Health inspection·November 15, 2023

42 CFR § 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 resident's choices, including but not limited to the following. 42 CFR §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. 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. (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. 22 CCR § 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. 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 10/10/2023, the California Department of Public Health (CDPH) conducted unannounced visit for an annual recertification survey. The facility failed to: 1. Follow physician’s orders to ensure that Resident 19 did not place weight onto the right leg after toileting due to non-weight bearing (NWB, inability to place any weight through the limb, including an operated limb to allow healing) precautions. 2. Develop and implement a care plan to provide Resident 19 with two-persons assistance for sit to stand transfers (transfers from a seated position to a standing position) and for toilet transfers and toilet hygiene (toileting, includes managing undergarments, clothing, and incontinence products and performing cleansing before or after voiding or having a bowel movement) as recommended by physical therapy and occupational therapy to maintain NWB precautions to the right leg. 3. Provide Resident 19 with adequate supervision and assistance to prevent accidents when Resident 19 only received assistance from one person transferring from the wheelchair to the toilet, one-person assistance standing up from the toilet, and then no support taking a step toward and standing at the sink, thus failing to maintain NWB precautions to the right leg after toileting. These failures resulted in Resident 19 falling from a standing position onto the floor in the restroom on 7/30/2023. On 7/31/2023, Resident 19 complained of right shoulder pain and received an X-ray (used to create images of the inside of the human body) which indicated Resident 19 had a right humeral (shoulder bone) fracture (break in the bone). The facility transferred Resident 19 to the general acute care hospital (GACH 2) on 8/1/2023 where Resident 19 underwent right shoulder surgery on 8/3/2023. A review of Resident 19’s Discharge Summary from the general acute care hospital (GACH) 1, dated 6/28/2023, indicated Resident 19 had a history of cerebral vascular accident (CVA or stroke, brain damage due to blocked blood flow) with right sided weakness and had worsening right knee pain after a fall onto the right knee at home. The Discharge Summary indicated Resident 19 had a distal femur (thigh bone close to the knee) fracture with hardware fracture (breaking of surgically placed pins, plates, or screws to help fix a broken bone). The Discharge Summary indicated Resident 19 underwent surgery on 6/26/2023 for rodding (operative insertion of a straight metal rod) with cement augmentation (injection of bone cement into a fracture) of the right leg and should maintain NWB on the right leg for at least six weeks. A review of Resident 19’s Admission Record indicated the facility admitted Resident 19 on 6/29/2023 with diagnoses including periprosthetic fracture around internal prosthetic right knee joint (fracture of the thigh bone occurring close to metal parts of a previous right knee surgery), encounter for other orthopedic aftercare, muscle weakness, difficulty walking, and hemiplegia and hemiparesis (weakness and paralysis [inability to move] to one side of the body) affecting the right dominant side. A review of Resident 19’s Physician’s Order, dated 6/29/2023 indicated Resident 19 was NWB on the right leg for six weeks. A review of Resident 19’s Fall Risk Evaluation, dated 6/29/2023, indicated the facility assessed Resident 19 as a high risk for falls. A review of Resident 19’s Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 6/29/23, indicated Resident 19’s was NWB on the right leg for at least six weeks. The PT Evaluation indicated Resident 19 was dependent (required more than 75% physical assistance to perform the task) requiring the assistance of two-persons with bed mobility from lying to sitting on the side of the bed. The PT Evaluation indicated Resident 19 was unable to perform sit to stand transfers, bed-to-chair transfers, and toilet transfers due to medical conditions or safety concerns. The PT Plan of Treatment included therapeutic exercises (movement prescribed to correct impairments and restore muscle function), neuromuscular reeducation (technique used to restore movement patterns through repetitive motion to retrain the brain), gait (manner of walking) retraining therapy, therapeutic activities [tasks that improve the ability to perform activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility)], and wheelchair management training (training on proper positioning and ability to propel the wheelchair), five times per week for four weeks. A review of Resident 19’s Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 6/29/2023, indicated Resident 19 was NWB on the right leg for at least six weeks. The OT Evaluation indicated Resident 19 was dependent for toileting, showering, upper body dressing, and lower body dressing. The OT Evaluation indicated toilet transfers were not attempted with Resident 19 due to medical conditions or safety concerns. The OT Plan of Treatment included therapeutic exercises, neuromuscular reeducation, therapeutic activities, and self-care management training, five times per week for four weeks. A review of Resident 19’s Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 7/3/2023, indicated Resident 19 had clear speech, clearly understood verbal content, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 19 was dependent for transfers (how resident moves between surfaces included to or from the bed, chair, wheelchair, and standing position), dressing, toilet use, and bathing. A review of Resident 19’s care plan titled, “At Risk For Falls,” initiated on 7/11/2023, included interventions to place the bed in the lowest position and maintain a clear pathway free of obstacles. A review of Resident 19’s ADL flow sheet (record of nursing assistance provided) for 7/2023 indicated Resident 19 received assistance with toilet use with one-person assistance on 7/25/2023, 7/26/2023, 7/27/2023, 7/28/2023, and 7/29/2023. A review of Resident 19’s PT Recert (Recertification, re-evaluation documenting the need for continued therapy), Progress Report, and Updated Therapy Plan, dated 7/27/2023, the PT Recert indicated Resident 19 required maximum assistance with two-persons for sit to stand transfers and dependent with two-persons for transfers. A review of Resident 19’s OT Recert, Progress Report, and Updated Therapy Plan, dated 7/27/2023, indicated Resident 19 was dependent for toilet hygiene and dependent with two-persons for toilet transfers. A review of Resident 19’s Progress Note for eMAR-Medication Administration, dated 7/30/2023 at 9:57 AM, indicated Licensed Vocational Nurse (LVN) 3 administered one (1) hydrocodone-acetaminophen (pain medication) 5-325 milligrams (MG, unit of measure) to Resident 19 by mouth for severe pain. A review of Resident 19’s Progress Note for Nursing, dated 7/30/2023 at 12:00 PM, indicated LVN 3 noted Resident 19 had “an episode of weakness during transfers from wheelchair to toilet” with Certified Nursing Assistant (CNA) 1 on 7/30/23 at approximately 10:20 AM that resulted in CNA 1 slowly lowering Resident 19 to the ground in a sitting position. LVN 3’s Nursing Progress Note further indicated Resident 19 stated she (Resident 19) felt weak upon transfer and both legs “gave out.” LVN 3’s Nursing Progress Note indicated Resident 19 had no apparent injury, denied hitting head, and was assisted back to bed with three staff members. LVN 3’s Progress Note also indicated Resident 19’s physician and family members were notified. A review of Resident 19’s care plan titled, “At risk for falls,” initiated 7/31/2023 after Resident 19’s assisted fall on 7/30/2023, included to increase staff assistance to two-persons assist during transfers as needed as an intervention for falls. A review of Resident 19’s Progress Note for Therapy, dated 7/31/2023 at 12:00 PM, indicated Physical Therapist (PT) 1 screened Resident 19 after the assisted fall on 7/30/23. PT 1’s Therapy Progress Note indicated Resident 19 complained of right shoulder pain, right knee pain, and Resident 19 refused further assessment on the right shoulder and knee. PT 1’s Progress Note for Therapy indicated nursing was aware and recommended an X-ray of the right shoulder and right knee. A review of Resident 19’s Radiology Results Report, dated 7/31/2023 at 9:41 PM, for the right shoulder X-ray indicated Resident 19 had a comminuted fracture (broken bone in at least two places) of the right humeral neck (part of the upper arm just below the shoulder joint). A review of Resident 19’s Progress Note for Laboratory/Radiology, dated 7/31/2023 at 11:51 PM, indicated LVN 4 reported the X-ray results from 7/31/23 to Resident 19’s physician (MD 1) without any new orders from MD 1. A review of Resident 19’s Progress Note for eMAR-Medication Administration, dated 8/1/2023 at 8:57 AM, indicated LVN 5 administered one (1) hydrocodone-acetaminophen 5-325 MG to Resident 19 by mouth for severe pain in the right shoulder. A review of Resident 19’s Progress Note for Transfer Out, dated 8/1/2023 at 11:11 AM, indicated Registered Nurse (RN) 2 noted Resident 19’s X-ray results were received on 8:50 AM which had a “significant finding” of a right comminuted humeral neck fracture. RN 2’s Progress Note indicated Resident 19 had sharp pain in the right shoulder which was swollen and warm to touch. RN 2’s Progress Note indicated RN 2 placed a sling (bandage used to support an injured arm) on the right shoulder to ensure the right arm was NWB. RN 2’s Progress Note indicated MD 1 was notified and provided orders to transfer Resident 19 to (GACH 2 for further evaluation and treatment. A review of GACH 2’s Emergency Department Note, dated 8/1/2023 at 11:14 AM, indicated GACH 2 admitted Resident 19 for right shoulder pain after a fall in the restroom. A review of GACH 2’s X-ray Report, dated 8/1/2023 at 12:46 PM, indicated Resident 19’s right shoulder had diffuse osteopenia (bones weaker than normal) with a displaced (bone came out of alignment) and comminuted fracture through the right humeral head (shoulder joint) and neck. A review of GACH 2’s X-ray Report, dated 8/3/2023 at 6:00 PM, indicated Resident 19’s right shoulder underwent an open reduction internal fixation (ORIF, surgical procedure where fractured bones are realigned and then stabilized in place with screws, plates, or rods) of the right humeral fracture. A review of GACH 2’s Progress Note, dated 8/4/2023 at 7:57 AM, indicated Resident 19 had to be transferred to the Intensive Care Unit (ICU, department of the hospital for patients who are dangerously ill require constant observation) due to acute hemorrhagic shock (severe blood loss which leads to inadequate oxygen delivery) and required a blood transfusion (process of transferring blood into the veins of a patient). A review of Resident 19’s Physician’s Orders, dated 8/7/2023, indicated the facility re-admitted Resident 19 with diagnoses including displaced comminuted fracture of the right humerus (bone of the upper arm) and subsequent encounter for fracture with routine healing. A review of the Physician’s Order, dated 8/7/2023, indicated Resident 19 was weight-bearing as tolerated (WBAT, able to place weight according to the person’s tolerance) to the right arm and NWB to the right leg. During a concurrent observation and interview on 10/10/2023 at 10:01 AM with Resident 19, in the resident’s room, Resident 19 was observed lying in bed with the head-of-bed elevated. Resident 19 appeared to understand questions but had limited ability to speak. Resident 19 stated she fell three months ago at home and broke the right leg. Resident 19 had difficulty lifting the right arm and raising the right leg. Resident 19 stated there was a problem with the right arm and the right leg but was unable to explain in further detail. During an observation on 10/10/2023 at 11:48 AM, in the Resident 19’s room, Resident 19 was seated in a wheelchair and observed using the left arm to operate a touch screen tablet. During an interview on 10/11/2023 at 9:23 AM with Resident 19, in Resident 19’s room, Resident 19 stated she was assisted to the restroom with one staff member when Resident 19 fell (7/30/2023). Resident 19 was unable to explain the incident in further detail. Resident 19 stated she had right arm pain after the fall and had surgery, which Resident 19 stated relieved the pain. During an observation on 10/11/2023 at 10:45 AM, in Resident 19’s restroom, the small room contained a toilet on the right side and a sink on the left side, which was approximately two feet (unit of measure) immediately in front of the toilet. During a follow-up observation on 10/11/2023 at 12:51 PM, in the restroom, there was a vertical grab bar (safety devices a person can grab onto to maintain balance and hold some body weight while transferring) mounted to the wall on each side of the toilet. During an interview on 10/11/2023 at 12:51 PM with CNA 1, in Resident 19’s restroom, CNA 1 stated Resident 19 was sitting up in a wheelchair and requested to use the restroom on 7/30/2023. CNA 1 wheeled Resident 19 to the restroom, close to the toilet, and transferred Resident 19 from the wheelchair to the toilet toward the right side. CNA 1 stated Resident 19 used the grab bar on the right side of the toilet to assist with the transfer. CNA 1 stated CNA 1 assisted Resident 19 from sitting on the toilet to standing while CNA 1 stood on Resident 19’s left side. CNA 1 stated Resident 19 took a step forward to hold onto the sink directly in front of the toilet. CNA 1 stated Resident 19 stood on both legs at the sink while CNA 1 was behind Resident 19 to clean and fasten Resident 19’s incontinence brief. CNA 1 stated CNA 1 noticed Resident 19’s right leg was getting weak and bent more. CNA 1 then grabbed t