Other·May 25, 2023

42 CFR § 483.25(d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; (2) and each resident receives adequate supervision and assistance devices to prevent accidents. 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 residents' choices. 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. The California Department of Public Health (CDPH) received a facility reported incident (FRI) on 9/27/2022 indicating on 9/25/2022, a resident (Resident 1) used the call light for assistance and alleges Certified Nursing Assistant (CNA) 1 assisted the resident to the restroom. CNA 1 closed the restroom door and stepped away. CNA 1 noted the call light was on and returned to the resident’s room. Resident 1 was found sitting on the restroom floor. On 10/4/2022, CDPH conducted an unannounced investigation at the facility. The facility failed to prevent an avoidable fall for Resident 1, who was left alone during toilet use, by failing to: 1. Ensure Resident 1 was provided with assistance from staff during toileting. 2. Ensure Resident 1 was not left alone in the bathroom during toilet use. As a result, Resident 1 waited for almost 15 minutes in the bathroom for assistance, stood up to clean herself and tried to walk back to her bed by herself and sustained an avoidable fall on 9/25/2022, with a subsequent transfer to a general acute care hospital (GACH) for treatment. Resident 1 was diagnosed with a left hip displaced fracture of the left femoral neck (break in the upper portion of the femur [thighbone]) and underwent left total hip arthroplasty (a surgical procedure in which a surgeon makes an incision over the side of the thigh, removes the diseased parts of the hip joint, and replaces them with new, artificial parts) on 9/28/2022. A review of Resident 1’s Admission Record, indicated Resident 1 was 81-year-old female admitted to the facility on 9/19/2022 with diagnoses that included muscle weakness, repeated falls, anemia (condition in which the blood does not have enough healthy red blood cells), and diabetes mellitus (a group of diseases that results in too much sugar in the blood). A review of Resident 1’s History and Physical (H&P) dated 9/20/2022, indicated Resident 1 had the capacity to make decisions. Resident 1 fell at home on 9/15/2022 and was to start Physical Therapy (PT, focuses on improving the patient’s ability to move their body) and Occupational Therapy (OT, focuses on improving the patient’s ability to perform activities of daily living) due to debility (physical weakness). A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/26/2022, indicated Resident 1’s memory was intact and could independently make decisions of daily life. The MDS indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for bed mobility, transfer, and personal hygiene; limited assistance (resident highly involved in activity; staff provided guided maneuvering of limbs or other non-weight bearing assistance) for toilet use; and total dependence for bathing. A review of Resident 1’s undated baseline care plan indicated impairment in physical function requiring physical therapy (PT), occupational therapy (OT), and speech therapy (training to help people with speech and language problems to speak more clearly). The interventions indicated to provide the level of assistance needed. A review of Resident 1’s care plan dated 9/20/2022 titled: Resident has self-care deficits with bed mobility, transfer, ambulation in room, and toileting. The care plan indicated assists with ADL’s as needed, assist with shower/bathing as scheduled and provide incontinent care as needed. A review of Resident 1’s care plan titled, “Superstar program,” dated 9/19/2022, indicated Resident 1 was at risk for falls related to a history of repeated falls. The staff’s approach indicated to respect Resident 1’s wishes for independence and dignity and attach call light to bed within access of the resident. The care plan did not address Resident 1’s toileting needs. A review of Resident 1’s Initial Occupational Therapy Assessment dated 9/20/2022, indicated Resident 1’s goal was to “safely perform toileting tasks using a raised toilet seat with modified independence for safe maneuvering in small spaces and for use of compensatory strategies with ability to maintain balance.” The assessment indicated Resident 1 needed maximum assistance with bathing, and moderate assistance (resident performs 50 percent [%] of the task) with toileting needs during activities of daily living with staff help. A review of Resident 1’s Fall Risk Assessment dated 9/20/2022, indicated a score of 18, indicating a high risk for falls. The Fall Risk Assessment indicated a “care plan should be developed, initiate a falling star /super star care plan, complete the rehab falls risk assessment, assess for environmental hazards, and implement useful interventions to reduce falls and injuries.” A review of Resident 1’s PT summary of daily skilled services dated 9/23/2022, indicated Resident 1 was a fall risk. The summary indicated Resident 1 was unsteady with gait (walking) with front wheel walker (FWW), had increased trunk (comprises of the chest, the back, the shoulders, and the abdomen) sway (moving side to side when walking) and uneven step length and stride length during gait. The summary indicated the caregiver was educated for safety to prevent falls and proper positioning for comfort, pressure relief, good body alignment and safety. A review of Resident 1’s PT Treatment Encounter Notes dated 9/25/2022, indicated Resident 1 needed moderate assistance with bed mobility, transfer, and gait training. A review of Resident 1’s Change of Condition (COC)/ Interact Assessment form dated 9/25/2022, indicated at 4 p.m., on 9/25/2022, Resident 1 called out needing to use the bathroom. The COC indicated CNA 1 responded to Resident 1 and assisted the resident to the bathroom. The COC indicated RN 1 was then informed Resident 1 was sitting on the bathroom floor. The charge nurse (RN1) responded and assessed Resident 1. The resident was able to verbalize she tried to clean herself, stood up but instead her foot slid down and she fell. The COC indicated Resident 1 denied pain and hitting her head, and range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point) was performed with no difficulty. The COC indicated two CNAs (CNA 1 and CNA 2) and RN 1 assisted Resident 1 back to bed. The COC indicated CNA 1 stated she stepped out the room to get Resident 1 a diaper and when she returned the resident was on the bathroom floor. The COC indicated at 4:25 p.m. (on 9/25/2022), Resident 1 began complaining of pain to the left hip. Resident 1’s physician was informed and gave an order for a stat (immediate) x-ray (photographic or digital image of the internal composition of something, especially a part of the body). A review of Resident 1’s x-ray dated 9/25/2022, indicated Resident 1 sustained a horizontal fracture through the left femoral neck with approximately 1.2-centimeter (cm, unit of measurement) cephalad (towards the head) displacement of the distal fracture. A review of Resident 1’s Rehab Fall Risk Assessment (RFRA) dated 9/26/2022, indicated Resident 1 was found on the floor in the bathroom (9/25/2022). The RFRA indicated Resident 1 recalled details of the incident and needed extensive assistance with bed mobility and was dependent with transferring. The RFRA indicated Resident 1 was able to ambulate (walk) with the use of a front wheel walker (FWW) prior to the fall and the resident used the call bell properly. The RFRA indicated for physician follow up and orthopedic consult (branch of medicine dealing with the correction of deformities of bones or muscles) at the GACH. A review of Resident 1’s GACH records dated 9/27/2022, indicated Resident 1 fell at the facility (9/25/2022) and began having complaints in the left leg area. The GACH records indicated Resident 1 was brought to the Emergency Room (ER) and was found to have a left femur neck fracture. The GACH records indicated Resident 1 was admitted to the GACH for surgery and remained in the GACH for 8 days. During an interview on 10/4/2022 at 10:11 a.m., with Resident 1, Resident 1 stated she could not move her legs like she used to because she fell on the floor “like a taco in the pan.” Resident 1 stated she remembered vividly, she was left in the bathroom alone and when she was ready to get up, she pulled the string (call light) to call for staff. Resident 1 stated she waited for almost 15 minutes in the bathroom, and no one came to help her. Resident 1 stated she stood up to clean herself and tried to walk back to her bed by herself. Resident 1 stated when she opened the bathroom door, she lost her balance and fell. During an interview on 10/4/2022 at 10:25 a.m. with the Infection Preventionist (IP) Nurse, the IP Nurse stated residents who were high risk for falls were assessed by the licensed vocational nurses (LVNs) during admission. The IP Nurse stated if residents needed more attention such as frequent checks, the resident was placed near the nursing station. The IP Nurse stated Resident 1 was a new admit to the facility and staff were not yet familiar with the resident when she fell. CNA 1 is not aware of Resident 1 tries to be always independent. During an interview on 10/4/2022 at 10:35 a.m. with LVN 1, LVN 1 stated during admission the nurses assessed the residents. LVN 1 stated if the resident was identified to be a high risk for falls, staff provided a lot of interventions that would prevent a fall from happening in the facility. LVN 1 stated that they (nursing staff) put Resident 1 close to the nursing station to monitor her whereabouts and assist her every time she tried to get up unassisted. LVN 1 stated that she does not know why CNA 1 left Resident 1 in the bathroom. During an interview on 10/4/2023 at 12 p.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 1 needed assistance with toileting and approximately 75 percent (%) would be from staff’s help. The DOR stated the CNAs should not leave residents that needed assistance to the bathroom alone. The DOR stated residents tend to try to be as independent as possible. The DOR stated the assessment during initial admission of the rehabilitation department was thorough and should reflect how nursing should help in the care or activities of daily living (ADLs, daily self-care activities such as grooming, bathing, dressing, and toileting) of the resident. The DOR stated high risk for fall residents were those residents who had history of falling, so staff should be more watchful of the residents. During an interview on 10/4/2022 at 12:23 p.m. with Restorative Nurse Assistant (RNA) 1, RNA 1 stated residents who were high risk for falls or on the Superstar Program should not be left alone in the bathroom. RNA 1 stated newly admitted residents should not be left alone because the residents try to be independent because at their home, they (residents) do everything independently. During a telephone interview on 4/3/2023 at 4:33 p.m. with CNA 1, CNA 1 stated on 9/25/2022, she used the shower chair (raised chair) and wheeled Resident 1 to the bathroom, then CNA 1 remembered that she (CNA 1) left Resident 1 in the bathroom because the resident asked for privacy. CNA 1 stated she went and grabbed a diaper at Resident 1’s bedside table and heard the resident scream for help. CNA 1 stated when she opened the door, Resident 1 was already on the floor. CNA 1 stated Resident 1 was continent (able to control) both bowel and bladder. A review of the facility’s undated policy and procedure (P&P) titled, “Fall Risk Assessment,” the P&P indicated to identify and assess any resident who may be at risk for falling and to begin interventions and reduce injury. The P&P indicated each resident will be given a score, and if the score is 18 or above, the resident will be considered for the super star program and a plan of care will be established immediately for implementation of interventions to attempt reduction of fall or injury. A review of the facility’s undated P&P titled, “Promoting Safety, Reducing Falls,” the P&P indicated major risk factors indicated history of falls, any information about previous falls should be reported immediately to the charge nurse. Important details include the specific activity the resident was doing at the time of the fall, any symptoms experienced just before or at the time of the fall and any injuries sustained. The P&P indicated since most falls occur when a resident is going to or from the bathroom, it is critical for caregivers (CNA’s and Licensed Nurses) to observe an individual’s elimination patterns (bodily discharges including urine, feces, and vomit) including how they get to and from the bathroom, how they get on and off the toilet, and how frequently they need to go. A review of the undated facility’s P&P titled, “Falling Star Program,” the P&P indicated the purpose was to identify and assess any resident who may be at risk for falling and to begin interventions, an identify colorful star will be placed in personal resident areas bathroom door, identifying the bed number of resident on the inside and outside of the door. The facility failed to prevent an avoidable fall for Resident 1, who was left alone during toilet use, by failing to: 1. Ensure Resident 1 was provided with assistance from staff during toileting. 2. Ensure Resident 1 was not left alone in the bathroom during toilet use. As a result, Resident 1 waited for almost 15 minutes in the bathroom for assistance, stood up to clean herself and tried to walk back to her bed by herself and sustained an avoidable fall on 9/25/2022, with a subsequent transfer to a GACH for treatment. Resident 1 was diagnosed with a left hip displaced fracture of the left femoral neck and underwent left total hip arthroplasty on 9/28/2022. 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.