Health inspection·May 26, 2023

F689 §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 1/6/2022, the California Department of Public Health (CDPH) received the facility reported incident (FRI) regarding Resident 1 sustaining an unwitnessed fall requiring transfer to a general acute care hospital GACH). On 1/21/2022, an unannounced FRI investigation was conducted. The facility failed to: 1. Ensure Certified Nurse Assistant 1 (CNA 1) placed the recliner’s (an armchair whose back can be lowered and foot can be raised to allow the sitter to recline in it) remote control in a safe area away from Resident 1’s reach to prevent Resident 1 from changing recliner’s positions leading to Resident 1 falling out of the recliner. 2. Ensure a plan of care was created and implemented after a safety concern with Resident 1’s daily use of the recliner was identified by the interdisciplinary team [(IDT)- Resident 1’s health care team which consists of different specialties). Resident 1 had a behavior of reaching for and playing (unintentionally pressing the remote-control buttons that recline or return the recliner to an upright position) with the recliner’s remote control. These deficient practices resulted in Resident 1 being able to change her recliner’s positions with the remote control, falling out of the recliner and sustaining blunt head trauma ([BHT]-the head collides with a surface or object) with a 3.0 centimeter ([cm] a unit of measurement of length) in length laceration (deep cut) to her mid-forehead and a 2.0 cm by 2.0 cm hematoma (a collection of blood due to injury or trauma) above her right eyebrow. Resident 1, a- 94-year-old female, who was a hospice (kind of medical care for people who are near the end of life and have stopped treatment to cure or control their disease) resident receiving comfort measures (medical interventions to ease suffering at the end of life) only, was transferred to GACH and had to receive five sutures (stitching used to hold tissue together after an injury or surgery) to repair the laceration to her forehead. During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility on 8/12/2016 with diagnoses including dementia (a progressive loss of memory) with behavioral disturbance, anxiety disorder (feelings of unease and worry), osteoarthritis (a joint disease characterized by pain, stiffness and swelling). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 10/14/2021, the MDS indicated Resident 1's cognitive skill for daily decision-making was severely impaired. The MDS indicated Resident 1 required extensive two-persons physical assistance for transfers, bed mobility and completion of her activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting). During a review of Resident 1's physician's order dated 10/1/2021, the physician's order indicated Resident 1 was admitted under hospice care (available to people with a life expectancy of six months or less; care does not focus on treatments to cure the cause of the terminal illness, but to keep the individual comfortable and make their remaining time as meaningful as possible) with the diagnosis of senile brain degeneration (cognitive decline) with comfort measures only and no transfers to GACH. During a review of Resident 1's untitled care plan (CP), dated 8/12/2016 and last updated on 1/13/2022, the CP indicated Resident 1 was at risk for falls or injury due to poor safety awareness, history of falls, use of morphine sulfate concentrate (a strong narcotic [a substance used to treat moderate to severe pain]) and Lorazepam ([Ativan] a drug used to treat anxiety). The staff's interventions dated 1/4/2022 included keeping the recliner remote fastened to the back of the recliner. During a review of Resident 1's Fall Risk Assessment Tool (FRAT), dated 8/30/2021 and 10/13/2021, the FRATs indicated Resident 1 had a fall score of 14. A score of 10 or more indicated a high fall risk. During a review of Resident 1's Post-Fall Supervisory Investigation Review (PFSIR), dated 1/4/2022 and timed at 5:44 p.m., the PFSIR indicated on the same day (1/4/2022), at 12:15 p.m., Resident 1 was in a reclining chair and CNA 1 placed the remote control of the chair, within Resident 1's reach on the right side of the recliner chair and walked to the doorway of the resident's room to speak with the Director of Staff Development (DSD). The PFSIR indicated the DSD heard a noise coming from behind Resident 1's privacy curtain and Resident 1 was found on the floor in a prone (face down) position with bleeding from the mid-forehead and right eyebrow due to lacerations. During a review of Resident 1's Physician's Order, dated 1/4/2022, the order indicated to transfer Resident 1 to the emergency room (ER) for further evaluation. During a review of Resident 1's nursing progress notes (NPN) dated 1/4/2022 and timed at 2:29 p.m., and a subsequent NPN on the same day timed at 2:45 p.m., the NPNs indicated Resident 1's family member (FM 1) requested to cancel Resident 1's X-ray and to send Resident 1 directly to the GACH. The NPN indicated Resident 1's FM 1 arrived at the facility at 2:45 p.m. on 1/4/2022 and transported Resident 1 to the GACH in their personal vehicle. During a review of Resident 1's GACH ER notes, dated 1/4/2022 and timed at 3:48 p.m., the ER note indicated Resident 1 presented to the GACH with a head injury/forehead laceration and reported loss of consciousness (the state of being awake and aware of one's surroundings) following a ground level fall out of a chair at the facility. The ER note indicated Resident 1 sustained BHT with a 3.0 cm in length forehead laceration and a 2.0 cm by 2.0 cm hematoma just above the forehead laceration. The ER note indicated Resident 1 underwent a laceration repair using a total of five sutures before being transferred back to the skilled nursing facility (SNF) on 1/4/2022. During a review of Resident 1's NPN, dated 1/4/2022 and timed at 10:19 p.m., the NPN indicated Resident 1 returned to the facility from GACH at approximately 7:40 p.m. on 1/4/2022 with five sutures to her mid-forehead, above her right eyebrow. During an interview on 1/21/2022 at 10:36 a.m. with CNA 1, CNA 1 stated on 1/4/2022, she transferred Resident 1 from the bed to the recliner. CNA 1 stated while Resident 1 was sitting in the recliner, she (CNA 1) was standing in the doorway of Resident 1's room talking to the DSD when she heard a loud bump. CNA 1 stated she found Resident 1 lying face down on the floor. CNA 1 stated the Director of Nursing (DON), the Licensed Vocational Nurse 1 (LVN 1) and the DSD assisted Resident 1 back to bed. CNA 1 stated she did not know how Resident 1 fell from the reclining chair because Resident 1 could not walk but she could move her arms. CNA 1 stated Resident 1 would usually play with the recliner' remote control causing the head of the chair to move up and down. During a telephone interview on 1/21/2022 at 11:01 a.m., with the DSD, the DSD stated on 1/4/2022 "around lunch time" she was looking for CNA 1 and located her in Resident 1's room. The DSD stated CNA 1 left Resident 1 behind the privacy curtain out of sight and she (CNA 1) came to the door of the resident's room to talk to her (the DSD). The DSD stated Resident 1 fell out of the reclining chair onto the floor while CNA 1 was away from the resident and talking to her. The DSD stated Resident 1 should be in a reclined position, however when she went to assist Resident 1 off the floor, the recliner was in an upright position, not in a reclining position, which would have allowed the resident to fall over out of the chair. During an observation on 1/21/2022 at 11:10 a.m., Resident 1 had discoloration to her right eyelid and forehead area (16 days after the fall incident). During a subsequent phone interview on 3/9/2023 at 9:29 a.m., with the DSD, the DSD stated the recliner's remote was pressed by Resident 1 causing the recliner to change positions (from a reclined to an upright position). The DSD stated after the fall incident, she provided an in-service (staff education) to CNA 1 regarding placement of the recliner's remote ensuring it was not within reach of Resident 1 and it should be off to the side in a secure location. During an interview on 1/21/2022 at 11:24 a.m. with LVN 1, LVN 1 stated on 1/4/2022, the DSD paged LVN 1 to go to Resident 1's room. LVN 1 stated when she arrived in Resident 1's room, the DSD was supporting Resident 1's head and applying an ice pack to Resident 1's forehead. LVN 1 stated the day Resident 1 fell (1/4/2022) CNA 1 had placed the recliner's remote control on the right side of the reclining chair, within reach of Resident 1. During a subsequent interview on 3/7/2023 at 1:20 p.m. with LVN 1, LVN 1 stated sitting in the recliner was part of Resident 1's daily routine. Resident 1 would sit in the recliner until lunch time then the staff would transfer the resident back to the bed. LVN 1 stated since Resident 1 was in the recliner every day, there should have been a care plan with safety interventions to prevent falls. During an interview on 1/21/2022 at 1:25 p.m., with the DON, the DON stated Resident 1's recliner remote should not have been put in a place where Resident 1 could easily reach it. The DON stated Resident 1's fall could have been prevented by placing the recliner's remote on the back of the resident's recliner where Resident 1 could not reach it. During a subsequent interview on 3/7/2023 at 1:46 p.m., the DON confirmed there should have been a care plan developed with safety interventions for Resident 1's use of the recliner but there was not. The DON confirmed safety interventions regarding the remote and PPA were implemented after the resident sustained the fall (1/4/2022). The DON stated care plans are important to inform staff of the care needs of Resident 1. During a review of the facility's revised policy and procedure (P/P), dated 12/2007 and titled, "Falls and Fall Risk Managing," the P/P indicated the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and minimize complications from falling. During a review of the facility's revised P/P dated 7/2017 and titled, "Safety and Supervision of Residents," the P/P indicated interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The facility failed to: 1. Ensure CNA 1 placed the recliner’s remote control in a safe area away from Resident 1’s reach to prevent Resident 1 from changing recliner’s positions leading to Resident 1 falling out of the recliner. 2. Ensure a plan of care was created and implemented after a safety concern with Resident 1’s daily use of the recliner was identified by IDT. Resident 1 had a behavior of reaching for and playing with the recliner’s remote control. These deficient practices resulted in Resident 1 being able to change her recliner’s positions with the remote control, falling out of the recliner and sustaining BHT with a 3.0 cm in length laceration to her mid-forehead and a 2.0 cm by 2.0 cm hematoma above her right eyebrow. Resident 1, a- 94-year-old female, who was a hospice resident receiving comfort measures only, was transferred to GACH and had to receive five sutures to repair the laceration to her forehead. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents. 2