Health inspection·November 21, 2024

§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). §483.25(k) Pain Management The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. §72523. Patient Care Policies and Procedure (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. §72311. Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. On 10/8/2024, 10/10/2024 and 10/22/2024, the California Department of Public Health (CDPH), received three complaints alleging a resident (Resident 1) fell at the facility and was found yelling and screaming in severe pain by Resident 1’s Responsible Party (RP), but the RP did not know that Resident had a fall at the facility until Resident 1 was transferred to a General Acute Care Hospital (GACH), where she was assessed with a left hip fracture (a break in the bone). On 10/9/2024, CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. The CDPH determined Resident 1, had an unwitnessed fall at the facility that was not reported to nursing staff, the Administrator (ADM), or Resident 1’s RP when a Licensed Vocational Nurse (LVN 1) was made aware of Resident 1’s fall. Resident 1 was in extreme pain for over two hours, before she was medicated for pain and transferred via paramedics to a GACH on 10/7/2024, where she was assessed with left hip fracture. The facility failed to: 1. Ensure LVN 1 reported Resident 1’s unwitnessed fall to Resident 1’s physician, so that care instructions including an order for pain medication would be prescribed and administered. 2. Ensure LVN 1 reported to Registered Nurse Supervisor 1 (RNS 1) that Resident 1 had an unwitnessed fall, and when Resident 1’s RP visited the resident and reported that Resident 1 was in excruciating pain. 3. Ensure Resident 1, who had an unwitnessed fall, did not experience extreme pain for over two hours after she was found on the floor, before care and treatment were rendered. 4. Ensure LVN 1 conducted a post-fall assessment of Resident 1 to determine if an injury had occurred or to determine Resident 1’s pain level. 5. Ensure LVN 1 reported to Resident 1’s physician when the facility’s Physical Therapist (PT 1) reported to her (LVN 1), that Resident 1 was screaming and guarding (involuntary reaction to protect an area of pain) her left hip, following PT 1’s evaluation of Resident 1. 6. Follow their policy and procedure (P/P) titled, “Pain-Clinical Protocol” indicating the nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and where there is onset or new pain or worsening existing. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident’s cognitive level. 7. Follow their P/P titled, “Change in a Resident’s Condition or Status” indicating the nurse supervisor or charge nurse will notify the resident ‘s physician when there has been an accident or incident involving the resident and if there is a significant change in the resident’s physical/emotional/mental conditions. These deficient practices resulted in Resident 1 experiencing unrelieved pain for over two hours following an unwitnessed fall, and a delay in evaluation, treatment, and transfer to the GACH. Resident 1 was subsequently transferred to a GACH on 10/7/2024, where she was assessed with a comminuted left intertrochanteric fracture (a broken hip where the bone is broken into multiple pieces) and underwent a surgical procedure to repair the fracture. This deficient practice had the potential for Resident 1’s pain to continue to go unmanaged if Resident 1’s RP had not intervened and reported that Resident 1 was in pain. A review of Resident 1’s Admission Record (Face Sheet) indicated Resident 1, an 80-year-old female, was admitted to the facility on 10/5/2024 with the diagnosis including a history of falls and a subdural hemorrhage (a buildup of blood on the surface of the brain). A review of Resident 1’s Nursing Admission Assessment dated 10/5/2024 indicated Resident 1 was alert, oriented to self and nonverbal. The Nursing Admission Assessment indicated Resident 1 required transfer assistance and assistance with activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 1’s Change of Condition (COC) form dated 10/7/2024 and timed at 2:21 p.m. indicated Resident 1 was found on the floor by facility staff (Certified Nursing Assistant [CNA] 1). The COC form indicated Resident 1 was unable to explain how the fall happened, did not complaint of pain, and no swelling or redness was noted on Resident 1. A review of Resident 1’s Joint Mobility Screening dated 10/7/2024 and timed at 8:59 a.m., indicated Resident 1 was screaming, guarding, and holding her left leg upon movement. A review of Resident 1’s Transfer Form dated 10/7/2024 and timed at 11:45 a.m., indicated Resident 1 was transferred to a GACH due to uncontrolled pain on the back of her left iliac crest (the curved part at the top of the hip bone). The Transfer Form indicated Resident 1 had a pain level of 9 out of 10, on an 11 eleven-point scale (0 = no pain, 1-3 = mild pain, 4-6 = moderate pain, and 7-10 = severe pain, and 10 = worst imaginable pain). A review of the Paramedic’s Report, dated 10/7/2024, indicated they were dispatched to the facility at 11:13 a.m., arrived at the facility at 11:19 a.m., left the facility at 11:47 a.m., and arrived at the GACH at 11:49 a.m. The Paramedic’s Report indicated Resident 1 complained of hip pain, without any traumatic events or reported falls and was in significant pain. The Paramedic’s Report indicated Resident 1 was administered 50 micrograms (mcg) of intravenous (IV) Fentanyl (a very strong pain medication used to treat patients with severe pain) at 11:36 a.m., and 50 mcg of IV Fentanyl at 11:41 a.m. A review of Resident 1’s GACH’s Admission record, indicated Resident 1 was admitted to the GACH on 10/7/2024. A review of Resident 1’s GACH Radiology (a branch of medicine that uses imaging technology to diagnose and treat disease) report dated 10/7/2024, indicated Resident 1 had a comminuted left intertrochanteric fracture. A review of Resident 1’s GACH Post-Operative Note dated 10/9/2024, indicated Resident 1 had surgery to repair the left hip fracture. During an interview on 10/9/2024 at 11:30 a.m., the RP stated he visited Resident 1 on 10/7/2024 at 10:30 a.m. and found Resident 1 in excruciating (unbearable) pain. The RP stated Resident 1 was screaming and wailing as if she had been hit by a car, she was grabbing her left hip, and grabbing his (the RP’s) arm, trying to say something to him (the RP). The RP stated he informed one of the facility staff that Resident 1 was in pain and how she was acting differently than her normal self. The RP stated facility staff tried to give Resident 1 pain medication and he could hear her “yelling bloody murder,” which was when he asked the facility to call 911. The RP stated when the paramedics arrived, they attempted to move Resident 1 to a gurney to transfer her to the GACH, and Resident 1 screamed in “pure pain” and the Paramedics administered Fentanyl to Resident 1 prior to moving her to the gurney. During an interview on 10/9/2024 at 2:30 p.m., CNA 1 stated on 10/7/2024, between 7 a.m. and 9:30 a.m., she found Resident 1 in her room on the floor, on her left side. CNA 1 stated she asked Resident 1 if she was okay, but Resident 1 was agitated and did not respond. CNA 1 stated she called CNA 2 and LVN 1 to Resident 1’s room. CNA 1 stated she, LVN 1, and CNA 2 transferred Resident 1 back to bed. During an interview on 10/9/2024 at 3:10 p.m., LVN 1 stated on 10/7/2024 around 9:20 a.m., she was called to Resident 1’s room by CNA 1, when she entered Resident 1’s room she observed Resident 1 on the floor lying on her left side in a fetal position (when a person curls up on their side with their arms and legs drawn up toward their chest and their head bowed forward) facing the restroom. LVN 1 stated Resident 1 was non-verbal and could not say she was in pain but was combative, held on to the linen, would not let go of staff’s hands, and she (LVN 1) could not tell if Resident 1 was experiencing pain. LVN 1 stated on 10/7/2024 at 10:30 a.m., Resident 1’s RP came to visit Resident 1 and informed her that Resident was in pain. LVN 1 stated the RP requested that Resident 1 be transferred to the GACH, via 911. During an interview on 10/10/2024 at 9:15 a.m., RNS 1 stated on 10/7/2024 around 10:40 a.m., LVN 1 notified her that Resident 1’s RP was very agitated and requested pain medication for Resident 1. RNS 1 stated she asked LVN 1 if Resident 1 was in pain and LVN 1 told her that Resident 1 had a baseline behavior of screaming and was not experiencing anything different from her baseline behavior. RNS 1 stated when she assessed Resident 1, Resident 1 moved her (RNS 1) hands away to prevent her from touching or assessing her (Resident 1). RNS 1 stated Resident 1 screamed when she (RNS 1) barely touched her gown, guarded her left hip, and grimaced (facial expression of pain or disgust). RNS 1 stated Resident 1 was combative and uncooperative when LVN 1 attempted to give her pain medication and was subsequently given intravenous ([IV] directly into the blood stream) pain medication (Fentanyl), by the paramedics, just before she was transferred to the gurney when the paramedics arrived. RNS 1 stated LVN 1 should have notified her and Resident 1’s physician when she (LVN 1) observed Resident 1 on the floor, so that resident 1’s physician could be notified to obtain an order for pain medication. RNS 1 stated LVN 1 should have assessed Resident 1’s mentation (mental activity), neurological status (brain and nervous system functioning), skin condition, range of motion ([ROM] the amount of movement that a particular joint or series of joints can achieve in a specific direction) to her extremities, and her vital signs ([v/s] measurements of the body’s most basic functions including the body temperature [BT], blood pressure [BP], heart rate [HR] and respiratory rate [RR]). During an interview on 10/10/2024 at 10:51 a.m., PT 1 stated on 10/7/2024 around 9:30 - 9:45 a.m., he assessed Resident 1 because Resident 1’s physician ordered PT to complete an initial assessment and evaluation (10/5/2024) on Resident 1. PT 1 stated when he tried to assess Resident 1’s mobility, she guarded her left leg and screamed when he moved her left leg. PT 1 stated he reported to LVN 1 that Resident 1 was guarding her left leg and in pain during her evaluation. PT 1 stated he was unaware Resident 1 had an unwitnessed fall that morning. During an interview on 10/10/2024 at 6:44 p.m., LVN 1 stated PT 1 reported to her that Resident 1 was guarding her left hip during PT 1’s evaluation. LVN 1 stated she did not have time to report PT 1’s findings to Resident 1’s physician or RNS 1 because on 10/7/2024, at 10:30 a.m., Resident 1’s RP came to the facility and reported Resident 1 was in pain and 911 was called. During an interview on 10/10/2024 at 5:06 p.m., the Director of Nursing (DON) stated LVN 1 should have notified himself (DON), Resident 1’s physician, RNS 1 and the Resident 1’s RP following Resident 1’s unwitnessed fall. The DON stated if RNS 1 had been notified of Resident 1’s unwitnessed fall, RNS 1 could have assessed Resident 1 immediately when Resident 1 was found on the floor. The DON stated, if Resident 1 was in pain, staff should have given her pain medication. The DON stated Resident 1 was transferred to a GACH because Resident 1’s pain was uncontrollable. A review of the facility’s P/P, titled “Pain-Clinical Protocol” dated 2001, indicated the nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and where there is onset or new pain or worsening existing. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident’s cognitive level. A review of the facility’s P/P titled “Change in a Resident’s Condition or Status” dated 9/2015, indicated the nurse supervisor or charge nurse will notify the resident ‘s physician when there has been an accident or incident involving the resident and if there is a significant change in the resident’s physical/emotional/mental conditions. The policy indicated the nurse supervisor/charge nurse will notify the resident’s family or representative when there is a significant change in the resident’s physical, mental or psychosocial status. The facility failed to: 1. Ensure LVN 1 reported Resident 1’s unwitnessed fall to Resident 1’s physician, so that care instructions including an order for pain medication would be prescribed and administered. 2. Ensure LVN 1 reported to Registered Nurse Supervisor 1 (RNS 1) that Resident 1 had an unwitnessed fall, and when Resident 1’s RP visited the resident and reported that Resident 1 was in excruciating pain. 3. Ensure Resident 1, who had an unwitnessed fall, did not experience extreme pain for over two hours after she was found on the floor, before care and treatment were rendered. 4. Ensure LVN 1 conducted a post-fall assessment of Resident 1 to determine if an injury had occurred or to determine Resident 1’s pain level. 5. Ensure LVN 1 reported to Resident 1’s physician when the facility’s Physical Therapist (PT 1) reported to her (LVN 1), that Resident 1 was screaming and guarding (involuntary reaction to protect an area of pain) her left hip, following PT 1’s evaluation of Resident 1. 6. Follow their policy and procedure (P/P) titled, “Pain-Clinical Protocol” indicating the nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and where there is onset or new pain or worsening existing. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident’s cognitive level. 7. Follow their P/P titled, “Change in a Resident’s Condition or Status” indicating the nurse supervisor or charge nurse will notify the resident ‘s physician when there has been an accident or incident involving the resident and if there is a significant change in the resident’s physical/emotional/mental conditions. These deficient practices resulted in Resident 1 experiencing unrelieved pain for over two hours following an unwitnessed fall, and a delay in