Other·March 23, 2023

42 CFR § 483.25(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. 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 residents' choices. 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. 42 CFR § 483.21(b) Comprehensive Care Plans (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. On 1/23/2023, the California Department of Public Health (CDPH) received a complaint, alleging a resident (Resident 1), who had dementia, was left unsupervised while attempting to go to the bathroom and fell sustaining injuries. On 2/7/2023, CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Supervise Resident 1, who had dementia and a history of falls, after an initial fall on 9/17/2022 and a repeat fall on 10/13/2022, less than a month later, and sustained a fracture (broken bone). 2. Revise Resident 1's plan of care after the first fall on 9/17/2022 to incorporate assistive devices and close supervision, as per the Director of Rehabilitation ([DOR] supervises all the OT, PT and Speech rehabilitation therapy staff) assessment to assist Resident 1 from having a second fall and to prevent further falls. 3. Ensure the facility's staff adhere to the facility's policy and procedure (P/P) titled "Promoting Safety, Reducing Falls," to promote Resident 1's safety and prevent falls. As a result, Resident 1 had two unwitnessed falls on 9/17/2022 and 10/13/2022. The second fall on 10/13/2022 resulted in Resident 1 sustaining a right intertrochanteric femur (proximal femur [thigh bone] that occurs between the greater and lesser trochanter) fracture causing pain. Resident 1 required a transfer to a general acute care hospital (GACH) and was admitted for five days after undergoing an open reduction internal fixation ([ORIF] a type of surgery used to stabilize and heal a broken bone) surgery of the right hip. During a review of Resident 1's Admission Record (face sheet), the face sheet indicated Resident 1, a 72 year-old female, was admitted to the facility on 8/30/2022 and last readmitted on 10/19/2022 with diagnoses including anxiety disorder (persistent feelings of nervousness, panic and fear which can interfere with daily life), unspecified dementia (loss of the ability to remember and reason to such an extent that it interferes with a person's daily life and activities), hypertension (high blood pressure), and a history of falls. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/5/2022, the MDS indicated Resident 1 had the ability to understand and be understood by others. According to the MDS, Resident 1 required extensive assistance (resident involved in activity, staff provide weight bearing [body weight] support) with two-person physical assistance during transfers (moving from between surfaces including to and from: bed, chair, wheelchair, standing position). During a review of Resident 1's history and physical (H/P), dated 9/8/2022, the H/P indicated it was unclear if Resident 1 had the ability to make her own medical decisions. During a review of Resident 1's "Fall Risk Assessment" (FRA), dated 8/30/2022, the FRA indicated Resident 1 had a high risk for falls. The FRA indicated the facility must develop and implement a care plan (C/P) to reduce falls and injuries for Resident 1 and to complete the following assessments and interventions: 1) Fall Interdisciplinary Team meeting ([IDT] a group of health care professionals with various areas of expertise who work together toward the resident's goals); 2) Initiate a Falling Star/Super star care plan; and 3) Complete a Rehabilitation (Rehab, assessment conducted by the therapy department) Fall Risk Assessment. During a review of Resident 1's C/P, initiated on 9/1/2022, the C/P indicated the resident was at risk for fall and injury due to dementia, general weakness, history of falls, impaired cognition (thought process), and cerebral infarction ([stroke] disrupted blood flow to the brain due to problems with the blood vessels that supply it when blood does not get to the brain). The C/P goal was to reduce risk of falls and injury daily. The interventions included the following: 1. Update/Review/Revise Resident 1's FRA upon admission, quarterly and as needed (PRN). 2. Place Resident 1 on a falling star program (facility's program for staff awareness which identifies residents who are on a high risk for falls [a yellow star placed by resident's name on their doors]). 3. Nursing staff to visibly observe Resident 1 frequently. 4. Provide Resident 1 proper fitting shoes. 5. Physical Therapy (PT) to assess Resident 1 quarterly and PRN for safety of gait (the way one walks), transfer, sitting balance, and need for safety devices, assess resident medication for possible adverse side effects. 6. Provide Resident 1 with a safe and clutter-free environment. 7. Keep Resident 1's call light within easy reach and encourage resident to use it to get assistance. 8. Keep Resident 1's frequently used personal items within easy reach. 9. Inform responsible party/resident quarterly during IDT meetings regarding fall risk, notify Medical Doctor (MD) if needed, encourage the resident to attend, and participate in activity programs. During a review of Resident 1's Change of Condition (COC) and a Situational Background Assessment Recommendation (SBAR) assessment form, dated 9/17/2022, the COC/SBAR (an internal communication document) indicated Resident 1 was alert with confusion with no behavioral outburst. The COC/SBAR indicated the resident was intermittently in and out of her room, using a wheelchair and had attempted to self-transfer multiple times with an unsteady gait and needed constant redirection. According to the COC/SBAR, on 9/17/2022, at approximately 8:30 p.m., Certified Nurse Assistant 1 (CNA 1) found Resident 1 sitting on the floor beside the wheelchair in her room. Resident 1 complained of hip pain rated 4 out of 10 on a pain scale (0 for no pain and 10 for being the worse pain). The COC/SBAR indicated Resident 1 was non-redirectable. During a review of Resident 1's FRA, dated 9/17/2022, the FRA indicated Resident 1 remained at high risk for falls. The FRA indicated the facility must develop and implement a C/P to reduce falls and injuries; complete a Fall IDT meeting; initiate a Falling Star/Super star care plan; complete a Rehab FRA, conduct an environmental hazards assessment; and implement useful interventions to prevent further falls. During a review of Resident 1's IDT conference record, dated 9/18/2022, the IDT record indicated Resident 1 had an unwitnessed fall on 9/17/2022. The IDT record indicated Resident 1 was admitted to the facility with a history of falls, muscle weakness, and an unsteady gait. The IDT record indicated Resident 1 had multiple episodes of attempting to self-transfer without calling for assistance, refusal to be assisted to bed from wheelchair and vice-versa and was very forgetful in using her wheelchair and calling for assistance. The IDT record did not indicate recommendations from the therapy department. During a review of Resident 1's C/Ps, there was no documented evidence the facility revised the resident's plan of care after the fall on 9/17/2022 to protect the resident and prevent further falls. During a review of Resident 1's Rehab FRA dated 9/19/2022, the assessment indicated the following: Resident 1 had an unwitnessed fall on 9/17/2022; Resident 1 does not use the call light properly; Resident 1 cannot recall and demonstrate proper use of a call light after one hour; Resident 1 does not demonstrate proper safety while using an assistive device; Resident 1 does not demonstrate proper safe sitting and standing balance; and Resident 1 does not show sufficient strength and correct posture in sitting and standing. The Rehab assessment recommended for the resident to have skilled occupational and physical therapy ([OT/PT] helps residents improve in movement and manage pain; focus on helping residents develop or regain the skills needed for daily tasks so they can function independently]) and to continue to reinforce safety education during mobility training. During a review of Resident 1's COC/SBAR dated 10/13/2022, the COC/SBAR indicated on 10/13/2022 at 4:30 p.m., the charge nurse saw Resident 1 laying on the floor mat on her right side next to her wheelchair in the resident's room. The COC/SBAR indicated Resident 1 was noted with facial grimacing (distortion of one's face in an expression usually of pain, disgust, or disapproval) and complaining of pain in her leg. According to the COC/SBAR on 10/14/2022 at 2:41 a.m., the X-ray (a photographic or digital image of the internal composition of something, especially a part of the body) report indicated the resident had an acute intertrochanteric right femoral neck fracture (broken right hip). On 10/14/2022 at 4:31 a.m. Resident 1 was transferred by paramedics to a GACH. During a review of Resident 1's GACH's H/P dated 10/14/2022, the H/P indicated Resident 1 was admitted to the GACH from the facility for complaints of hip and neck pain. The H/P indicated the resident's X-ray showed an acute right intertrochanteric right femoral neck fracture. During a review of Resident 1's GACH Discharge summary dated 10/19/2022, the summary indicated Resident 1 was discharged from the GACH back to the facility on 10/19/2022 (five days after admission) after undergoing surgical procedure of an intermedullary nailing (used to align and stabilize fractures) of the right hip fracture. During a review of Resident 1's IDT re-admission document, dated 10/19/2022, the document indicated Resident 1 was re-admitted from the GACH after sustaining an intertrochanteric femur fracture. The document indicated Resident 1 had two surgical sites on the right outer thigh. During a concurrent interview and review of the facility's undated policy and procedure (P/P) titled, "Initial Fall Risk Assessment on 2/7/2023 at 3:30 p.m. with the Director of Nursing (DON), the DON stated according to the P/P, a FRA would be completed within 72 hours of admission for all new admissions to attempt to reduce the number of falls. According to the P/P, PT services and nursing would review each new admission for the plan of care including interventions for fall preventions for the next three months and the C/P would be reviewed by the IDT quarterly and PRN for updates for the resident's current needs. The DON stated when Resident 1 was initially admitted to the facility on 8/30/2022, a fall risk IDT meeting (involving nursing and therapy services) and the Rehab FRA were not conducted as indicated on Resident 1's C/P and per facility's P/P. The DON stated by not conducting the IDT meeting and Rehab FRA, Resident 1 was at higher risk for falls by not having appropriate and specific interventions in place to prevent falls. The DON stated the facility's records indicated Resident 1 had a fall on 9/17/2022 and a second fall on 10/13/2022. During a concurrent interview and review of Resident 1's Rehab FRA on 2/10/2023 at 3:30 p.m. with the DOR. The DOR reviewed Resident 1's Rehab FRA, dated 9/19/2022 and stated due to Resident 1's cognitive status and confusion, recommendations should have been incorporated on the assessment conducted after the fall on 9/17/2022. The DOR stated the interventions should have been focused on supervision to include placing Resident 1 in a wheelchair in the dining room or out in the hall close to the nursing station where she could be directly supervised. The DOR stated Resident 1 should have not been left alone in her room unattended while in a wheelchair. The DOR stated the staff should have line of sight (a straight line along which an observer has unobstructed vision) on Resident 1, who was known to have confusion and poor safety awareness. The DOR stated future fall assessments should have included more specific, detailed, and individual interventions. The DOR stated Resident 1 had a second fall on 10/13/2022. During a review of the facility's undated P/P titled, "Rehabilitation-Fall Assessment/Risk Assessment," the P/P indicated during initial admissions each resident will be screened by the Therapy Department per the facility's policy. A FRA will be completed by nursing with input from the Therapy Department. The P/P further indicated when a fall occurs the therapist will re-screen the resident using the fall assessment form. According to the P/P, an investigation and IDT meeting should address all the resident's safety issues and a C/P should be developed to prevent recurrence. During a review of the facility's undated P/P titled, "Promoting Safety, Reducing Falls," the P/P indicated if caregivers are to prevent falls, they must first have a working knowledge of the key factors that determine which residents are at most risk. The P/P indicated the following are major risk factors for falls: history of falls, gait and balance disturbances, and elimination patterns. The P/P further indicated caregivers must be alert to residents who have a history of falls and make conscious effort to "eyeball" them more frequently. Caregivers should observe residents' elimination patterns and develop regularly scheduled trips to the bathroom for residents who need assistance. This prevents residents from trying to go unassisted, causing falls. The facility failed to: 1. Supervise Resident 1, who had dementia and a history of falls, after an initial fall on 9/17/2022 and a repeat fall on 10/13/2022, less than a month later, and sustained a fracture. 2. Revise Resident 1's plan of care after the fall on 9/17/2022 to incorporate assistive devices and close supervision, as per the DOR assessment to assist Resident 1 from having a second fall and to prevent further falls. 3. Ensure the staff adhere to the facility's P/P titled "Promoting Safety, Reducing Falls," to promote Resident 1's safety and prevent falls. As a result, Resident 1 had two unwitnessed falls on 9/17/2022 and 10/13/2022. The second fall on 10/13/2022 resulted in Resident 1 sustaining a right intertrochanteric femur fracture causing pain. Resident 1 required a transfer to a GACH and was admitted for five days after undergoing an ORIF surgery of the right hip. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.