Other·May 1, 2024

F689 (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) §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. 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 3/06/2024, the California Department of Public Health (CDPH) received a complaint regarding a resident (Resident 1) who sustained a laceration on her head when she fell out of bed due to a seizure. Resident 1 did not have side rails to protect her from falling out of the bed during the seizure. On 3/13/2024 at 11:45 a.m., CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation CDPH determined the facility did not ensure Resident 1 safety during possible seizure resulting in Resident 1 fall from the bed during a seizure activity, sustaining a laceration on top of her head that required admission to a general acute care hospital (GACH) for evaluation and treatment. The facility failed to: 1. Ensure Resident 1, who had diagnosis of epilepsy, was identified upon admission to the facility on 2/10/2024, as being at risk for seizures and placed on seizure precautions. 2. Have a policy and procedure (P&P) in place regarding the management and care of residents with the diagnoses of seizures, convulsions, and epilepsy, including how to identify those residents at risk and implement seizure precautions. As a result, Resident 1 fell from the bed during a seizure activity, sustaining a laceration on top of her head that required admission to a general acute care hospital (GACH) for evaluation and treatment. Resident 1 became unresponsive and was intubated and the resident's cut on top of her head was sutured. A review of Resident 1's Admission Record indicated Resident 1, a 27-year-old female, admitted to the facility on 2/10/2024 with diagnoses including epilepsy and systemic lupus erythematosus. A review of Resident 1's History and Physical (H&P) dated 2/13/2024 indicated Resident 1 had a fluctuating capacity to understand and make decisions. A review of Resident 1's Care Plan titled "High risk for injury due to seizure activity" dated 2/12/2024, indicated a goal for Resident 1 was to have no injury daily for the next three months. The care plan interventions included to implement fall and seizure precautions, and provide a safe environment free of clutter, adequate lighting and non-slippery. A review of Resident 1's care plan titled "High risk for trauma/injuries and ineffective breathing pattern related to diagnosis of complex partial epilepsy" dated 2/12/2024 indicated Resident 1 will not have a significant injury if seizure activity occurred through next review. The care plan's interventions included keep environment free of safety hazards. A review of Resident 1's Situation, Background, Assessment, Recommendation ([SBAR] a verbal or written communication tool that helps provide essential, concise information, usually during a crucial situation) dated 3/4/2024 indicated Resident 1 was found lying on the floor on the left side of the bed, non-responsive to verbal stimuli. The SBAR indicated Resident 1 had tonic clonic generalized seizures (loss of consciousness and violent muscle contractions), and bleeding on the left side of the head. The SBAR indicated Resident 1's physician was notified, and the physician recommended staff to apply pressure to Resident 1's left side of the head and transfer the resident to the GACH. A review of Resident 1's ambulance report dated 3/4/2024 indicated the facility's staff found Resident 1 on the ground beside her bed with blood on the ground. The report indicated Resident 1 had a two inches laceration to the back of her head and exhibited decerebrate posturing (posture characterized by a stiff body, straight legs, and clenched fists usually from severe brain damage). The ambulance report indicated upon emergency services assessment Resident 1 began to have full body tonic clonic shaking. The ambulance report indicated Midazolam (medication commonly used as emergency treatment for seizures) was administered to Resident 1 via intravenous (IV) access. The ambulance report indicated upon arrival to the GACH, Resident 1 had another seizure. A review of Resident 1's Face Sheet from the GACH indicated Resident 1 was admitted on 3/4/2024 with diagnosis of status epilepticus (a seizure that lasts longer than 5 minutes or has more than one seizure within a five-minute period without returning to a normal level of consciousness between seizures). A review of Residents 1's Trauma H&P from the GACH dated 3/4/2024, the Trauma H&P indicated Resident 1 had an unwitnessed fall. The Trauma H&P indicated upon arrival to the GACH, Resident 1 was actively seizing and was intubated for airway management (procedures used to maintain or restore a patient's airway). The Trauma H&P indicated Resident 1 had a small left tempo-parietal (side of the head) hematoma. During an interview on 3/13/2024 at 11:05 a.m., with Paramedic ([PAR] a person trained to give emergency medical care) 1, PAR 1 stated when he entered the room, Resident 1 was in bed, actively seizing. PAR 1 stated Resident 1's bed did not have side rails and there were no floor mats. PAR 1 stated he observed a 12-inch blood stain on the floor, next to the resident's bed. PAR 1 stated Resident 1 was transported to the GACH via ambulance and had a seizure activity upon arrival to the GACH. During an interview on 3/13/2024 at 12:45 p.m. Resident 1 stated there were no padded side rails or floor mats prior to her fall and seizure on 3/4/2024. Resident 1 stated she did not remember the details surrounding her seizure and only remembered when she was receiving stitches for the laceration on her head. Resident 1 stated she had her first seizure on 11/2023. During an interview on 3/13/2024 at 12:58 p.m. the Director of Staff Development (DSD) stated on 3/4/2024 he found Resident 1 on the floor laying on her left side shaking. The DSD stated Resident 1's bed had no side rails. The DSD stated he supported Resident 1's head up so the resident would not hit her head on the floor repeatedly. The DSD stated residents with a history of seizures should be placed on seizure precautions including bed in lowest position, floor mats, pillows tuck under the resident on the side of their bed to prevent them from falling. During an interview on 3/14/2024 at 1:27 p.m., a Certified Nursing Assistant (CNA) 1 stated when she provided care to Resident 1 on 3/4/2024 around 11 a.m., Resident 1 did not have padded side rails on the bed and floor mats. CNA 1 stated she was not aware Resident 1 had a history of seizures. During an interview on 3/14/2024 at 1:44 p.m., the Assistant Director of Nursing (ADON)stated she responded to the DSD's call for help on 3/4/2024, at 11:35a.m., and found Resident 1 on the floor, seizing. The ADON stated when she put a pillow under Resident 1's head, she noticed a large amount of blood on the resident's head. The ADON stated she was familiar with the resident's history of SLE and End Stage Renal Disease ([ESRD] medical condition in which a person's kidneys stop functioning on a permanent basis) but not of seizures. The ADON stated she reviewed Resident 1's medication list but could not find any anti-seizure medications. The ADON stated she was unsure about Resident 1's seizure history. The ADON stated Resident 1 should have had padded siderails which would have prevented her from falling out of the bed and being injured. During an interview on 3/14/2024 at 2:56 p.m., LVN 2 stated residents with a history of seizures identified during admission should have seizure precautions implemented. LVN 2 stated the facility did not have a policy on how to identify residents with diagnosis of seizures, convulsions, or epilepsy, on anti-seizure medications and safety measures to implement. During an interview on 3/14/2024 at 3:14 p.m., the Minimum Data Set Nurse (MDSN) stated the diagnosis list for each resident was generated from the resident's hospital records. The MDSN stated care plans were created from the diagnosis list. The MDSN stated seizure precautions should have been implemented for all residents with diagnosis of seizure, convulsions, and epilepsy. The MDSN stated if seizure precautions were not in place, a resident could fall from their bed and be injured. During an interview on 3/16/2024 at 9:36 a.m., LVN 3 stated residents at risk for seizures were identified on admission by their diagnosis and medications ordered for seizures. LVN 3 stated seizure precautions should be implemented when residents were admitted with diagnoses of seizure, convulsion and epilepsy and were on anti-seizure medications to prevent falls and injuries seizures. During an interview on 3/16/2024 at 10:04 a.m., RNS 2 stated seizure precautions should be implemented upon admission if a resident was identified as being at risk for seizure. RNS 2 stated during meetings and huddles staff were notified of residents at risk for seizures. RNS 2 stated she was unsure if the facility had a method to identify residents at risk for seizures such as a wrist band. RNS 2 stated any resident on seizure medications should be on seizure precautions because the medications could limit seizures, but not prevent them. During an interview on 3/16/2024 at 11:45 a.m. the Director of Nursing (DON) stated upon admission a resident was identified as at risk for seizure based on the resident's seizure medications. The DON stated since Resident 1 was not prescribed any seizure medication, Resident 1's seizure history was unknown. The DON stated if the seizure diagnosis was not identified and seizure precautions were not implemented, residents could suffer an injury during a seizure. The DON stated the MDSN and RNS should have followed up to ensure care plan interventions were implemented for seizure precautions for Resident 1. The DON stated the facility did not have a policy on seizure management and precaution. A review of a facility's document titled "Facility Assessment" dated 2/15/2024, the Facility Assessment indicated residents accepted to the facility with diagnosis including seizure disorders that require complex medical care and management. A review of the facility's P&P titled "Comprehensive Care Planning," (undated) the P&P indicated the care plans were developed to address minimum health care information required to properly care for each resident, including goals and objectives. The P&P indicated the care plan must address effective and person-centered care that met professional standards for quality of care. The facility failed to: 1. Ensure Resident 1, who had diagnosis of epilepsy, was identified upon admission to the facility on 2/10/2024, as being at risk for seizures and placed on seizure precautions. 2. Have P&P in place regarding the management and care of residents with the diagnoses of seizures, convulsions, and epilepsy, including how to identify those residents at risk and implement seizure precautions. As a result, Resident 1 fell from the bed during a seizure activity, sustaining a laceration on top of her head that required admission to a GACH for evaluation and treatment. Resident 1 became unresponsive and was intubated and the resident's cut on top of her head was sutured. These violations had a direct or immediate relationship to the health, safety, or security of Resident 1.