Other·April 21, 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. 42 CFR § 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. 22 CCR § 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. 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. (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The California Department of Public Health (CDPH) received a complaint on 2/15/2023 alleging a resident (Resident 1) was brought to the hospital due to a fall and head injury. The complaint alleged this was Resident 1’s fourth fall in the facility in the last four months. The complaint also alleged that another resident physically hit Resident 1 a few months prior which resulted in multiple bruises and bilateral (pertaining to both sides) subdural hematoma (a pool of blood between the skull and the brain). On 3/2/2023, CDPH conducted an unannounced complaint investigation at the facility. The facility failed to provide the required supervision for Resident 2, who was assessed as high risk for falls, after two fall incidents. Resident 2 fell on 2/1/2023 (first fall) and then fell on 2/7/2023 (second fall), two days after being readmitted to the facility from a general acute care hospital (GACH) after the resident’s wheelchair alarm failed to activate. The facility failed to: 1. Revise the resident's care plan after the fall on 2/1/2023. 2. Reassess the resident's fall risk after the fall on 2/1/2023. 3. Ensure the resident's wheelchair alarm was functional. 4. Ensure an interdisciplinary team (IDT, group of different disciplines working together towards a common goal for a resident) meeting was held after the 2/1/2023 fall. As a result, Resident 2 sustained a contusion (bruise) and skin tear to the left side of the forehead from a fall incident on 2/1/2023 resulting in the resident’s transfer to the GACH. The resident received a computerized tomography scan (CT, combines a series of X-ray images taken from different angles around your body) and wound care. Resident 2 then returned to the facility on 2/5/2023, and sustained another subsequent fall on 2/7/2023 after the resident’s wheelchair alarm failed to activate. A review of Resident 2's Admission Records indicated Resident 2 was a 72 year-old male who was admitted to the facility on 12/12/2022 with diagnoses that included dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), schizoaffective disorder (a mental health problem where the resident experience psychosis [people loose contact with reality] as well as mood [predominant emotion] symptoms), irritable bowel syndrome (common disorder affecting stomach and intestines causing pain in the belly, gas, diarrhea [loose stools], and constipation [difficult bowel movements]), and essential hypertension (high blood pressure). A review of Resident 2's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/28/2023, indicated Resident 2's cognitive skills for daily decision making were severely impaired (the ability to understand or to be understood by others). The MDS indicated Resident 2 required limited assistance with dressing, eating, personal hygiene, and walking, and extensive assistance with bed mobility, transfer, and toilet use. The MDS indicated Resident 2 used a wheelchair for mobility and had a bed and wheelchair alarm. A review of Resident 2’s Fall Risk Assessments (used to estimate a resident's fall risk) initiated on 12/12/2022, 12/23/2022, and 1/28/2023, indicated Resident 2 was a high fall risk with a score of 19 (a score of 10 or more indicates high risk) and had multiple risk factors that predisposed the resident to falls. The risk factors indicated Resident 2 had the following: a) Intermittent confusion, b) A history of 1 to 2 falls in the last 3 months,  c) 1 to 2 medical diagnoses predisposing to falls, d) Chairbound and/or assist with elimination,  e) Poor gait and balance (balance problem while standing, walking, change in gait when walking through doorway, unstable when making turns, and required assistive devices); and f) Takes 3 to 4 medications that increase risks for falls. The Fall Risk Assessments instructions indicated a prevention protocol should be initiated immediately and documented on Resident 2's care plan.  A record review of Resident 2's care plan titled, "Safety compromised related to risk for fall," initiated 12/23/2022, indicated the care plan goal that Resident 2 would be free of falls and injury for three months. The staff's interventions indicated all equipment (wheelchair alarm) would be free of damage and malfunction, to monitor for falls, assess for injury, and notify the physician and family, and implement the “least restrictive measures per protocol, and monitor for effectiveness of least restrictive measures.” A review of Resident 2’s Physician’s Order dated 2/1/2023 to 2/28/2023, indicated starting on 12/12/2022, the resident may have a wheelchair alarm to alert staff if the resident was getting up unassisted. The order indicated the alarm did not limit freedom of movement for the resident and was ordered due to the resident’s poor safety awareness. The order indicated staff were to monitor episodes of the resident attempting to get out of bed unassisted and tally by hashmark and if 10 or more episodes were noted to notify the physician. A review of Resident 2's Licensed Progress Note dated 2/1/2023 at 7 p.m., indicated staff found Resident 2 on the floor bleeding with complaints of pain to the left forehead. A review of Resident 2’s Situation, Background, Assessment, and Recommendation ([SBAR] a communication tool used by licensed nurses when a resident has a change in condition) dated 2/1/2023 at 7 p.m., indicated Resident 2 fell on 2/1/2023, which resulted in a head contusion and a skin tear on the left forehead.  A review of Resident 2's Licensed Progress Note, dated 2/2/2023 at 12:40 p.m., indicated on 2/2/2023 at 12:40 a.m., Resident 2 was transferred to a GACH for further evaluation.  A review of Resident 2's GACH Physician History and Physical (H&P) dated 2/2/2023 at 11:02 p.m., indicated Resident 2 was alert, oriented to self only, did not follow commands well, and had poor safety awareness. The GACH H&P indicated Resident 2 had a fall incident and was found on the floor at the facility with complaints of head pain. The GACH H&P indicated Resident 2 sustained a skin tear on the left side of the forehead and had a CT scan of the head. A review of Resident 2's GACH Discharge Summary dated 3/2/2023 at 11:02 p.m., indicated Resident 2 was admitted to the GACH on 2/2/2023 status post fall. The discharge summary indicated Resident 2 sustained a head contusion and a skin tear on the left side of the forehead. The discharge summary indicated wound care done for the lacerated wound, suturing (stitch up) versus steri-strips (adhesive skin closure). The discharge summary indicated a urine culture (urine tested for infection) revealed the resident had a urinary tract infection (bladder infection) and was treated with intravenous ([IV] medication given directly to the bloodstream) hydration and IV Rocephin (medication that fight infections caused by bacteria [tiny organisms]). A review of Resident 2's Licensed Progress Note dated 2/5/2023 at 7:40 p.m., indicated Resident 2 was readmitted back to the facility. During a record review of Resident 2’s medical records, there was no documented evidence Resident 2's "Safety" care plan was revised with new or updated interventions, a post-fall risk assessment was completed, nor an IDT meeting was held to address the resident's new fall prevention measures after the resident was readmitted to the facility on 2/5/2023. A record review of Resident 2’s Licensed Progress Note dated 2/7/2023 at 8 a.m., indicated a Certified Nursing Assistant (CNA 3) reported Resident 2 fell in the hallway on 2/7/2023. The note indicated Resident 2 was observed by the CNA trying to get up from the resident’s wheelchair several times prior to the fall incident but the CNA was with another resident when Resident 2 fell. The note indicated Resident 2's wheelchair alarm was not working properly at the time of the fall.  During a record review of the facility's Interview Record of CNA 3 regarding Resident 2's fall dated 2/7/2023, the written statement indicated Resident 2's wheelchair alarm did not alarm when the resident was trying to get up. The written statement indicated Resident 2's wheelchair alarm activated after the resident was already on the floor.  During a concurrent interview and record review on 3/2/2023 at 11:05 a.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 2's Fall risk assessment dated 1/28/2023 and care plan titled, "Safety compromised related to risk for fall," initiated 12/23/2022, were reviewed. LVN 1 stated after Resident 2’s fall incident on 2/1/2023, the resident's Fall risk assessment was not reassessed and new interventions for fall prevention were not found in the care plan. During a telephone interview with the Director of Nursing (DON) on 3/15/2023 at 9:58 a.m., the DON verified the licensed nurses’ documentation indicated Resident 2's wheelchair alarm was not working when the resident fell. The DON stated Resident 2's care plan should have been revised after the resident was readmitted back to the facility on 2/5/2023. The DON stated the staff should have made sure Resident 2's wheelchair alarm was working. The DON stated there should be updated fall interventions to prevent future falls. A record review of the facility's policy and procedure (P&P) titled, “Resident Fall” (undated), indicated the facility will promptly respond to all residents after a fall to provide necessary care and treatment to medically stabilize, and to initiate prompt interventions to prevent or reduce further falls with or without injury. The P&P indicated the facility will develop a care plan based upon the post fall report. The P&P indicated the interdisciplinary team will discuss the fall during the stand-up meeting and revise the care plan and inform the direct care staff to prevent or minimize further falls. The facility failed to provide the required supervision for Resident 2, who was assessed as high risk for falls, after two fall incidents. Resident 2 fell on 2/1/2023 (first fall) and then fell on 2/7/2023 (second fall), two days after being readmitted to the facility from a GACH after the resident’s wheelchair alarm failed to activate. The facility failed to: 1. Revise the resident's care plan after the fall on 2/1/2023. 2.Reassess the resident's fall risk after the fall on 2/1/2023. 3. Ensure the resident's wheelchair alarm was functional. 4. Ensure an interdisciplinary team (IDT, group of different disciplines working together towards a common goal for a resident) meeting was held after the 2/1/2023 fall. As a result, Resident 2 sustained a contusion and skin tear to the left side of the forehead from a fall incident on 2/1/2023 resulting in the resident’s transfer to a GACH. The resident received a CT scan and wound care. Resident 2 returned to the facility and sustained another subsequent fall on 2/7/2022 after the resident’s wheelchair alarm failed to activate. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 2.