Other·July 5, 2023

F689 §483.25(d) Accidents The facility must ensure that – §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 72311 (a)(2) Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (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 § 72523(a) 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. On 10/25/2023, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) indicating Resident 1 complained of pain to his right hip and his right lower extremity (right leg) due to a fall with a fracture to his L4 (a fracture of the fourth lower lumbar [lower part of the back] vertebra [a series of small bones forming the backbone). On 10/26/2022, at 10:24 a.m., an unannounced visit to the facility was conducted to investigate the report of a resident fall and fracture. Upon investigation it was determined Resident 1, who required a two-person extensive physical assist (resident involved in activity, staff provide weight bearing support) during toileting, was not supervised while in the bathroom. A certified nursing assistant (CNA 2) left Resident 1 alone and unsupervised in the bathroom. Resident 1 became frustrated when no one came to his assistance, attempted to leave the bathroom, and fell from a shower chair. The facility failed to: 1. Ensure Resident 1 was Supervised and not left unattended while he was in the bathroom. 2. Ensure Resident 1’s care plan that indicated Resident 1 required two- person extensive assistance during toilet use was implemented. 3. Ensure their Policy and Procedure (P/P) titled “Quality of Care- ADL, Services to Carry Out,” that stipulated the facility provides appropriate treatment and services to maintain and improve resident’s grooming and personal hygiene was followed. As a result of Resident 1 being left alone and unsupervised in the bathroom, Resident 1 fell from a shower chair onto the floor sustaining a fracture causing pain to his back, right hip, and right leg. Resident 1 was transferred to a General Acute Care Hospital (GACH) where he was diagnosed with a fracture of the vertebrae. Findings: A review of Resident 1’s Admission Record (Face Sheet), indicated Resident 1, a 72-year-old male, was admitted to the facility on 9/15/2017, with diagnoses including cerebral infarction (stroke, when something blocks the blood supply to part of the brain), hemiplegia (paralysis to one side of the body), hemiparesis (a slight paralysis or weakness on one side of the body), diabetes mellitus ([DM] a chronic condition associated with abnormally high levels of sugar in the blood) and hypertension ([HTN] high blood pressure). A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 9/14/2022, indicated Resident 1 was able to make independent decisions that were reasonable and consistent and Resident 1 required an extensive two-person physical assistance to complete his activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting). The MDS indicated Resident 1 was not steady when moving from a seated to standing position, moving on and off the toilet, surface to surface transfers, and could only stabilize herself with staff assistance. A review of Resident 1’s Fall Risk Evaluation (FRE) dated 9/14/2022, indicated Resident 1 was a medium risk for falls due to balance problems while walking and/or standing, use of psychotropic (drug that affect a person’s mental state) medication, use of hypoglycemic (drugs that lowers blood sugar levels) medication and use of antihypertensive (drugs that lowers the blood pressure) medications. A review of Resident 1’s Care Plan (CP), dated 12/14/2022, indicated Resident 1 had actual self-care performance deficits related to his disease process. The CP’s goal was for Resident 1 to be supervised and assisted during his ADLs. The CP’s interventions indicated Resident 1 required extensive assistance to transfer onto and off the toilet with one to two staff support. A review of Resident 1’s Situation Background Assessment Recommendation ([SBAR] a tool and a guide to communicate a patient’s information with other healthcare professionals) dated 10/7/2022 and timed at 4:40 p.m., indicated Resident 1 was heard screaming for help at 3:45 p.m., (10/7/2022) and found sitting on the floor by the bathroom door and was in no pain or discomfort. A review of Resident 1’s Diagnostic Result (DR) dated 10/13/2022 and timed at 5:16 p.m., indicated Resident 1’s x-ray (a digital images of a human body internal tissues, bones, and organs on film) of his right femur was negative for a fracture (break in the bone) or dislocation (bones pushed out of their proper place). A review of Resident 1’s Progress Notes (PN) dated 10/21/2022 and timed at 2:32 p.m., by the Nurse Practitioner, indicated Resident 1 had no initial injury from his fall on 10/7/2022 but began complaining of right lower extremity/hip pain during mobility during physical therapy ([PT] the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery). The PN indicated due to continued complaints of pain an order was placed for an urgent CT ([computed tomography] a computerized x-ray in which a narrow beam of x-rays is aimed at the patient and quickly rotated around the body) of Resident 1’s pelvis and right femur to rule out a fracture. A review of Resident 1’s Physician’s Order (PO), dated 10/21/2022, and timed at 2:32 p.m., indicated to transfer Resident 1 to a GACH’s emergency room (ER) on 10/22/2022 for CT of the right hip and the right femur. A review of Resident 1’s Nurse Progress Notes (NPN) dated 10/22/2022 and timed at 4:32 p.m., indicated Resident 1 was transferred to a GACH for computerized scanning of his right hip and right leg. A review of the GACH’s Face Sheet, dated 10/22/2022, indicated Resident 1 was admitted to the GACH on 10/22/2022 at 7:54 p.m., for a CT scan because of pain related to a fall. A review of the GACH’s CT scan dated 10/23/2022 and timed at 1:37 a.m., indicated Resident 1 had an acute comminuted fracture (bone broken in two places) anterior column (directed forward) of the 4th lumbar spine with 15% loss of vertebral (backbone) height with no retropulsion (no displacement of bone into the spinal canal [a bony channel located in the vertebral column that protects the spinal cord and nerve roots]). A review of the GACH’s Neurosurgery (surgery performed on the nervous system, especially the brain and spinal cord) Consult (NC) dated 10/25/2022 and timed at 6:10 p.m., indicated an order for Resident 1 to wear a brace used to limit motion in the thoracic (the area of the body between the neck and the abdomen), lumbar (relating to the lower part of the back) and sacral (tailbone) regions of the spine) and an order for a lumbar MRI ([magnetic resonance imaging] a procedure that uses radio waves and a computer to make a series of detailed pictures of areas inside the body). An interview on 10/26/2022 at 11:23 a.m., with Restorative Nursing Assistant 1 (RNA 1), indicated RNA 1 stated Resident 1 was alert and coherent but was impatient and the staff should not leave Resident 1 alone in the bathroom because Resident 1 may try to do things beyond his capacity. An interview on 10/26/2022 at 11:32 a.m., with Licensed Vocational Nurse 1 (LVN 1), indicated LVN 1 stated Resident 1 required maximum assistance with ADL care. LVN 1 stated prior to Resident 1’s fall (10/7/2022), Resident 1 could move in his bed using his left extremities (left arm and leg) however, after Resident 1 fell he mostly wanted to stay in bed, probably because of pain. A telephone interview on 10/26/2022 at 1:22 p.m., with CNA 2, indicated CNA 2 stated Resident 1 needed maximum assist by 1 person when using the toilet. CNA 2 stated Resident 1 understood the need to use the call light although she observed Resident 1 being more impatient and more frustrated with the nurses lately. CNA 2 stated she assisted Resident 1 to the bathroom and left him unattended. CNA 2 stated when she was on her way back to assist Resident 1 in the bathroom, she heard Resident 1 scream, heard a sound of commotion (disturbing noise) and when she entered Resident 1’s room, she found him sitting on the floor outside the bathroom. CNA 2 stated Resident 1 was “freaking out” (losing emotional control because of extreme shock and fear) and yelling for help. An interview on 10/26/2022 at 3:43 p.m., with Registered Nurse Supervisor 2 (RNS 2), indicated RNS 2 stated Resident 1 required maximum assistance with 1 to 2 persons during ADL care. RNS 2 stated Resident 1 needed supervision and assistance while using the toilet and routine personal hygiene to always ensure Resident 1’s safety. A telephone interview on 10/28/2022 at 7:38 a.m., with Resident 1’s Responsible Party (RP), indicated the RP stated Resident 1 was in the GACH and told him that he (Resident 1) was having extreme pain in his back. The RP stated he was concerned that Resident 1 was not being supervised and assisted by the nursing staff in the facility while he was using the toilet. The RP stated Resident 1 was alert but was unsteady on his feet and could be forgetful and impatient and required constant supervision. An observation and interview on 5/19/2023 at 11:51 a.m., indicated Resident 1 was sitting in his bed and was noted with a contracted (tightening of the muscles causing stiffness) right knee. Resident 1 stated his right leg felt stiffer since he fell (10/7/2022), and he was frustrated because it was hard for him to sit up in his wheelchair and roll himself around the facility like he did before he fell. Resident 1 stated, CNA 2 helped him to the bathroom (10/7/2022) but left him there alone and said she would be back. Resident 1 stated he finished using the toilet and put on the call light, but CNA 2 did not come back right away (unknown amount of time). Resident 1 stated the shower chair he was sitting on was uncomfortable and he needed to be cleaned so he tried to leave the bathroom to find CNA 2. Resident 1 stated he tipped over out of the shower chair onto the floor and hit his bottom, back, his right leg and right hip on the floor. An interview on 5/19/2023 at 12:25 p.m., with RNS 1, indicated RNS 1 stated, Resident 1 was readmitted to the facility on 10/30/2022 with an order to wear a back brace when he was out of bed. RNS 1 stated all nursing assistants were reminded during huddle at the start of the shift to ensure safety precautions for all residents, and it was a basic rule for all nurses to not leave a resident alone in the bathroom because the resident might forget to call for help, try to get up unassisted, perform tasks beyond their capabilities and end up falling and hurting themselves. An interview on 5/19/2023 at 1:15 p.m., with the Administrator (ADM), indicated the ADM stated there was no policy related to resident supervision and/or accident prevention. An interview on 5/19/2023 at 1:27 p.m., with the Director of Nursing Services (DNS), indicated the DNS stated CNA 2 should not have left Resident 1 in the bathroom alone because of safety reasons. A review of the facility’s P/P titled “Quality of Care- ADL, Services to Carry Out,” revised 11/2007, indicated the facility provides the appropriate treatment and services to residents to maintain and improve their abilities and this includes but is not limited to grooming and personal hygiene. The facility failed to: 1. Ensure Resident 1 was Supervised and not left unattended while he was in the bathroom. 2. Ensure Resident 1’s care plan that indicated Resident 1 required two- person extensive assistance during toilet use was implemented. 3. Ensure their Policy and Procedure (P/P) titled “Quality of Care- ADL, Services to Carry Out,” that stipulated the facility provides appropriate treatment and services to maintain and improve resident’s grooming and personal hygiene was followed. As a result of Resident 1 being left alone and unsupervised in the bathroom, Resident 1 fell from a shower chair onto the floor sustaining a fracture causing pain to his back, right hip, and right leg. Resident 1 was transferred to a General Acute Care Hospital (GACH) where he was diagnosed with a fracture of the vertebrae. These violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Residents.