Health inspection·July 19, 2024

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 resident's choices, including but not limited to the following: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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. 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. On 6/4/2024, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) regarding Resident 1 who fell out of her wheelchair and sustained a closed nondisplaced fracture (a broken bone in which the bone cracks or breaks but retains its proper alignment often requiring only bracing, booting, or casting) of her left tibia (shin bone). On 6/5/2024 at 9:45 a.m., CDPH conducted an unannounced visit at the facility to investigate the FRI. Upon investigation, CDPH determined Resident 1's wheelchair was placed at her bedside making it accessible for the resident to use, even though the resident required contact guard assistance (care giver places one or two hands on resident's body to help with balance). Resident 1 had a fall on 1/2/2024, and another fall on 6/5/2024, due to transferring herself into a wheelchair unassisted. The facility failed to: 1. Revise Resident 1's care plan after Resident 1's fall on 1/2/2024 and develop comprehensive person-centered interventions to address Resident 1's poor safety awareness and the resident's noncompliance to ask for assistance prior to getting out of bed. 2. Ensure staff did not leave a wheelchair within Resident 1's reach next to her bed thus providing Resident 1 with the opportunity to get into a wheelchair without calling for assistance prior to getting out of bed and transferring into a wheelchair causing her to fall on 1/2/2024 and 6/2/2024. 3. Ensure staff followed the facility's policy and procedure (P/P) titled, "Fall and Fall Risk, Managing," which indicated that based on previous evaluations and current data, the staff will identify interventions related to Resident 1's specific risks and causes to try to prevent Resident 1 from falling and to minimize complications from a fall. These deficient practices resulted in Resident 1 sustaining a fracture (break in a bone) of her left tibia on 6/2/2024 due to an unassisted transfer from her bed into a wheelchair. Resident 1 was transferred to a General Acute Care Hospital (GACH) on 6/2/2024 for evaluation and treatment of a displaced (when two or more pieces of a broken bone are out of alignment, creating a gap around the fracture) comminuted (bone broken into three of more pieces) oblique (broken at an angle) fracture of her left tibia, pain, and decreased mobility. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1, a 73 year-old female, was admitted to the facility on 9/8/2023 with diagnoses including generalized muscle weakness, difficulty walking, and schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors). A review of Resident 1's Minimum Data Set ([MDS]) a standardized assessment and care screening tool), dated 3/14/2024, indicated Resident 1's cognitive skills (thinking process) for daily decision-making were moderately impaired. The MDS indicated Resident 1 was able to understand and was understood by others and required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs) with transfers between surfaces, including from a bed to a chair and from a chair to a bed. A review of Resident 1's Fall Risk Observation/Assessment dated 1/2/2024, indicated Resident 1's fall risk score was 18. A score of 16 and above indicated a high risk for falls. A review of Resident 1's untitled Care Plan, dated 1/2/2024, indicated Resident 1 had an unwitnessed fall on 1/2/2024 and was at risk for falls. The Care Plan's goals for Resident 1 included minimizing the risk for additional falls to the extent possible, and for Resident 1 to be compliant with fall interventions to reduce the risk of additional falls. A review of Resident 1's Change of Condition (COC) dated 1/2/2024, indicated on 1/2/2024 at approximately 10 a.m., a Certified Nursing Assistant (CNA X) found Resident 1 on the floor. A review of Resident 1's Fall Risk Observation/Assessment, dated 3/14/2024, indicated Resident 1's fall risk score was 22. A review of Resident 1's Physical Therapy ([PT] treatment used to restore functional movement, such as standing, walking) Discharge Summary, dated 3/8/2024, indicated Resident 1's functional status for transfers and for gait (the way a person walks) on level surfaces was contact guard assist. A review of Resident 1's COC dated 6/2/2024, indicated on 6/2/2024 at approximately 4:45 a.m., CNA 1 found Resident 1 on the floor in her room next to her wheelchair. The COC indicated Resident 1 complained of pain in her left lower leg rated 10 out of 10 on a pain scale from zero to 10 (a pain screening tool using numerical value to assess the pain level ranging from 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-9=severe pain, and 10=worst pain possible). A review of Resident 1's Nurses Notes, dated 6/2/2024, indicated at 4:45 a.m., a noise was noted coming from Resident 1's room. Resident 1 was found on the floor in her room close to her wheelchair. The Nurses Notes indicated on 6/2/2024 at 5:30 a.m., 911 was called due to Resident 1's uncontrolled pain in her left lower leg and the resident was transferred to a GACH for further evaluation. A review of the facility's Unusual Incident/Injury Report, dated 6/3/2024, indicated on 6/2/2024 Resident 1 was found "lying on the floor on her left side." The Unusual Incident/Injury Report indicated Resident 1 reported she was sitting in her wheelchair and was trying to shift her weight because she was not sitting in her wheelchair properly. The Unusual Incident/Injury report indicated Resident 1 tried to get up from her wheelchair, but her legs got stuck/twisted and she fell. The Unusual Incident/Injury Report indicated Resident 1 was transferred to a GACH on 6/2/2024 for further evaluation and on 6/3/2024, the GACH reported Resident 1 sustained a fracture of her left tibia. A review of Resident 1's Face Sheet, from the GACH, indicated Resident 1 was admitted to the GACH on 6/2/2024. A review of Resident 1's History and Physical (H/P), from the GACH, dated 6/2/2024, indicated Resident 1's X-ray result indicated Resident 1 sustained a left tibia fracture and her left leg was placed in a long leg splint (an external device used to immobilize an injury or body part). A review of Resident 1's Imaging report (X-ray), from the GACH, dated 6/5/2024, indicated Resident 1 sustained a slightly displaced comminuted oblique fracture of the mid to distal (along the length of the bone closer to the ankle) third of her left tibia. During an interview on 6/5/2024 at 10:30 p.m., Resident 1 stated a few days ago (6/2/2024), she got out of bed and transferred to her wheelchair. Resident 1 stated she was not steady in her wheelchair and fell from it. Resident 1 stated she was able to get into her wheelchair because her bed was high enough and her wheelchair was at her bedside. Resident 1 stated she does not usually ask for assistance to get out of bed to her wheelchair because she could transfer independently, and the nursing staff would leave her wheelchair next to her bed so she could reach it easily. Resident 1 stated she felt frustrated and uncomfortable because she was in pain and could not get out of bed because of her broken leg. During an interview on 6/6/2024 at 3 p.m., the Licensed Vocational Nurse (LVN 1) stated Resident 1 was a high fall risk and should be supervised during transfers from the bed to a wheelchair, but she was noncompliant and did not ask for assistance with transfers. LVN 1 stated, nursing staff often placed Resident 1's wheelchair next to Resident 1's bed within the resident's reach. LVN 1 stated, Resident 1 had poor safety awareness and judgement and placing a wheelchair within her reach could increase the likelihood that Resident 1 would not call for assistance prior to getting out of bed, placing the resident at an increased risk of falls. During an interview on 6/6/2024 at 3:15 p.m., the Director of Rehabilitation (DOR) stated Resident 1 required staff assistance when transferring out of bed into a chair or wheelchair and back into bed. The DOR stated Resident 1 was a high fall risk and could be unsteady when transferring or ambulating without assistance. The DOR stated, the Interdisciplinary Team ([IDT]a group of healthcare professionals from different disciplines who work together to treat a patient's condition or injury) had not revised Resident 1's comprehensive care plan after her fall on 1/2/2024 and prior to her fall on 6/2/2024 to address Resident 1's noncompliance with asking for staff assistance prior to getting out of bed. The DOR stated the IDT should have discussed specific interventions to promote Resident 1's safety to prevent future falls. The DOR stated she was not aware the nursing staff placed Resident 1's wheelchair at her bedside unattended and because Resident 1 had poor judgment and safety awareness, the wheelchair could be considered an environmental hazard and increase Resident 1's risk of falls. During an interview on 6/6/2024 at 4 p.m., the Director of Nursing (DON) stated nursing staff should have ensured Resident 1's Care Plan interventions such as anticipate the resident needs and supervised the resident during transfer were implemented and revised as needed to ensure proper care and services were provided to prevent Resident 1 from falling. The DON stated he was not aware Resident 1's wheelchair was left unattended at the resident's bedside. The DON stated placing the wheelchair next to Resident 1's bed enabled the resident to transfer into the wheelchair unassisted. The DON stated it was important for staff to supervise and assist Resident 1 during transfers to ensure her safety. A review of the facility's P/P titled "Fall and Fall Risk, Managing," revised 1/2001, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P/P indicated the staff with the input of the attending physician will implement resident centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. The P/P indicated if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. A review of the facility's P/P titled "Safety and Supervision of Residents," revised 7/2017, indicated "our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities." The P/P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The facility failed to: 1. Revise Resident 1's care plan after Resident 1's fall on 1/2/2024 and develop comprehensive person-centered interventions to address Resident 1's poor safety awareness and the resident's noncompliance to ask for assistance prior to getting out of bed. 2. Ensure staff did not leave a wheelchair within Resident 1's reach next to her bed thus providing Resident 1 with the opportunity to get into a wheelchair without calling for assistance prior to getting out of bed and transferring into a wheelchair by herself unassisted causing her to fall on 1/2/2024 and 6/2/2024. 3. Ensure staff followed the facility's policy and procedure (P/P) titled, "Fall and Fall Risk, Managing," which indicated that based on previous evaluations and current data, the staff will identify interventions related to Resident 1's specific risks and causes to try to prevent Resident 1 from falling and to minimize complications from a fall. These deficient practices resulted in Resident 1 sustaining a fracture (break in a bone) of her left tibia on 6/2/2024 due to an unassisted transfer from her bed into a wheelchair. Resident 1 was transferred to a General Acute Care Hospital (GACH) on 6/2/2024 for evaluation and treatment of a displaced (when two or more pieces of a broken bone are out of alignment, creating a gap around the fracture) comminuted (bone broken into three of more pieces) oblique (broken at an angle) fracture of her left tibia, pain, and decreased mobility. These violations jointly, separately or in any combination, presented either imminent danger that death or serious harm would result, or a substantial probability of death or serious physical harm would result to Resident 1.