Health inspection·November 26, 2024

T22 § 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. (2) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. (1) 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. F689 Free of Accident Hazards/Supervision/Devices §483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The Patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each Patient receives adequate supervision and assistance devices to prevent accidents. On 11/4/2024 at 12 PM, an unannounced visit was made to the facility to investigate a complaint regarding an incident of patient fall. The facility failed to provide adequate supervision for Patient 1 who has a diagnosis of dementia (a progressive state of decline in mental abilities), Guillain-Barre syndrome (a neurological condition causing muscle weakness or paralysis [the loss of the ability to move some or all of the body]) and was assessed as a high risk for falls by failing to: 1. Increase the patients’ need for supervision, including the development of an individualized care plan indicating the frequency of supervision to be provided to the patient after the first fall at the facility on 10/22/24, as indicated in the facility’s policy and procedure [P&P] titled “Safety and Supervision of Patients.” 2. Implement Patient 1’s care plan titled “Witnessed Fall Care Plan” to monitor Patient 1’s whereabouts and frequent visual monitoring after sustaining a fall on 10/22/24 [3 days after admission to the facility]. 3. Analyze the risk in identifying the trends of Patient 1’s fall incidents on 10/22/24 and 10/24/24, according to Patient 1’s behaviors of frequent attempts of getting out of bed, and inability to void, in accordance with the facility’s P&P titled “Safety and Supervision of Patients.” 4. Assist and supervise Patient 1 with toileting, in accordance with the patient’s Fall Risk Assessment indicating the patient required assistance with toileting due to the patient falling two (2) times in the last 90 days. As a result of the investigation, the California Department of Public Health (CDPH) determined Patient 1 sustained two unwitnessed falls at the facility on 10/22/24 (three days after admission) and 10/24/24 (five days after admission), resulting in a laceration to the back of the head, requiring transfer to the General Acute Care Hospital (GACH). Patient 1 required a laceration repair of the scalp with one staple placed on the patient's scalp with a post closure length of 1 centimeter. A review of Patient 1’s GACH 1 Orthopedic Consult Report dated 10/14/2024 at 11:39 AM, prior to Patient 1’s admission to the facility, indicated the patient was complaining of minimal pain over the patella but did not have swelling during the physical examination. The Consult Report indicated the patient performed a straight leg raise and no effusion was noted. The Consult Report indicated an assessment and plan of the patient’s questionable right patellar fracture was not complete and the patient could wear a knee brace for comfort only. The Consult Report indicated the patient could weight bear as tolerated and was cleared for discharge. A review of Patient 1’s Admission Record indicated an 89 year old, male patient admitted to the facility on 10/19/2024, with diagnoses including repeated falls, dementia (a progressive state of decline in mental abilities), Guillain-Barre syndrome (a rare neurological condition that occurs when the body’s immune system attacks the peripheral nervous system causing muscle weakness or paralysis [the loss of the ability to move some or all of the body]), and benign prostatic hyperplasia (BPH - a condition that occurs when the prostate gland enlarges, which could cause urinary problems). A review of Patient 1’s Fall Risk Assessment dated 10/19/2024 at 9:30 PM, indicated the patient had one to two (2) falls during the last 90 days. The Assessment indicated Patient 1’s gait (the pattern that you walk) was unsteady, and the patient required assistance with toileting. Patient 1’s fall risk score was 24 (Low risk - zero [0] to eight [8], Moderate risk – nine [9] to 15, and high risk – 16 to 42) indicating the patient was assessed as a high fall risk. A review of Patient 1’s Bowel and Bladder (B&B) Program Screener dated 10/19/2024 at 9:30 PM, indicated the patient was continent for B&B and was not a candidate for the B&B program. The B&B Program Screener did not indicate the patient’s ability to get to the bathroom, transfer to the toilet, adjust clothing, and wipe as part of the assessment. A review of Patient 1’s Risk for Falls Care Plan initiated 10/20/2024, indicated a goal for the patient’s risk for fall and injury would be minimized with interventions. The Care Plan interventions indicated to identify the time of day the patient was most vulnerable to falls, identify type of assistance needed, and to provide assistance as identified in transfer and mobility. A review of Patient 1’s Dementia Care Plan initiated 10/20/2024, indicated a goal for the patient to have minimal adverse behaviors and no complications. The Care Plan interventions indicated to approach the patient in a calm manner, explain all procedures prior to initiating them, provide cueing and prompting when performing activities of daily living (ADL’s) as tolerated, and reorient patient as needed and allow ample time to respond. A review of Patient 1’s Occupational Therapy (OT) Evaluation & Plan of Treatment dated 10/20/2024, indicated the patient had fallen two times in the past year and was unsteady when standing, walking, and was worried about falling. The OT evaluation indicated the patient required substantial/maximal assistance for toilet transfers and toileting hygiene. The OT evaluation indicated the patient’s short-term goal was to improve the ability to complete toilet transfers with partial/moderate assistance with recognition of safety hazards. The OT evaluation indicated the patient’s long-term goal was to be able to complete toileting with caregiver assistance for safety and stability. A review of Patient 1’s Physical Therapy (PT) Evaluation & Plan of Treatment dated 10/21/2024, indicated the patient had fallen two times in the past year and was unsteady when standing, walking, and was worried about falling. The PT evaluation indicated the patient required substantial/maximal assistance for toilet transfers and partial/moderate assistance for walking 10 feet (ft. – a unit of measurement). The PT evaluation indicated walking 50 ft. with two turns, walking 150 ft., and walking 10 ft. on uneven surfaces was not attempted due to medical conditions or safety concerns. A review of Patient 1’s Privileged and Confidential Document (R&C) dated 10/22/2024 at 1:05 PM, provided by the Director of Nursing (DON), indicated the patient slid off the wheelchair in the restroom witnessed by Registered nurse(RN)1 and RN 1 could not catch the patient in time. The R&C indicated the patient was confused with a gait imbalance, impaired memory, and predisposing situation factors which included ambulating without assist. The R&C indicated RN1 provided a statement indicating she was passing by the room when RN1 saw Patient 1 was?about to fall; RN1 tried to assist Patient 1 but was too late, and Patient 1 sustained a fall.? A review of Patient 1’s Change of Condition (COC) dated 10/22/2024 at 1:15 PM, indicated the patient slid off the wheelchair in the restroom witnessed by RN 1 who was unable to catch the patient on time and the patient sat to the floor. The COC indicated no injuries or pain were noted and that Patient 1’s representative (RR) and physician were notified with orders to continue monitoring the patient for any changes. A review of Patient 1’s Witnessed Fall Care Plan initiated 10/22/2024, indicated a goal for the patient to not sustain an injury related to the fall daily for seven (7) days. The Care Plan Interventions included an alarm device when Patient 1 was up in the wheelchair and in bed, monitor the patient whereabouts, and frequent safety reminders and visual monitoring. A review of Patient 1’s Post Fall Assessment dated 10/22/2024 at 1:25 PM, indicated the patient had recently fell and had one to two falls during the last six (6) months. The Post Fall Assessment indicated the patient in the last 14 days had occasional incontinence. The Post Fall Assessment indicated the patient was unable to independently come to a standing position. A review of Patient 1’s initial Physical Restraint form dated 10/23/2024 at 9:43 AM, indicated the patient’s behavior prompting restraint use was due to the patients attempts to self-transfer and was at risk for repeat falls due to repeat attempts of trying to get up unassisted. The Physical Restraint indicated alternatives attempted to reduce the risk of harm to the patient prior to the application of the restraint included directed/supervised ambulation, anticipating hunger, pain, heat, cold, and medication review. The Physical Restraint indicated the decision to restrain was recommended by IDT to use the alarm device to alert staff of unsafe mobility. The Physical Restraint indicated the date and time of the first application of the alarm device was on 10/23/2024 at 9:45 AM and the RR was notified and agreed to the restraint. The Physical Restraint indicated the physician’s order for the alarm device when up in the wheelchair and in bed to alert staff of unsafe mobility. A review of Patient 1’s Interdisciplinary Team (IDT) Fall Incident Review dated 10/23/2024 at 1:21 PM, indicated on 10/22/24, Patient 1 slid off the wheelchair in the restroom and was witnessed by a staff member (Registered Nurse 1) who was unable to catch the patient on time, and the patient sat to the floor. The IDT review indicated the patient was at a high risk for falls secondary to a history of multiple falls, dementia, and the patient having a behavior asking to go to the restroom even when he just went to the restroom. The IDT review indicated the root cause analysis was due to the patient trying to transfer from the wheelchair to the toilet. The IDT review indicated new interventions for frequent visual checks, anticipate patient’s needs, and to implement an alarm device. A review of Patient 1’s Minimum Data Set (MDS – a federally mandated patient assessment tool) dated 10/24/2024, indicated the patient had severe cognitive impairment (problems with a person’s ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the patient required substantial/maximal assistance (helper did more than half the effort) from facility staff with toileting hygiene and toileting transfers. The MDS indicated the patient required partial/moderate assistance (helper did less than half the effort) from facility staff with walking 10 ft.? The MDS indicated the patient had a fall in the last month prior to admission and had a fall since admission. The MDS indicated the patient’s fall on 10/24/24 resulted in lacerations to the back of the head. The MDS indicated the patient had urinary and bowel continence (the ability to control bodily functions) and was not part of a urinary or bowel toileting program. The MDS indicated the patient did not have pain in the last five (5) days from the assessment. A review of Patient 1’s COC dated 10/24/2024 at 7:45 PM, indicated the patient was found on the floor inside his room with a laceration to the back of the head with minimal bleeding. The COC indicated the patient complained of pain to the back of the head with non-verbal signs of pain included feeling sad, frightened, and frowning. The COC indicated the RP and physician were notified with orders to send the patient to the GACH for further evaluation. A review of Patient 1’s Pain Assessment dated 10/24/2024 at 7:45 PM, indicated the patient verbalized mild pain to the injury site from the fall. The Pain Assessment indicated the patient had mild pain of a three (3) to four?on the numeric pain scale. The Pain Assessment indicated the patient did not receive an as needed (PRN) medication. A review of Patient 1’s Actual Fall Care Plan dated 10/24/2024, indicated care plan interventions that included to apply an alarm device when up in the wheelchair and when in bed, to monitor the Patient 1’s?whereabouts, and to use a self-release belt (prevent the patient from falling out of the wheelchair) when up in the wheelchair for safety. A review of Patient 1’s GACH 2 Emergency Department (ED) Note dated 10/24/2024 at 8:13 PM, indicated the patient’s chief complaint was a fall with a laceration to the back of the head. The GACH Note indicated the Physician’s Assistant (PA) performed a laceration repair for the patient’s scalp laceration. The GACH Note indicated 1% lidocaine without epinephrine (a local anesthetic that acts as a vasodilator increasing blood flow and the risk of bleeding at the injection site) was the anesthesia used to perform the repair. The GACH Note indicated 1 staple was placed on the patient's scalp with a post closure length of 1 centimeter (cm – a metric unit of length). A review of Patient 1’s IDT Fall Incident Review dated 10/25/2024 at 1:57 PM, indicated the patient was found on the floor in his room on 10/24/24, with a laceration (a deep cut or tear in skin) to the back of the patient’s head with minimal bleeding. The IDT Review indicated the patient was at a high risk for falls secondary to a history of multiple falls, dementia, the patient having a behavior asking to go to the restroom even when he just went to the restroom, and a history of falls from home times four with a patellar fracture. The IDT Review indicated the root cause analysis was due to dementia. The IDT Review indicated new interventions with an order for a self-release belt when Patient 1 was up in the wheelchair and low bed against the wall with a floor mat. ? A review of Patient 1’s Rehab Status Post Fall Screen dated 10/28/2024 at 10:29 AM, indicated the patient was found on the floor lying on his back after hearing a triggered alarm. The Rehab Status Post Fall Screen indicated recommendations for one-to-one supervision and for the patient to use a walker with assistance. The Rehab Status Post Fall Screen indicated the patient would continue to be a high fall risk due to his impaired safety awareness with cognitive decline secondary to dementia. The Rehab Status Post Fall Screen indicated the patient had a chair alarm. The Rehab Status Post Fall Screen indicated the patient currently was receiving PT, OT, and ST. During an interview on 11/5/2024 at 2:06 PM, the Licensed Vocational Nurse (LVN) 1 stated Patient 1’s bed was positioned by the wall, closest to the window, and the patient’s dresser was at the feet of the bed. LVN 1 stated on 10/24/2024, she?placed?the patient into bed and?put the alarm clip on before going to the nurse’s station. LVN 1 stated less than five minutes later Patient 1’s alarm was triggered and when she entered the ro