Health inspection·December 13, 2024

§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) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. §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. §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 10/11/2024, the California Department of Health (CDPH) received a Facility Reported Incident (FRI) indicating a resident (Resident 1) had an unwitnessed fall and sustained an acute (severe and sudden in onset) fracture or dislocation (when the ends of two or more bones are separated from their normal position at the joint) of her pelvis (the bones between the lower abdomen and the upper thighs that connect the sine to the legs) and a minimally displaced fracture (the break in the bone does not go all the way through) of the medial tibia plateau (the flat inner surface of the shinbone that connects to the thighbone). On 10/15/2024 the CDPH received a complaint alleging Resident 1 had a fall incident at the facility, which resulted in Resident 1 sustaining a tibial ([shin] the inner and usually larger of the two bones between the knee and the ankle) fracture, and compression fracture of the T11 and T12 (the part of the spine between the neck and the abdomen that make up vertebrae [a series of small bones forming the backbone] from T1 through T12 and mostly protect the heart and lungs), as a result of Resident 1's bed being too high up from the floor. On 10/25/2024, the CDPH conducted an unannounced visit to the facility to investigate the complaint and FRI allegations. Upon investigation, the CDPH determined Resident 1 had an unwitnessed fall and was found kneeling on the floor by the left side of her bed, holding onto the bed's siderail with the bed in a high position and no floor mats on the floor beside Resident 1's bed. Resident 1 was transferred to a General Acute Care Hospital (GACH) on 10/10/2024, where she was assessed and found to have a hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) and deformity (a part of someone's body which is not the normal shape because of injury or illness, or because they were born that way) with loss of sensation (ability to feel) to the area below her right knee, an acute minimally displaced fracture of the right knee, tibia, and fibula ([calf bone] the outer and usually smaller of the two bones between the knee and the ankle), and a new compression fracture (a type of broken bone that can cause the vertebrae to collapse, making them shorter) of the T11 and T12 thoracic bones. The facility failed to: 1. Implement and provide care in accordance with Resident 1's care plan including placing Resident 1's bed in the lowest position setting with floor mats on both sides of the bed per Resident 1's care plan titled, "At risk for falls/injury related to cognitive impairment" dated 3/20/2022 with a goal to minimize falls and to decrease significant injuries as a result of any sustained falls. 2. Ensure Resident 1's environment was accident hazards free as a much as possible and provide assistive devices to prevent accidents. This includes but is not limited to placing Resident 1's bed in the lowest position setting with floor mats on both sides of the bed in accordance with Resident 1's care plan. 3. Implement facility policy and procedures (P/P), titled "NP04 Comprehensive Person-Centered Care Planning" revised 8/24/2023, that documents the residents' care plans must be developed and implemented based on the residents' goals and objectives. 4. Implement facility P/P titled "Resident Safety" revised 4/15/2021, which documents the facility shall provide the residents a safe environment. These facility failings resulted in Resident 1 being seriously harmed, and in fact, Resident 1 sustained a fracture to her T11 and T12 thoracic bones and fractures to her right tibia and fibula. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 76 year-old female, was initially admitted to the facility on 2/18/2022 and readmitted on 7/11/2024 with diagnoses including glaucoma (an eye disease that can cause vision loss and blindness), legal blindness, and dementia (a progressive state of decline in mental abilities). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 8/15/2024, indicated Resident 1 was able to make decisions that were reasonable and consistent. The MDS indicated Resident 1's vision was severely impaired. A review of Resident 1's History and Physical (H&P) dated 9/2/2024, indicated Resident 1 had diagnoses that included osteoarthritis (a degenerative joint disease in which the tissue in the joint break down over time), and encephalopathy (a change in how the brain works due to an underlying condition and causes confusion, memory loss and loss of consciousness). A review of Resident 1's Fall Risk Assessment, dated on 9/2/2024 and timed at 10:23 a.m., indicated a score of 15. A score of 10 or more indicated a high risk for falls. A review of Resident 1's Order Summary Report (Physician's Order), dated 10/2024, indicated the following physician's orders: 1. On 3/20/2022 Resident 1 may have bilateral (both) floor mats (a cushioned floor pad designed to help prevent injury should a person fall) every shift. 2. On 3/20/2022 keep Resident 1's bed at the lowest position every shift. A review of Resident 1's untitled Care Plan, dated 3/20/2022, indicated Resident 1 was at risk for falls/injury related to her cognitive impairment (a condition where there are problems of the person's ability to think, learn, remember, use judgement, and make decisions), encephalopathy, chronic obstructive pulmonary disease ([COPD] a lung disease that causes breathing problems and restricted airflow), legal blindness, dementia, fibromyalgia (a chronic condition that causes widespread pain and tenderness in the body), and age-related debility (a state of general weakness or feebleness that may be a result or an outcome of one or more medical conditions). The Care Plan indicated a goal to minimize Resident 1's risk of falls and decrease significant injuries as a result of the falls. The Care Plan's interventions included ensuring Resident 1's bed was kept at the lowest position with floor mats on both sides of Resident 1's bed. A review of Resident 1's Change in Condition (COC) form, dated 10/10/2024 and timed at 2:24 a.m., indicated Resident 1 had a fall incident with left leg pain (later determined at the GACH to be the right leg/knee) level rated 10 out of 10 on a pain scale of zero to 10 (an 11 eleven point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain), blood pressure (BP) of 230/159 millimeters of mercury (mmHg, reference range for BP is 120/80), heart rate (HR) of 129 beats per minute ([bpm], HR reference range is 60-100 bpm), and respiratory rate (RR) of 22 breaths per minute (reference range is 12-18 breaths per minute). A review of Resident 1's Nurses Progress Notes dated 10/10/2024 and timed at 4:22 a.m., indicated Resident 1 was found kneeling on the floor, holding the siderail of her bed. The Nurses Progress Note indicated Resident 1 complained of a pain rated 10 out of 10 to her left leg (later determined at the GACH to be the right leg/knee) and the same day (10/10/2024) was transferred to a GACH at 2:30 a.m. A review of Resident 1's Order Summary report, dated 10/10/2024, indicated the physician's order to transfer Resident 1 to a GACH for further evaluation due to a fall. A review of the GACH's Emergency Department (ED) documentation dated 10/10/2024 and timed at 2:45 a.m., indicated Resident 1 presented with a hematoma and deformity, with loss of sensation to the area below her right knee after a non-syncopal (not cause by fainting) fall out of bed at the facility. The ED documentation indicated Resident 1 complained of a pain level of 10 out of 10 to the lower area of her right knee and was administered Morphine for pain. The ED documentation indicated on 10/10/2024 at 4:11 a.m., Resident 1 had an Xray (special pictures of the inside of the body) of the right hip, pelvis, right knee, right tibia, and fibula, and the right femur (the thigh bone). The ED documentation indicated Resident 1 sustained an acute minimally displaced fracture of the right knee, tibia, and fibula. The ED documentation indicated on 10/10/2024 at 4:16 a.m., Resident 1 underwent a CT scan (a diagnostic imaging [picture] procedure that uses a combination of Xray and computer technology to produce images of the inside of the body) of her abdomen and pelvis with contrast (a solution given to a patient before a CT scan to help make certain parts of the body appear more clearly in the images). The ED documentation indicated Resident 1 sustained a new compression fracture of the T11 and T12 thoracic bones, as compared to a previous CT scan done on 3/14/2024. A review of GACH's Orthopedic (a branch of medicine that focuses on the care of the bones, muscles, and joints) Surgery Consultation notes dated 10/10/2024 and timed at 9:25 a.m., indicated Resident 1's fractures could be treated with weight bearing restrictions (limitations placed on a patient's ability to bear weight on a specific part of their body, typically due to an injury or surgery) and a knee immobilizer (a removable device that maintains the stability of the knee). During a telephone interview on 10/25/2024 at 4:05 a.m., Resident 1's Responsible Party (RP) 1 stated over the past few months every time she visited Resident 1, she noticed Resident 1's bed was always in a high position and there was never a floor mat on the floor next to the Resident 1's bed. RP 1 stated she kept reminding nurses about her concerns. RP 1 stated the staff were aware that Resident 1 was legally blind and could get disoriented at times. RP 1 stated Resident 1 had a fall in the past at the facility and needed frequent supervision and a lot of reminders not to get up unassisted. RP 1 stated Resident 1 told her that she (Resident 1) was calling for assistance the night she fell (10/9/2024) because her pillow fell on the floor, no one came to help her get her pillow, so she (Resident 1) tried to get up to get the pillow herself and she rolled out of the bed. RP 1 stated she felt the facility was negligent because the fall precautions (a low bed and floor mats) the facility was supposed to provide, were not implemented all the time. RP 1 stated after Resident 1 fell and broke her backbones and her right knee, her pain become more difficult to control, and there were days she could not participate with the physical therapy ([PT] a health profession that uses physical activities and treatments to help people improve their movement and physical function) provided in the facility. RP 1 stated she was concerned that Resident 1's condition would get worse. During an interview on 10/28/2024 at 6:14 a.m., Certified Nursing Assistant (CNA ) 2 stated Resident 1 could be forgetful at times and needed supervision and frequent reminders to call for assistance. CNA 2 stated Resident 1 had a fall in the past and had floor mats in place on each side of her bed, but for the past couple of months (not sure how long) there had been no floor mats at Resident 1's bedside and she was not sure why. CNA 2 stated the floor mats could have helped lessen the impact when Resident 1 fell (10/10/2024) and might have helped prevent Resident 1's injuries. During an interview on 10/28/2024 at 6:39 a.m., CNA 4 stated Resident 1 had a floor mat in place on the right side of her bed only because Resident 1 had a tendency to lean on that side of the bed. CNA 4 stated she did not expect Resident 1 to fall off the left side of her bed. During a telephone interview on 10/28/2024 at 9:59 a.m., Licensed Vocational Nurse (LVN 4) stated she found Resident 1 kneeling on the bare floor, on the left side of her bed while holding onto the bed's siderail. LVN 4 stated she had to lower Resident 1's bed when she assisted Resident 1 during the fall incident. LVN 4 stated Resident 1's injuries might have been prevented or minimized if there had been floor mats in place and her bed was in a low position, per her care plan. During an interview on 10/28/2024 at 12:43 p.m., the Assistant Director of Nursing Services stated the nursing staff were expected to implement fall precautions intervention as indicated in the resident's care plan and as ordered by the doctor. A review of the facility's P/P titled "NP04 Comprehensive Person-Centered Care Planning" revised 8/24/2023, indicated the facility provides a person-centered, comprehensive, and interdisciplinary care that reflects the best practice standards for meeting the health, safety, psychosocial, behavioral, environmental needs of the residents in order to obtain or maintain their highest physical, mental, and psychosocial well-being. The P/P indicated the residents' care plan must be developed and implemented based on the residents' goals and objectives. A review of the facility's P/P titled "Resident Safety" revised 4/15/2021, the P/P indicated the facility shall provide the residents a safe environment. The facility failed to: 1. Implement and provide care in accordance with Resident 1's care plan including placing Resident 1's bed in the lowest position setting with floor mats on both sides of the bed per Resident 1's care plan titled, "At risk for falls/injury related to cognitive impairment" dated 3/20/2022 with a goal to minimize falls and to decrease significant injuries as a result of any sustained falls. 2. Ensure Resident 1's environment was accident hazards free as a much as possible and provide assistive devices to prevent accidents. This includes but is not limited to placing Resident 1's bed in the lowest position setting with floor mats on both sides of the bed in accordance with Resident 1's care plan. 3. Implement facility P/P, titled "NP04 Comprehensive Person-Centered Care Planning" revised 8/24/2023, that documents the residents' care plans must be developed and implemented based on the residents' goals and objectives. 4. Implement facility P/P titled "Resident Safety" revised 4/15/2021, which documents the facility shall provide the residents a safe environment. These facility failings resulted in Resident 1 being seriously harmed, and in fact, Resident 1 sustained a fracture to her T11 and T12 thoracic bones and fractures to her right tibia and fibula. The above violations jointly, separately, or in 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 1.