Other·June 12, 2024

42 CFR §483.25(d) Free of Accident Hazards/Supervision/Devices 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. (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 – 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 4/15/2024 the California Department of Public Health (CDPH), received a facility reported incident (FRI) indicating Resident 1 fell and hit her head. On 4/29/2024 at 8:04 AM, an unannounced visit was conducted at the facility. The facility failed to: Ensure Resident 1 walked with assistance after being assessed by the physical therapist (PT- professionals who educate patients about exercises for muscle strength, coordination, and balance) as requiring moderate assistance (staff does half the work for the resident) while walking, which led to a fall with injury on 4/14/2024. As a result, Resident 1 fell in the front lobby, sustained a bump on the back side of her head and a right hip fracture (broken bone) which required admission and surgical intervention at the general acute care hospital (GACH) for six days. Resident 1 was a 56-year-old female, originally admitted to the facility on 1/2/2019 and readmitted on 4/7/2024. Resident 1’s diagnosis included muscle weakness, schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), epilepsy (seizures- sudden electrical activity in the brain), cerebral infarction (stroke causing disrupted blood flow to the brain), heart failure, and difficulty walking. A review of Resident 1’s Minimum Data Set ([MDS]), (a standardized assessment and care planning tool), dated 2/10/24 indicated Resident 1 had severe cognitive impairment (ability to reason, understand, remember, judge, and learn). The MDS indicated Resident 1 required supervision or touching assistance (staff provides touching and/or steadying assistance) when walking more than 50 feet. A review of Resident 1’s care plan, dated 4/8/24, indicated Resident 1 was at high risk for falls and injuries related to generalized weakness, psychotropic medications (drugs that affect brain activity associated with mental processes and behavior), having lack of awareness, poor judgement of safety, and gait (manner of walking) instability. Staff’s interventions included to check the environment that increased risk for falls such as wet spots on the floor and broken handrails, educate resident to change position slowly from sitting to standing, educate resident to use call light to ask for assistance, and referral to rehabilitation services (healthcare services to improve skills for daily living). A review of Resident 1’s Fall Risk Evaluation, dated 4/8/24 indicated Resident 1 was at risk for falls and had a balance problem while standing and walking, had decreased muscular coordination and required the use of assistive devices (a device to help someone perform a task). A review of Resident 1’s PT Evaluation and Plan of Treatment, dated 4/9/24, indicated Resident 1 was referred to PT for a decline in functional capacity (capability for an individual to perform tasks necessary or desirable in their life), functional ambulation (ability to walk), and functional mobility. The PT evaluation indicated precautions (measures taken in advanced to prevent something dangerous) and contraindications (anything that serves as a reason not to provide a procedure or treatment) for Resident 1 included being a fall risk. The PT evaluation indicated Resident 1 had a significant decline in function and generalized weakness due to deconditioning (a decline in physical function because of inactivity), unsteady gait (a person’s manner of walking) and has poor endurance in functional mobility. A review of Resident 1’s Situation Background Appearance Review (SBAR) Communication Form, dated 4/14/24, indicated Resident 1 fell on 4/14/24 at approximately 11:15 AM. The SBAR indicated Resident 1 had a head injury with a bump on the back side of her head. The SBAR indicated Resident 1 complained of right leg pain. A review of Resident 1’s GACH History and Physical (H&P) Final Report dated 4/14/24, indicated Resident 1 was being evaluated for right leg pain and headache after a fall on 4/14/24. The H&P indicated a right hip x-ray (a medical test that takes pictures of bones in the body) showed mildly displaced (movement from its usual position) intertrochanteric (area on the femur [thigh bone] where the hip and thigh meet) fractured on the right femur. During an interview on 4/29/24 at 12:50 PM with the Security Guard (SG), the SG stated she saw Resident 1 fall in the front lobby on 4/14/24 around 11:00 AM. The SG stated she was sitting at her desk and saw Resident 1 walking out the door from the patio across from the front lobby when Resident 1 turned, fell, and hit the ground. The SG stated Resident 1 was walking by herself without a walker. The SG stated she noticed Resident 1 had blood on her head that looked like an abrasion (a rub or wearing off the skin). The SG stated she has often seen Resident 1 walking by herself. During an interview on 4/29/24 at 1:00 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the charge nurse on the day Resident 1 fell, 4/14/24 but she (LVN 1) did not witness the fall. LVN 1 stated she was alerted of Resident 1’s fall by Activities Assistant (AA) 1. LVN 1 stated Resident 1 wore a pair of non-skid socks, and the resident was alert with no change in her level of consciousness (state of being awake). LVN 1 stated Resident 1 often walked on her own without the use of assistive devices and could be impulsive. LVN 1 stated staff had to remind Resident 1 to slow down when walking or hold onto the handrails to prevent falls and injuries. During an interview on 4/29/24 at 1:50 PM with LVN 2 and Certified Nurse Assistant (CNA) 1, LVN 2 and CNA 1 both stated they were familiar with Resident 1, and often walked around the facility by herself, and did not use any assistive devices when doing so. CNA 1 stated the staff did not walk with Resident 1 but would check up on her to make sure she was okay. CNA 1 stated staff did not need to help her when getting up off the bed or chair and going to the restroom. LVN 2 stated he was not aware that Resident 1 required more assistance or supervision while walking. During a concurrent interview and record review on 4/30/24 at 9:51 AM with the Registered PT (RPT), Resident 1’s PT Discharge Summary was reviewed. The RPT stated she has worked with Resident 1, and the resident was sometimes non-compliant with safety measures and could be impulsive. The RPT stated Resident 1 did not like using a walker and preferred to walk on her own. During a concurrent observation and interview on 4/30/24 at 11:20 AM with Resident 1, in Resident 1’s room, Resident 1 was observed lying on her bed with a dressing noted on her right hip. Resident 1 stated she had surgery for a broken bone after she fell. Resident 1 stated she finished smoking in the patio and was walking back to her room when she felt dizzy. Resident 1 stated she could not catch herself and fell to the ground. Resident 1 stated she was working with physical therapy to be able to walk again. During a concurrent interview and record review on 4/30/24 at 2:36 PM with the PT Assistant (PTA), Resident 1’s PT Treatment Encounter Notes dated 4/9/24- 4/14/24 were reviewed. The PTA stated Resident 1 was referred to PT due to a need in performing activities of daily living ([ADL]-tasks related to personal care), decreased coordination, reduced balance, decrease in strength and a high risk for falls. The PTA stated Resident 1 was last evaluated on the morning of 4/14/24 before the fall occurred. The PTA stated Resident 1’s functional status indicated that Resident 1’s gait on level surfaces required moderate assistance, the distance on level surfaces was 50 ft., and an assistive device used was handheld assistance which means they would hold their hand to guide the resident while walking. The PTA stated moderate assistance was defined as the resident performing 50 percent (%) of the activity or task and the staff did the other 50% which could include verbal and tactile cues (physical touch to guide or remind completion of a task or activity), setup of equipment such as siderails and wheelchairs, holding onto the residents gait belt (device put on a person with mobility issues to help them move around), or resident holding or using assistive devices such as the staff members hand or a handrail. The PT Treatment Encounter Notes from 4/10/24 to 4/14/24 indicated Resident 1’s gait on level surfaces required moderate assistance going 50 ft on level surfaces with assistive device being handheld assist. The PTA stated that her method of communication to the nursing staff was done verbally, and it was assumed the information would be endorsed to the nurses on the next shift. The PTA stated the PTA ’s did not have access to document in the system the nurses used. During an interview on 4/30/24 at 3:20 PM with the Director of Rehabilitation (DOR), the DOR stated the bulk of the rehabilitation department’s documentation was done in their own system that did not cross over to the system the nursing staff used and could not see their assessment and notes. The DOR stated if there was something important that needed to be discussed regarding a resident, they would have a verbal conversation with the nursing staff. The DOR stated Resident 1 could be impulsive and needed some verbal or visual cues from staff to remind her to walk slower. During a concurrent interview and record review, on 5/1/24 at 11:14 AM with LVN 1, Resident 1’s PT Treatment Encounter Notes dated 4/9/24- 4/14/24 was reviewed. LVN 1 stated based on the notes from the rehabilitation department, Resident 1 was not as independent as she thinks when ambulating and required more assistance and supervision from staff. LVN 1 stated she was not made aware of this assessment from PT and was not aware of any special instructions for Resident 1. LVN 1 stated if she knew the resident required more assistance and supervision, there would have been more interventions in place to keep the resident safe while walking and the resident might have avoided the fall. During a concurrent interview and record review on 5/1/24 at 12:39 PM with RPT, Resident 1’s PT Discharge Summary, dated 4/9/2024, was reviewed. RPT stated one of Resident 1’s long-term goals were to ambulate on level surfaces for 150 ft. using no assistive devices but with contact guard assist (CGA) which means the staff was standing by to provide reminders and nudges as necessary. RPT stated on the day Resident 1 fell, she did not meet this goal of having CGA and ambulating 150 ft. with no assistive devices and Resident 1 still required moderate assistance from staff. During an interview on 5/1/24 at 2:30 PM with RN 1, RN 1 stated Resident 1 had a history of seizures, was a high fall risk and needed redirection at times. During an interview on 5/1/24 at 3:05 PM with the Director of Nursing (DON), the DON stated Resident 1 walked independently with a short stride, was a high fall risk, had a history of seizures, and was impulsive. The DON stated Resident 1 could ambulate independently and did not require staff to be by her side constantly to supervise her. The DON stated if there were concerns or precautions to take regarding a resident but was not communicated or followed up on, the resident might get hurt. A review of the facility policy and procedure (P&P) titled, “Fall Prevention and Management”, revised 2018, indicated the facility will have a fall prevention and management program that provides an environment free from hazards over which the facility has control. A review of the facility P&P titled, “Resident Rights- Quality of Life”, dated 5/1/2023, indicated facility staff provide care and services that ensure the resident’s abilities in activities of daily living do not diminish while in the care of the facility, except when unavoidable as evidenced by clinical condition. The facility failed to: Ensure Resident 1 walked with assistance after being assessed by the physical therapist (PT- professionals who educate patients about exercises for muscle strength, coordination, and balance) as requiring moderate assistance (staff does half the work for the resident) while walking, which led to a fall with injury on 4/14/2024. As a result, Resident 1 fell at the front lobby, sustained a bump on the back side of her head and a right hip fracture which required admission and surgical intervention at the GACH, for six days. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.