 to GACH 3 per the resident's family request. On 4/20/2023, Resident 1 had a left femoral vein to right femoral bypass surgery. A review of Resident 1's Care Plan (CP), undated, indicated the resident's status post-unwitnessed fall (1st fall incident). The CP interventions included frequent visual checks, attending to the resident's needs in a timely manner, and offering and assisting the resident to use restroom as needed. During an interview on 5/11/2023, at 2:39 p.m., with Certified Nursing Assistant 2 (CNA 2) via telephone, CNA 2 stated when she started her shift on 3/21/23 at 6:30 a.m., she received a report from the night shift staff (outgoing shift) regarding Resident 1's first fall incident that happened on 3/21/2023 at 6:00 a.m. CNA 2 stated, later that day she heard a loud thud and found Resident 1 on the floor in a sitting position on 3/21/2023, at 10:00 a.m. CNA 2 stated, there was no floor mat by Resident 1's bedside to prevent injury from the fall, and no Falling Star symbol (a visible symbol indicating a resident was at risk of falls and a falling star graphic placed on a resident's door) placed in Resident 1's room door to indicate Resident 1 was a fall risk. CNA 2 stated, she noticed Resident 1 was getting more confused, and repeatedly saying, "I need to go to the bathroom now." CNA 2 stated, she notified LVN 3 regarding Resident 1's increased confusion. CNA 2 stated Resident 1 was trying to get up and go to the bathroom unassisted when she fell. A review of the facility's "Fall Prevention Program Guidelines: Falling STAR Program" (FSP), undated, indicated the purpose of the FSP was to reduce facility's fall percentage and prevent recurrent falls resulting in major injury. Identification of Residents in the FSP: The Yellow STAR represents a resident's history of falls and is placed over the headboard of a resident's bed. The Red STAR represents a resident's history of multiple fall incidents and a fall with a major injury. A review of Resident 1's right foot X-ray (medical imaging that creates pictures of bones and soft tissues) report, dated 3/21/2023, indicated Resident 1 had a nondisplaced (not moved out of alignment) fracture, distal (away from the center of the body) end of right fifth metatarsal bone. During an interview on 5/11/2023, at 4:00 p.m., the Assistant Director of Nursing (ADON) stated, Resident 1 should have been on one to one (1:1) supervision (resident has a staff member assigned to them for constant monitoring and ensuring the resident stays safe) or moved closer to the nursing station if 1:1 supervision was not possible. The ADON stated staff did not place Resident 1 on a FSP after the first fall on 3/21/2023 at 6 a.m. The ADON stated the second fall on 3/21/2023 at 10:00 a.m., could have been avoided if those interventions (the FSP and 1:1 monitoring) were implemented right after the first fall. The ADON stated Resident 1 should have been assigned a Red Star (indicating a higher level of monitoring requirement since the resident has had multiple fall incidents and a fall with major injury) after the second fall because of the multiple falls with injury. The ADON stated, since Resident 1's fall on 3/21/2023, Resident 1 was hospitalized multiple times for fall-related complications that led to possible amputation, and femoral bypass surgery of the right leg. During an interview on 5/9/2023, at 2:45 p.m., Licensed Vocational Nurse (LVN 2) stated a Fall Risk Assessment ([FRA] a nursing tool that uses a scoring system to evaluate resident's risk of fall) should be completed accurately because fall prevention interventions for each resident were based on the FRA. LVN 2 stated a resident's fracture could interfere with normal blood circulation on the fractured extremity, causing immobility which could result in an amputation due to lack of blood flow, causing tissue death to the area past the fracture. During a concurrent interview and record review, on 5/9/2023, at 4:10 p.m., with the ADON, Resident 1's FRAs, dated 3/2/2023 (FRA 1), FRA dated 3/21/2023 and timed at 6:00 a.m., (FRA 2), and FRA dated 3/21/2023 and timed at 10 a.m., (FRA 3) were reviewed. FRA 1 dated 3/2/2023 indicated Resident 1 had one to two falls in the past three months, a balance problem while walking and standing, taking one to two medications that increased Resident 1's risk for falls, and no predisposing (to have a tendency toward something) disease to contribute to Resident 1's fall risk. FRA 2 dated 3/21/2023 and timed at 6:00 a.m. (completed after the first fall on 3/21/2023) indicated Resident 1 was assessed as no history of falls and no risk or potential for falls and was scored eight which indicated no fall risk (score 0-9: no risk for fall & 10 or above: high risk for fall). According to the FRA, for a score of 10 or above the resident should be considered as High Risk for potential for falls, and the "Fall Prevention protocol" should be initiated immediately and documented on the care plan. The resident's gait and balance must be assessed, a review of the resident's medications should be done with a focus on medications which could be a contributing factor to falls including antihypertensives (lowering blood pressure), diuretics (getting rid of excess water from body and lowering blood pressure), hypoglycemics (lowering blood sugar), and the resident's predisposing conditions including Hypotension (low blood pressure), Vertigo (dizziness), Cerebral Vascular Accident (stroke-a loss of blood flow to part of the brain), Osteoporosis (weakened bones), and fractures must be considered. FRA 3 dated 3/21/2023 and timed at 10 a.m., incorrectly indicated Resident 1 was still considered as not being at risk for the potential for falls and scored nine which indicated no fall risk. During an interview on 5/9/2023, at 4:10 p.m., the ADON confirmed all three FRAs (FRA 1, FRA 2, FRA 3) reflected an incorrect assessment of Resident 1's risk for falls. The ADON stated, the licensed nurses that completed FRAs failed to identify and to evaluate Resident 1 as a high fall risk. A review of Resident 1's GACH 3 medical records (GACHMR), dated 4/16/2023, indicated Resident 1 had an altered cognitive status, had right foot toes cyanosis (a bluish color in the skin caused by a shortage of oxygen in the blood) with no pedal pulse via doppler (a noninvasive device that can be used to estimate the blood flow) examination. The GACHMR Operative Report," dated 4/20/2023, indicated Resident 1 had a left femoral vein to right femoral bypass surgery. A review of the facility's policy and procedure (P&P) titled, "Fall Management Program," dated 3/13/2021, indicated the facility will implement a Fall Management Program that supports and provides an environment free from fall hazards. The P&P section Fall Risk Evaluation indicated as part of the admission assessment, a licensed nurse will complete a fall risk evaluation. If a fall risk factor is identified, the licensed nurse will document interventions on the resident's care plan and document interventions for every resident regardless of fall risk evaluation score. The P&P under section Recurrent Falls indicated a resident who endures more than one fall in a day, week, or month, will be considered at high risk for falls. The facility failed to: 1. Offer Resident 1 assistance and assist the resident in going to the restroom as indicated in Resident 1's untitled CP to prevent the resident from falling again after the resident's first fall on 3/21/2023 at 6:00 a.m.