Health inspection·November 14, 2024

42 CFR §483.25(c) Mobility (1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and (2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. (3) A resident with limited mobility receives appropriate services, equipment, and to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. 42 CFR §483.10(g)(14) Notification of Changes (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention. (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) 22 CCR §22 72315 Nursing Services - Patient Care (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her. professional licensure. (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures, and deformities. Such care shall include: (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities (g) Each patient requiring help in eating shall be provided with assistance when served and shall be provided with training or adaptive equipment in accordance with identified needs, based upon patient assessment, to encourage independence in eating. 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 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: (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. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (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. On 10/4/2024, the California Department of Public Health (CDPH) conducted a standard annual Recertification Survey of the facility. The facility failed to: 1. Obtain baseline (initial measurement taken at an early point and used for comparison over time to monitor changes) ROM measurements of Resident 43's both arms and legs upon admission on 8/12/2023 using the Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs) in accordance with the facility's policy titled, "Joint Mobility and Screening and Assessment" revised on 1/25/2024. 2. Obtain a baseline ROM measurement of Resident 43's left arm during the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation on 8/14/2023. 3. Assess Resident 43's left wrist hand orthosis ([WHO] material secured with straps that extends from the fingers to the forearm to properly position the fingers and wrist and prevent contractures [condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness]) for fit and wear tolerance (amount of time a person can wear an orthosis before experience discomfort or any other side effects) of up to eight hours upon discharge from OT services on 9/10/2023 in accordance with professional standards (guidelines that outline the practices, skills, and qualifications that professionals in a given field should follow), including assessment of the orthosis (external medical device used for supporting, immobilizing and treating joints) for fit and wear tolerance. 4. Provide Resident 43 with Restorative Nursing Assistant ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) services from 9/11/2023 to 9/20/2023 (10 days) and from 10/20/2023 to 11/30/2023 (over one month) for passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) exercises to the left arm and the application of Resident 43's left WHO in accordance with the OT Discharge Summary recommendations on 9/10/2023. 5. Monitor ROM changes in both of Resident 43's arms and legs from 9/11/2023 to 4/1/2024 (over 6 months). 6. Apply Resident 43's left WHO on 9/30/2024. 7. Perform ROM exercises to Resident 43's left elbow on 10/1/2024. As a result of these failures, Resident 43 developed ROM limitations in the left shoulder, elbow, and hand, including the development of a left-hand contracture. A review of Resident 43's Admission Record, indicated Resident 43 a 62 year old female was initially admitted to the facility on 8/12/2023 with diagnoses including end stage renal disease ([ESRD] irreversible kidney failure), dependence on renal (kidney) dialysis (treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left nondominant side (less often used during completion of daily living tasks). A review of Resident 43's PT Evaluation and Plan of Treatment, dated 8/13/2023, indicated Resident 43 fell from the bed and had a right-side brain hemorrhage (bleeding), which caused weakness on the left side of Resident 43's body. The PT Evaluation indicated the ROM in both of Resident 43's legs were within functional limits ([WFL] sufficient movement without significant limitation). A review of Resident 43's OT Evaluation and Plan of Treatment, dated 8/14/2023, indicated Resident 43's ROM in the right arm, left wrist, and left hand were WFL. The OT Evaluation indicated Resident 43's ROM in the left shoulder and elbow was impaired (unspecified). A review of Resident 43's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 8/16/2023, indicated Resident 43 had functional ROM impairments in one arm and one leg. A review of Resident 43's PT Discharge Summary, dated 9/10/2023, indicated Resident 43 was dependent (required more than 75 percent [%] physical assistance to perform the task) with bed mobility and transfers, requiring a mechanical lift (a device that helps residents who have difficulty moving on their own to be transferred or moved from one place to another) for transfers. The PT Discharge Summary recommendations indicated for Resident 43 to receive an RNA program for PROM exercises to both legs. A review of Resident 43's OT Discharge Summary, dated 9/10/2023, indicated Resident 43 required moderate assistance (required between 26 to 50% physical assistance to perform the task) for hygiene, grooming, and self-feeding. The OT Discharge Summary recommendations indicated for Resident 43 to receive an RNA program for PROM exercises to the left arm and application of a left WHO. The OT Discharge Summary did not include an OT goal related to monitoring Resident 43's wear tolerance of the left WHO. A review of Resident 43's Documentation Survey Report (record of nursing assistant tasks) for RNA, dated 9/2023, indicated Resident 43 started receiving PROM on both arms and legs and application of the left WHO for up to 8 hours, five times per week, on 9/21/2023 (10 days after OT Discharge Resident 43). A review of Resident 43's Nurses Progress Notes, dated 10/19/2023, indicated Resident 43 was transferred to a general acute care hospital (GACH) to replace Resident 43's permanent catheter ([PermaCath]- flexible tube interested into a blood vessel in the neck or upper chest and threaded to the right side of the heart) for dialysis. A review of Resident 43's Documentation Survey Report for RNA, dated 10/2023, indicated Resident 43 stopped receiving PROM on both arms and legs and application of the left WHO for up to 8 hours, five times per week, on 10/20/2023. A review of Resident 43's Physician Orders, dated 10/20/2023, indicated to readmit Resident 43 to the facility and resume all medications. The Physician's Orders did not include an RNA task for Resident 43 upon their admission to the facility on 10/20/2023. A review of Resident 43's MDS, dated 11/16/2023, indicated Resident 43 had functional ROM impairments in one arm and one leg (unspecified side). A review of Resident 43's Documentation Survey Report, dated 12/2023, indicated Resident 43 started receiving RNA program for PROM on both arms and legs and application of the left WHO for up to 8 hours, five times per week, on 12/1/2023 (over one month from the last treatment and application of WHO). A review of Resident 43's MDS, dated 2/14/2024, indicated Resident 43 had functional ROM impairments in one arm and one leg (unspecified side). A review of Resident 43's OT Evaluation and Plan of Treatment, dated 4/1/2024, indicated Resident 43 had WFL ROM in the left arm but impaired (unspecified) ROM in the left shoulder, elbow/forearm, wrist, and hand. The OT Evaluation indicated Resident 43 had a contracture in the left hand, limiting Resident 43's ability to grasp and release. A review of Resident 43's OT Discharge Summary, dated 4/5/2024 and signed on 4/16/2024, indicated Resident 43 went to GACH. A review of Resident 43's Change in Condition ([CIC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) Evaluation, dated 4/8/2024, indicated Resident 43 refused dialysis in the morning, vomited multiple times, and refused meals. The CIC Evaluation indicated the physician ordered Resident 43's transfer to GACH. A review of Resident 43's Nurses Progress Notes, dated 4/11/2024, indicated Resident 43 was readmitted to the facility on 4/11/2024. A review of Resident 43's Joint Mobility Assessment (JMA), dated 4/12/2024, indicated Resident 43's ROM was within normal limits ([WNL] normal ROM for that joint) at all joints of the right arm and both legs. The JMA indicated Resident 43's ROM was minimally impaired (51 to 75% available range for that joint) for left wrist flexion (bending the wrist downward) and left wrist extension (bending the wrist upward), moderately impaired (26 to 50% available range for that joint) for the left elbow flexion (bending the elbow) and extension (straightening the elbow), and severely impaired (less than 25% available range for that joint) for left shoulder flexion (lifting the arm upward), left shoulder abduction (lifting the arm up and away from the body), left hand/fingers flexion (bending the fingers toward the palm), and left hand/fingers extension (straightening out the fingers). A review of Resident 43's OT Evaluation and Plan of Treatment, dated 4/12/2024, indicated Resident 46 had WFL ROM in the right arm but impaired (unspecified) ROM in the left shoulder, elbow/forearm, wrist, and hand. The OT Evaluation indicated Resident 43 had a contracture in the left hand, limiting Resident 43's ability to grasp and release. A review of Resident 43's PT Evaluation and Plan of Treatment, dated 4/14/2024, indicated Resident 43 had WFL ROM in both legs. A review of Resident 43's MDS, dated 6/3/2024, indicated Resident 43 had functional ROM impairments in one arm and one leg (unspecified side). A review of Resident 43's OT Discharge Summary, dated 7/25/2024, the indicated Resident 43 required maximum assistance (required 41 to 75% physical assistance to perform the task) for hygiene, grooming, and self-feeding. The OT Discharge Summary indicated Resident 43 achieved an OT goal of safely wearing a left WHO for 8 hours without any redness, swelling, discomfort and pain. The OT Discharge Summary recommendations included RNA program to provide Resident 43 with PROM to both arms and legs and to apply the left WHO. A review of Resident 43's PT Discharge Summary, dated 7/25/2024, the indicated Resident 43 required maximum assistance for bed mobility and dependent for transfers. The PT Discharge Summary recommendations included RNA to provide Resident 43 with PROM to both legs. A review of Resident 43's Documentation Survey Report, dated 8/2024, indicated Resident 43 received RNA for PROM to the left arm and both legs and application of the left WHO on 8/7/2024 (14 days after PT and OT recommendations). A review of Resident 43's care plan titled, "Restorative Nursing Program," initiated 9/19/2023 and revised on 8/7/2024, the care plan interventions included for RNA to provide PROM to the left arm, PROM of both legs, and application of the left WHO for up to six hours, five times per week. A review of Resident 43's MDS, dated 8/12/2024, indicated Resident 43 had clear speech, understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 43 required substantial/maximal assistance (helper does more than half the effort) for eating and rolling to either side while lying in bed and dependent for hygiene, dressing, bathing, and chair/bed-to-chair transfers. The MDS indicated Resident 43 had functional ROM impairments in one arm and one leg (unspecified side). During a concurrent observation and interview on 9/30/2024 at 11:04 a.m. in Resident 43's bedroom, Resident 43 was observed lying awake in bed and unable to move the left arm. Resident 43 stated she required physical assistance from someone to move her left arm. During an interview on 9/30/2024 at 11:23 a.m. with the Director of Rehabilitation (DOR), the DOR stated the therapists (PT and OT) complete a JMA on each resident upon admission and annually. The DOR stated the purpose of the RNA program was to maintain the residents' function to prevent decline in mobility. The DOR stated the RNA program included providing mobility, including walking and transfers, ROM exercises, and application of orthoses (also known as splints; material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion). The DOR stated the purpose of ROM exercises (in general) included to maintain a resident's joint flexibility to prevent stiffness. The DOR stated the purpose of orthoses (in general) included to maintain ROM and prevent the development of contractures, which can cause pain and lead to skin breakdown (tissue damage caused by friction [surfaces rubbing again