Health inspection·April 4, 2024

42 CFR §483.25(c) Mobility (1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and (2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. (3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. 42 CFR §483.10(g)(14) Notification of Changes (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention. (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) 22 CCR §22 72315 Nursing Services - Patient Care (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her. professional licensure. (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures, and deformities. Such care shall include: (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities (g) Each patient requiring help in eating shall be provided with assistance when served and shall be provided with training or adaptive equipment in accordance with identified needs, based upon patient assessment, to encourage independence in eating. 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: (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. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: . . . (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety, or security of the patient. On 2/20/2024, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility for a Recertification Survey. The facility failed to: 1.Ensure Resident 59 who did not have problems with range of motion ([ROM], full movement potential of a joint) to the right hand and arm did not acquire a decline in ROM and did not develop a contracture (loss of motion associated with stiffness and joint deformity) to the right wrist and right hand. 2. Accurately assess and code the Minimum Data Set ([MDS], a comprehensive assessment and care screening tool) dated 12/28/2023, to indicate ROM limitations in Resident 59's right arm. 3. Assess Resident 59's ROM of arms for any changes or decline in ROM on the quarterly Joint Mobility Screens ([JMS] a brief assessment of a resident's ROM in both arms and both legs), dated 11/21/2023 and 12/28/2023. 4. Ensure Resident 59 was provided with a Restorative Nursing Aide program ([RNA] a nursing program that uses restorative nursing aides RNAs to help residents maintain their function and mobility) treatment in accordance with the Occupational Therapy (OT), Rehabilitation Screening ([Rehab Screen] a quarterly evaluation of a resident's need for skilled therapy recommendations on 9/28/2023 to prevent a decline in Resident 59's right arm ROM and in accordance with the facility's P&P titled, "Restorative Nursing Program." As a result, Resident 59 developed a severe contracture greater than (>)50 % loss of motion to the right wrist and right hand. A review of Resident 59's Admission Record, indicated Resident 59 was admitted to the facility on 4/3/2012 and re-admitted on 6/7/2023. Resident 59's diagnoses included right sided hemiplegia (weakness to the right side of the body), osteoarthritis (loss of protective cartilage that cushions the ends of bones), and anoxic brain damage (injury to the brain caused by lack of oxygen). A review of Resident 59's MDS, dated 9/28/2023, Resident 59 had a clear speech and severely impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 59 required extensive assistance (resident involved in activity while staff provided support) for bed mobility, transfers between surfaces, dressing, toilet use, and personal hygiene. The MDS indicated Resident 59 had functional limitations in ROM. The MDS indicated Resident 59 had no ROM limitations in both arms but had ROM limitations in both legs. A review of Resident 59's Physician's Orders dated 2/28/2020, indicated RNA to provide passive range of motion ([PROM] a movement at a given joint with full assistance from another person) exercises to Resident 59's right arm followed by the application of a right-hand splint for four to six hours, five times a week as tolerated. The Physician's Orders discontinue RNA. The Physician's Order did not indicate a reason for discontinuation of the RNA order. A review of Resident 59's care plan titled "ROM Limitations Related to Right Hemiplegia and Arthritis," revised 1/1/2024, indicated the goal was for Resident 59 to avoid complications related to contractures and a ROM decline. The care plan interventions indicated RNA will provide PROM exercises to the right arm followed by the application of a right-hand splint, for four to six hours, five times a week as tolerated. A review of Resident 59's Physical Therapy (PT) Evaluation and Plan of Treatment dated 6/8/2023, indicated Resident 59's ROM in both arms was within functional limits (WFL). A review of Resident 59's Physician's Orders, dated 6/9/2023, indicated OT evaluation and treatment. The Physician's Order also indicated discontinue OT. The Physician's Order did not indicate a reason for the discontinuation. A review of Resident 59's Occupational Therapy Re-admission Joint Mobility Screening, dated 6/14/2023, indicated Resident 59 had full PROM in both wrists, hands, fingers, elbows, and shoulders. A review of Resident 59's PT Discharge Summary, dated 7/27/2023, indicated Resident 59's RNA Program was not applicable because Resident 59 refused. A review of Resident 59's Physician's Orders, dated 7/27/2023 at 9:05 p.m., for RNA to provide PROM exercises to Resident 59's both legs, five times a week as tolerated. A review of Resident 59's Occupational Therapy Rehabilitation Screening dated 9/28/2023, indicated an RNA Program was recommended for Resident 59. A review of Resident 59's Nursing Quarterly Joint Mobility Screen, dated 11/21/2023, indicated for Resident 59 will continue PROM exercises with RNA to both legs. There was no evaluation or recommendations for Resident 59's arm was documented. A review of Resident 59's MDS, dated 12/28/2023, indicated Resident 59 had clear speech and severely impaired cognitive skills for daily decision making. The MDS indicated Resident 59 required substantial/maximal assistance (helper does more than half the effort to complete the task) for hygiene and lying to sitting on the side of the bed, partial/moderate assistance (helper does less than half the effort to complete the task) for dressing, and supervision/touching assistance (helper provides verbal cues or steadying assistance for activity) for eating and rolling to both sides. The MDS indicated Resident 59 had no ROM limitations in both arms and had ROM limitations in one leg. A review of Resident 59's Nursing Quarterly Joint Mobility Screen, dated 12/28/2023, indicated to continue PROM exercises with RNA to both legs. There was no documented evaluation or recommendations for Resident 59's arm. A review of Resident 59's OT Rehab Screen, dated 12/28/2023, indicated an RNA Program was recommended for Resident 59. A review of Resident 59's OT JMS, dated 2/22/2024, the JMS indicated Resident 59 had severe (>50% ROM loss) ROM limitations in the right wrist, right hand, and right fingers. The JMS indicated Resident 59 had minimal (<25% loss) ROM limitations in the right elbow and right shoulder. The JMS indicated Resident 59 had severe contractures of the right wrist, hand, and fingers. The JMS indicated a skilled OT therapy evaluation was recommended. A review of Resident 59's OT Rehab Screen, dated 2/22/2024, indicated Resident 59 had contractures to the right wrist and right hand. The OT Rehab Screen recommended skilled OT services to provide evaluation and treatment of Resident 59's contractures. During a concurrent observation and interview on 2/20/2024 at 2:33 p.m., in Resident 59's room, Resident 59 was observed sitting upright in bed with the left ankle crossed over the right knee. Resident 59's right elbow was bent, the right wrist was bent downwards, the fingers were bent into a fist, and the resident's right thumb was fully straight. Resident 59 attempted to straighten the right wrist and open the right hand using her left arm but was unable to do so. Resident 59 stated she previously had full range of motion in her right arm, but currently she had difficulty moving it because her right wrist and right hand were "stuck." Resident 59 stated facility staff assisted her with exercises to both legs but did not provide exercises for her arms and hands. During an interview on 2/21/2024 at 3:15 p.m., Certified Nursing Assistant (CNA 8) stated Resident 59's did not use her right arm to assist with care during activities of daily living ([ADLs], basic activities such as eating, dressing, and toileting) and mobility. During an interview on 2/21/2024 at 3:19 p.m., RNA 1 stated she assisted Resident 59 with PROM exercises to the legs because there was no order for ROM for the resident's arms. RNA 1 stated she did not recall ever performing ROM exercises to Resident 59's arms throughout Resident 59's stay at the facility. During an interview on 2/21/2024 at 3:47 p.m., RNA 2 stated he assisted Resident 59 with PROM exercises to both legs only because there was no order to provide exercises for Resident 59's arms. RNA 2 stated that in the past, there was an order for RNA to assist with exercises to the right arm and apply a right-hand splint. RNA 2 stated he did not know why the order was discontinued. During an interview on 2/22/2024 at 10:27 a.m., with a Physical Therapist (PT 1), PT 1 stated the Rehabilitation Department performed JMS (a brief assessment of a resident's ROM in both arms and both legs) for all the residents in the facility upon admission, re-admission, annually, and when there was a change of condition, to monitor for changes in joint ROM. PT 1 stated the nursing department performed quarterly JMS and notified the rehab department of any changes or decline noted in a resident's ROM. PT 1 stated the OT Rehab Screen assessed the resident's overall level of function related to ADLs and ROM of the arms. PT 1 stated the PT Rehab Screen assessed the resident's overall level of function related to mobility and ROM of the legs. PT 1 stated the results of the Rehab Screen and JMS indicated if a resident required skilled therapy services or an RNA Program. Resident 59's PT Evaluation was reviewed; PT 1 stated Resident 59 was evaluated by PT on 6/8/2023 and indicated ROM of both arms were WFL. PT 1 stated he did not recommend an RNA Program upon discharge from PT treatment on 7/27/2023 due to multiple resident's refusals with mobility. PT 1 stated he wrote an RNA order for RNA to perform PROM to Resident 59's legs because Resident 59 had a high risk for developing a contracture without RNA intervention. PT 1 stated Resident 59 had fluctuating cooperation levels with mobility but did not refuse to participate in ROM exercises. During a concurrent interview and record review on 2/22/2024 at 10:40 a.m. with OT 1, Resident 59's therapy record, physician's orders (dated 2/28/2020), and OT Annual JMS (dated 6/14/2023) were reviewed. OT 1 stated the purpose of the JMS was to monitor if resident's joint ROM was maintained, improved, or declined. OT 1 stated it was important to regularly monitor for changes in joint ROM to ensure the proper RNA services were provided to residents to prevent a decline in ROM and or development of contractures. OT 1 stated she performed an OT JMS on 6/14/2023 on Resident 59, which indicated Resident 59 had full ROM of both wrists, hands, fingers, elbows, and shoulders. OT 1 stated the physician ordered and discontinued RNA to perform PROM exercises to Resident 59's right arm followed by the application of a right-hand splint order on 2/28/2020. OT 1 stated she did not know the reason Resident 59's RNA order was discontinued and was unable to find documentation to indicate the reason of discontinuance of the order for PROM exercises and right-hand splint on 2/28/2020. OT 1 stated Resident 59 did not receive any RNA services for the arms while in the facility since the RNA order, dated 2/28/2020, was discontinued and no other RNA orders addressing Resident 59's arms were found in the clinical record. OT 1 stated Resident 59 was at high risk for contracture development due to Resident 59's diagnosis of right hemiplegia and could have benefitted from OT and/or an RNA program while in the facility to maintain and prevent a decline of ROM of the arms. During a concurrent observation and interview on 2/22/2024 at 11:15 a.m., in Resident 59's room, OT 1 was performed an OT JMS on Resident 59, and re-assessed the resident's ROM on both arms. Resident 59 stated she was unable to straighten her right wrist and right hand. Resident 59 screamed when OT 1 attempted to straighten her (Resident 59's) right wrist and fingers. OT 1 stated Resident 59's had severe contractures of the right wrist and fingers and recommended skilled OT services for management of the right-hand contracture. OT 1 stated Resident 59 was at high risk for contracture development due to diagnosis of hemiplegia and because the resident did not receive treatment and services, to maintain arm ROM and prevent a decline. OT 1 stated Resident 59's right hand and right wrist contractures could have been prevented if the OT evaluated Resident 59 when the resident had a decline in ROM and established an RNA program for right arm ROM exercises. During an interview on 2/22/2024 at 12:45 p.m., the Minimum Data Set Nurse (MDSN) stated the facility monitored any changes in joint ROM by the MDS and JMS performed by the Rehab and nursing departments. The MDSN stated the Rehab Departm