Health inspection·February 27, 2024

F689 Code of Federal Regulations, Title 42, Section 483.25(d) Accidents. The facility must ensure that - (d)(1) The resident environment remains as free of accident hazards as is possible; and (d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 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 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: (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. California Code of Regulations, Title 22, Section 72313 Nursing Service--Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. California Code of Regulations, Title 22, Section 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 1/24/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident received on 1/11/2024. On 1/8/2024, Resident 2 sustained an ankle fracture (a complete or partial break of a bone) due to “seizure activity” (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness) after not receiving the entire dosage of prescribed seizure medication between 1/1/2024 through 1/7/2024. The facility failed to: 1. Implement Resident 2’s care plan which indicated the resident will be free from seizure activity, and staff will medicate Resident 2 with Levetiracetam (medication used to treat seizures) two times a day. 2. Follow its policy and procedures (P&P) titled “Care Plans, Comprehensive Person-Centered,” which indicated a comprehensive, person-centered care plan with measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs was developed and implemented for each resident. As a result, Resident 2 had an unwitnessed fall in the bathroom during a seizure activity and sustained a right ankle fracture which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment. It also resulted in a decline in Resident 2’s functional mobility and activities of daily living (ADLs, self-care activities performed daily such as grooming, dressing, and personal hygiene). A review of Resident 2’s admission record (Face Sheet), indicated Resident 2 was, a 78-year-old female, admitted to the facility on 11/6/2023 with diagnoses that included epilepsy (a neurological condition involving the brain that causes seizure), diabetes (abnormal blood sugar), dysphagia (swallowing difficulties), muscle weakness (lack of muscle strength), and hypertension (high blood pressure).  A review of Resident 2’s History and Physical (H&P) dated 11/17/2023, indicated Resident 2 did not have the capacity to understand and make decisions.  A review of Resident 2’s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 11/28/2023, indicated Resident 2 required maximal assistance from staff with toileting, bathing, and personal hygiene.  A review of Resident 2’s Physician’s Order dated, 11/16/2023, indicated Resident 2 was to be given Levetiracetam 1000 milligrams ([MG] unit of measurement), 1 tablet by mouth two times a day for seizure. A review of Resident 2’s Care Plan titled, “Resident has a seizure disorder,” dated 11/30/2023, indicated the care plan’s goal was that the resident would remain free of seizure activity. The staff’s interventions indicated to monitor Resident 2 for seizure activity every shift and give 1 tablet of Levetiracetam by mouth two times a day for seizure.  A review of Resident 2’s Medication Administration Record (MAR) for the month of January 2024, indicated Resident 2 refused the 9 AM dose of Levetiracetam from January 1, 2024, to January 7, 2024. A review of Resident 2’s Progress Note dated 1/8/2024, indicated on 1/8/2024, Resident 2 was found in the bathroom, on the floor near the toilet, in vomit. The progress note indicated while assessing Resident 2, Resident 2 had one episode of an active seizure that lasted approximately 10-15 seconds.  A review of Resident 2’s GACH Admission Record, dated 1/8/2024, indicated Resident 2 was admitted to the GACH on 1/8/2024 with diagnosis of seizures. The GACH record indicated an Orthopedic (branch of medicine dealing with the correction of deformities of bones or muscles) consult was scheduled on 1/10/2024 for an ankle fracture. The GACH record indicated a posterior (back) short leg splint (used to stabilize injuries by decreasing movement and providing support to prevent further injury) was applied. The record indicated, based on imaging and physical exam, Resident 1 did not require emergent surgical intervention at time but would require surgical intervention when a durable power of attorney ([DPOA], someone appointed to make decisions on one’s behalf) was obtained. The GACH record indicated Resident 1 was stable for discharge to the facility, and to follow up outpatient with an orthopedic provider, for surgical planning. A review of Resident 2’s GACH X-ray (process of creating pictures of the inside of your body) of the right ankle, dated 1/9/2024, indicated Resident 2 sustained a closed right trimalleolar (the lower leg sections that forms the ankle joint) ankle fracture dislocation.  During an interview on 1/24/2024 at 10:46 AM, Registered Nurse (RN) 1 stated on 1/8/2024 during the 11 PM to 7 AM (night) shift, she (RN 1) was doing morning rounds and observed Resident 2 on the restroom floor near the toilet. RN 1 stated Resident 2’s fall was unwitnessed. RN 1 stated during the resident’s assessment, she observed Resident 2 had one episode of an active seizure that lasted 10 to 15 seconds.  During a concurrent observation and interview on 1/24/2024 at 11:33 AM with Resident 2, in Resident 2’s room, Resident 2 was in bed awake and alert. Resident 2 was observed with a cast (a shell made from plaster or glass used to immobilize injured bones, promote healing, and reduce pain and swelling while the bone heals) to the right lower leg. Resident 2 stated she had a fall but could not recall the date of the fall or events prior to the fall incident. Resident 2 stated she was transported to a GACH and readmitted to the facility with a cast. Resident 2 stated she wanted the cast removed because it was uncomfortable. Resident 2 stated she was walking prior to the fall but was unable to walk after the fall. Resident 2 stated she felt uncomfortable and unhappy.  During an interview on 1/24/2024 at 12:51 PM, Licensed Vocational Nurse (LVN) 1 stated on 1/8/2024, Resident 2 refused her seizure medications prior to the resident’s fall incident on 1/8/2024. LVN 1 stated she did not remember how many days Resident 2 refused the seizure medications. LVN 1 stated she did not notify Resident 2’s physician (MD 1) that Resident 2 had refused her seizure medications. LVN 1 stated Resident 2 was not monitored for seizure activity. LVN 1 also stated it was important to follow the resident’s care plan, and administer medications as ordered by MD 1. LVN 1 stated not following the care plan and physician orders placed Resident 2 at risk for seizures, falls, injuries and death. LVN 1 stated “unfortunately Resident 2 had a fall and sustained an injury.”  During a concurrent interview and record review on 1/24/2024 at 1:34 PM with the Director of Nursing (DON), Resident 2’s MAR, for the month of January 2024, was reviewed. The DON stated there was no documentation to indicate Resident 2 was monitored for seizure activity. The DON stated, Resident 2 refused to take Levetiracetam at 9 AM from 1/1/2024 to 1/7/2024 (a total of seven days), placing Resident 2 at risk for seizures and injuries.  A review of Resident 2’s Physical Therapy ([PT], branch of rehabilitative health that uses specially designed exercises and equipment to help patients regain or improve their physical abilities) Recertification and Updated Plan of treatment for Progress & Response to Treatment dated 1/12/2024, indicated Resident 2’s functional performance was improving because of skilled treatment. The report indicated after Resident 2’s fall on 1/8/2024, Resident 2 was to have a right lower extremity (leg) non-weight bearing ([NWB], not to put any weight on the affected extremity) activity. The report indicated, the fall affected Resident 2’s ability to walk and perform ADLs. The report indicated Resident 2’s change in condition and decline in function required skilled therapy services to improve quality of life, increase level of care, and resident safety. The report also indicated Resident 2 had increased anxiousness (feeling of unease, excessive worry), confusion, perseveration (continuation of something such as activity or thought) on topics unrelated to skilled therapy services with difficulty to be redirected.  A review of the facility’s Policy and Procedure (P&P) titled, “Care Plans, Comprehensive Person-Centered”, revised 12/2016, indicated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs was developed and implemented for each resident. The P&P indicated assessments of residents were ongoing and care plans revised as information about the residents and the residents’ conditions changed. The facility failed to: 1. Implement Resident 2’s care plan which indicated the resident will be free from seizure activity, and staff will medicate Resident 2 with Levetiracetam two times a day. 2. Follow its P&P titled “Care Plans, Comprehensive Person-Centered,” which indicated a comprehensive, person-centered care plan with measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs was developed and implemented for each resident. As a result, Resident 2 had an unwitnessed fall in the bathroom during a seizure activity and sustained a right ankle fracture which required hospitalization in a GACH for evaluation and treatment. It also resulted in a decline in Resident 2’s functional mobility and activities of daily living (ADLs, self-care activities performed daily such as grooming, dressing, and personal hygiene). 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.