Other·November 16, 2023

§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. §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) §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. § 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. On 10/3/2023, the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey. During the recertification survey it was determined that on 8/8/23 the facility failed to prevent Resident 89 a 78-year-old male from falling out of bed while preparing to change the resident’s incontinence briefs. Based upon observation, interview, and record review, the facility failed to: 1. Ensure a Certified Nurse Assistant (CNA 6) did not leave Resident 89 unsupervised when Resident 89 needed his soiled incontinence briefs changed CNA 6 left the resident’s room to collect items for incontinence care. 2. Ensure CNA 6 followed the facility’s policy and procedure (P&P) titled “Answering the Call Light” and used Resident 89’s call light to summon other staff to bring incontinence care items to Resident 89’s room and did not leave Resident 89 unsupervised. 3. Ensure Resident 89 was moved to a room closer to the nursing station for closer monitoring and observation as care planned. These deficient practices resulted in Resident 89 using his call light without response and then attempting to remove his soiled incontinence briefs himself, falling out of bed and sustaining a left hip fracture (break) and subsequent transfer to a General Acute Care Hospital (GACH) for evaluation and treatment on 8/8/2023. While at the GACH Resident 89 was diagnosed with closed left basicervical (area located at the junction between the femoral [the bone of the thigh] neck [part of the bone that connects the head of the bone with the middle part of the bone] and intertrochanteric region [area where the femur changes from a vertical bone to a bone angling at a 45 degree angle]) femur fracture requiring a left hip open reduction internal fixation ([ORIF]-a type of surgery used to hold the broken bone together) with cephalomedullary nail (a surgical devise to stabilize the fracture). On 8/11/2023 Resident 89 returned to the facility with 11 staples on the incision (surgical cut) that measured 5.0 centimeters (cm) by 0.1 cm to the superior (top) surgical site of the left hip and seven staples on the incision that measured 4.0 cm by 0.1 cm to the inferior (bottom) surgical site of the left hip. A review of Resident 89’s Admission Record indicated Resident 89 was initially admitted to the facility on 12/16/2022 and readmitted on 5/31/2023 with diagnoses including difficulty walking, unspecified dementia (impaired ability to remember, think, or make decisions), spinal stenosis (space inside the backbone is too small) of lumbar region (lower part of the back) type 2 diabetes (a disease that occurs when a person’s blood glucose, also called blood sugar, is too high) and transient ischemic attack ([TIA] when blood supply is briefly interrupted to a part of the brain which may cause tissue damage or death). A review of Resident 89’s Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 6/07/2023, indicated Resident 89’s cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making were mildly impaired. The MDS indicated, Resident 89 required extensive physical assistance from staff for bed mobility (moving around in bed or moving from lying to sitting and sitting to lying), transfer (movement from one surface to another), walk in room, toilet use, and personal hygiene. The MDS indicated Resident 89 was frequently (seven or more episodes) incontinent of urine and frequently (two or more episodes) incontinent of bowel within the past seven days. A review of Resident 89’s History and Physical, dated 8/12/2023, indicated Resident 89 had the capacity to understand and make decisions. A review of Resident 89’s Fall Risk Evaluation dated 6/07/2023 and timed at 5:00 p.m., indicated Resident 89 scored a seven (0–5 low risk, 6–20 medium risk, 21–45 high risk) which represented a moderate risk for falls. The Fall Risk Evaluation indicated to provide Resident 89 with a safe, clutter free environment, keep necessary belongings within reach, and attend to needs in a timely manner. A review of the Physical Therapy Evaluation and Plan of treatment dated 6/20/2023 indicated Resident 89 had a history of falling out of bed and sustaining a head injury. Resident 89 was trying to get out of bed to change his own soiled incontinence briefs. A review of Resident 89’s Care Plan (CP) titled, “Risk for fall related to balance problem during transition (sit to stand)” initiated on 6/1/2023, indicated the resident required assistance with walking and bed mobility. The CP indicated the goal for Resident 89 was to decrease significant injury as a result of falls, and to minimize the risk for potential falls related to Resident 89’s getting out of bed without waiting for staff assistance. The CP interventions included to provide Resident 89 with adequate support from staff during activities of daily living (ADL activities related to personal care) and transfers. The CP also indicated to move Resident 89 to a room close to the nursing station for a better visibility. A review of the facility’s Licensed Nurses Progress Note dated 8/07/2023, and timed at 9:56 p.m., indicated Resident 89 was found lying on the floor in the resident’s room. The Progress Note indicated Resident 89 was complaining of left hip pain and had a purple discoloration on his forehead. The progress note indicated 911 (emergency number) was called and Resident 89 was transferred to the GACH. A review of the Situation Background Assessment and Recommendation ([SBAR] a communication tool that can help teams share information about the medical status of a resident after a sudden change of condition) form dated 8/7/2023, indicated at around 8:30 p.m., the clinical nurse (CN) summoned the registered nurse supervisor (RNS) to Resident 89’s room. The CN observed Resident 89 lying on the floor. The SBAR indicated Resident 89 complained of left hip pain level of five out of 10 on a zero to ten pain rating scale (0 is no pain and 10 is the worst possible pain). The SBAR indicated Resident 89 was transferred to the GACH for further evaluation on 8/8/2023 at 8:45 p.m. During an interview on 10/05/2023 at 11:42 a.m. with Resident 89, the resident stated, that on the day he was injured (8/7/2023) he called for assistance by using the call light and waited for a long time and no one came to help him. Resident 89 stated he needed his soiled incontinence briefs changed. Resident 89 stated it felt like he was waiting for more than an hour. Resident 89 stated he just kept on pressing the call light and no one was responding to his call for help. Resident 89 stated, when CNA 6 came in response to his (Resident 89’s) call light, CNA 6 saw his soiled incontinence briefs needed to be changed. Resident 89 stated CNA 6 did not change his soiled incontinence briefs right then and told him (Resident 89) to wait until he (CNA 6) came back and left the room. Resident 89 stated that, he had been waiting for a long time in soiled incontinence briefs, so he decided to remove his incontinence briefs by himself. Resident 89 stated that, when he attempted to sit up in bed, he felt dizzy and rolled out of his bed to the floor. Resident 89 stated, he had severe pain to his left side and screamed in pain. A review of Resident 89’s GACH Emergency Department (ED) notes dated 8/08/2023 and timed at 10:51 a.m., indicated Resident 89 presented to the ED after rolling out of bed and landing on his left hip. The ED notes indicated Resident 89 was diagnosed with a nondisplaced intertrochanteric left hip fracture. The ED notes indicated Resident 89 underwent ORIF of the left hip. A review of Resident 89’s GACH Computerized tomography (CT a computerized x-ray of a body part) scan dated 8/08/2023, indicated Resident 89 had an acute nondisplaced intertrochanteric fracture of the proximal left femur neck. During a phone interview on 10/05/2023, at 3:01 p.m., with CNA 6, CNA 6 stated on 8/07/2023 around 8:20 p.m., he answered Resident 89’s call light and found Resident 89 trying to remove his incontinence briefs while in bed. CNA 6 stated he told Resident 89 to leave the incontinence briefs on and left the room. CNA 6 stated he explained to Resident 89 that he would grab some towels and water to clean him with. CNA 6 stated that when he came back to the room, Resident 89 was on the floor next to his bed laying on his back complaining of left-sided pain. During an interview on 10/5/2023 at 3:24 p.m. with Licensed Vocational Nurse (LVN 3), LVN 3 stated Resident 89 could make his needs known to staff. LVN 3 stated Resident 89 was assessed as a moderate risk for falls and should not have been left alone. LVN 3 stated the Director of Rehabilitation ([DOR] a professional that specializes in improving and restoring functional ability to residents with physical impairments) assessed residents upon admission and that staff should provide the residents with assistance based on the DOR’s assessment and recommendations. During a concurrent interview and record review on 10/06/2023, at 8:41 a.m., with the DOR, the DOR reviewed the Physical Therapy ([PT] treatment of injury, deformity or disease by methods like exercise, and massage rather than drug therapy) Discharge Summary dated from 6/20/2023 to 8/7/2023, and stated, Resident 89 was able to safely ambulate using a front-wheeled walker (assistive device) with supervision or touching assistance for proper sequencing (correct way of walking with assistive device) and that Resident 89 required supervision or touching assistance with bed mobility, transfer, and ambulation. The DOR stated, there was a great possibility that Resident 89 could fall if Resident 89 gets out of bed by himself and/or walks by himself (unassisted). The DOR stated, he did not recommend at all, for Resident 89 to walk or get out of bed by himself. During a phone interview on 10/6/2023 at 8:54 a.m. with LVN 4, LVN 4 stated he remembered that on 8/7/2023 during the 3 p.m. to 11 p.m. shift at around 8 p.m. he heard a loud scream coming from Resident’s 89’s room while he (LVN 4) was tending to another resident. LVN 4 stated he walked to Resident 89’s room and saw Resident 89 lying on the floor, on his left side. LVN 4 stated, he remembers that Resident 89 needed moderate to maximum physical assistance from one staff for ADL’s. Resident 89’s room was located about 40 feet away from the nursing station. LVN 4 stated, CNA 6 told him that CNA 6 walked out of Resident 89’s room to get water and towels and when CNA 6 came back to Resident 89’s room, Resident 89 was found on the floor. LVN 4 stated, Resident 89 was not supposed to be left alone when the resident needed help because Resident 89 had been trying to stand up by himself trying to be independent with his ADL’s. During an interview on 10/06/2023, at 12:11 p.m., with the Director of Nursing (DON), the DON stated if a resident was a moderate risk for falls, she educated the resident to use the call light for assistance. The DON stated after Resident 89’s fall, the next day on 8/8/2023 they moved the resident to a room closer to the nursing station. The DON stated the facility staff should answer a call light promptly, especially when a resident is at risk for falls. The DON stated the facility staff discuss and communicate with each other to identify residents who were at a moderate to high risk for falls. The DON stated the facility staff should not have left Resident 89 alone since CNA 6 noticed Resident 89 felt uncomfortable with having soiled incontinence briefs on. The DON stated if staff noticed that the resident would try to clean himself or herself up, when it was not safe to do that, staff should stay with and monitor the resident, so they do not get hurt trying to get out of bed and ask other staff (CNA/LVN) to get the needed supplies. The DON stated CNA 6 should have used the call light to ask for staff assistance and should not have left Resident 89’s room. During a review of the facility’s P&P titled, “Safety and Supervision of Residents” revised 7/2017, the P&P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. During a review of the facility’s undated P&P titled, “Answering the Call Light.” (undated) the P&P indicated staff to answer the resident’s call as soon as possible. The P&P indicated, if assistance is needed when staff enter the room, summon help by using the call signal. The facility failed to: 1. Ensure CNA 6 did not leave Resident 89 unsupervised when Resident 89 needed his soiled incontinence briefs changed CNA 6 left the resident’s room to collect items for incontinence care. 2. Ensure CNA 6 followed the facility’s P&P titled “Answering the Call Light” and used Resident 89’s call light to summon other staff to bring incontinence care items to Resident 89’s room and did not leave Resident 89 unsupervised. 3. Ensure Resident 89 was moved to a room closer to the nursing station for closer monitoring and observation as care planned. These deficient practices resulted in Resident 89 using his call light without response and then attempting to remove his soiled incontinence briefs (diaper) himself, falling out of bed and sustaining a left hip fracture (break) and subsequent transfer to a General Acute Care Hospital (GACH) for evaluation and treatment on 8/8/2023. While at the GACH Resident 89 was diagnosed with closed left basicervical neck and intertrochanteric region femur fracture requiring a left hip ORIF with cephalomedullary nail. 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 Resident 89.