Health inspection·October 18, 2024

F689, Code of Federal Regulations, Title 42, Section 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. California Code of Regulations, Title 22, Section 72311 Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. § 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 9/4/24 at 10:20 am, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a facility reported incident regarding resident safety. As a result of the investigation, the Department determined the facility failed to provide care and services to prevent a fall for Resident 1 who was assessed as needing contact guard assistance (CGA, place one or two hands on the resident's body to help with balance) with ambulation, by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1, CNA 2, Licensed Vocational Nurse (LVN) 1, and LVN 2, who were assigned to take care of Resident 1, were made aware by Physical Therapist 1 (PT 1, a licensed medical professional who helps patients/residents improve their ability to move and function) that Resident 1 required touching assistance (helper provides verbal cues and/or tactile [touch] cues or CGA while the resident completes activity) with ambulation on level surfaces and walking ten feet. 2. Provide touching assistance to Resident 1 while Resident 1 walked in the room, from the closet to Resident 1's bed. As a result of these failures, on 8/23/24 at "around" 9 pm, Resident 1 fell while walking from the closet to Resident 1's bed. Resident 1 experienced 10/10 pain (on a scale of 0 to 10 [0 representing no pain and 10 representing the worst pain imaginable]) on the right groin. The facility transferred Resident 1 to General Acute Hospital 1 (GACH 1) for further evaluation. At GACH 1, Resident 1 was found to have a fracture through the transcervical region (the middle portion) of the right femoral neck (the part of the thigh bone that connects the femoral head [the top of the thigh bone] to the femoral shaft [the long, straight part of the thigh bone]). Resident 1 was hospitalized at the GACH 1 for 20 days (from 8/23/24 to 9/12/24). On 8/26/24, Resident 1 underwent a partial right hip arthroplasty (a surgical procedure to replace part of the hip joint with a prosthetic [artificial] implant). A review of Resident 1's Admission Record indicated the facility admitted Resident 1, an 84-year-old female on 7/19/24. Resident 1 had diagnoses that included hemiplegia (weakness and paralysis of one side of the body) affecting the right dominant side, gout, difficulty in walking, generalized muscle weakness, and epilepsy. A review of Resident 1's Physical Therapy (PT) Evaluation and Plan of Treatment dated 7/20/24, indicated Resident 1 was assessed as feeling unsteady when walking and was worried about falling. The PT Evaluation and Plan of Treatment indicated Resident 1 had impaired right and left lower extremity strength and required CGA with transfers and gait on level surfaces. The PT Evaluation and Plan of Treatment indicated Resident 1 presented with impaired mobility and impaired coordination due to the documented physical impairments, and Resident 1 was at risk for falls. A review of Resident 1's History and Physical (H&P) dated 7/22/24, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's untitled care plan (CP), initiated on 7/22/24, indicated Resident 1 was at risk for falls due to hemiplegia. The CP interventions included for staff to anticipate Resident 1's need, explain the call system if appropriate, and assess ability to use the call light. A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment) dated 7/25/24 indicated Resident 1 had intact cognition. The MDS indicated Resident 1 required touching assistance with toilet transfer and to walk 10 feet. A review of Resident 1's Physical Therapy Encounter Notes (PT EN) dated 8/21/24, indicated Resident 1 had compromised balance, coordination, functional activity tolerance, postural support/control, safety awareness, and strength. The PT EN indicated Resident 1 required CGA with gait on level surfaces and standby assistance with transfers. A review of Resident 1's Physical Therapy Discharge Summary (PT DS), dated 8/21/24, indicated Resident 1 required CGA with ambulation on level surfaces using a two-wheeled walker. The PT DS indicated Resident 1 required standby assistance with functional transfers. A review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR, a structured communication framework to share information about the condition of a resident) dated 8/23/24, timed at 10:01 pm, indicated that on 8/23/24, at "around" 9 pm, Resident 1 was found lying on the floor on her back and Resident 1 complained of discomfort in the right groin area. The SBAR indicated Resident 1 stated she tripped over the wheelchair footrest while she was walking back to her bed from the closet. The SBAR indicated there was a bone protruding (location was not indicated). The SBAR indicated LVN 2 notified Resident 1's Attending Physician/Medical Doctor 1 (MD 1) of the fall and MD 1 ordered to transfer Resident 1 to GACH 1 for further evaluation. A review of Resident 1's Physician Order (PO) dated 8/24/24, timed at 12:15 am, indicated to transfer Resident 1 to GACH 1's emergency room for further evaluation. A review of Resident 1's GACH 1 Emergency Department (ED) Narrative dated 8/24/24, timed at 12:41 am, indicated Resident 1 reported a mechanical fall resulting in Resident 1 hitting her head on the door. The ED Narrative indicated Resident 1 experienced an onset of right groin pain radiating down Resident 1's right leg which began immediately after the fall. A review of Resident 1's GACH 1 Computed Tomography Scan (CT scan, an imaging test that uses X-ray techniques to create detailed images of the body) Report dated 8/24/24, timed at 3:53 am, indicated a fracture through the transcervical region of the right femoral neck. A review of Resident 1's Operative Report (OR) dated 8/27/24, indicated that on 8/26/24, Resident 1 had an "Open treatment of right femoral neck fracture using partial hip arthroplasty." During an interview on 9/4/24 at 2:27 pm, CNA 1 stated when assigned to Resident 1 (unable to recall date and time) CNA 1 had observed Resident 1 get up and walk by herself to the bathroom. CNA 1 stated CNA 1 was not aware Resident 1 needed assistance with ambulation. During an interview on 9/4/24 at 3:20 pm, LVN 1 stated Resident 1 was alert and oriented to person, place, and time. LVN 1 stated Resident 1 did not use the call light. LVN 1 stated Resident 1 was very independent and liked to do things on her own. LVN 1 stated Resident 1 had been getting up and walking independently to the bathroom since admission to the facility. During a concurrent interview with the Director of Rehabilitation (DOR) and record review on 9/4/24 at 3:31 pm, Resident 1's PT EN, dated 8/21/24 was reviewed. The PT EN indicated Resident 1 required CGA with gait on level surfaces and standby assistance with transfers. The DOR stated there were different levels of functions, starting with independent, set-up, supervised assist, standby assist, CGA, and dependent. The DOR stated CGA required a little contact with the resident to keep the resident steady during the activity. The DOR stated Resident 1 required CGA for safety. During a phone interview on 9/4/24 at 4:07 pm, CNA 2 stated she was assigned to Resident 1 the night the resident fell (8/23/24). CNA 2 stated Resident 1 would get up every morning independently. CNA 2 stated she would see Resident 1 get up while CNA 2 assisted Resident 1's roommate with incontinent care. CNA 2 stated Resident 1 would walk slowly, would hold the bed and the table, and would hold the wall towards the bathroom. CNA 2 stated Resident 1 was able to walk independently. During an interview on 9/4/24 at 5:25 pm, LVN 2 stated LVN 2 had observed Resident 1 "walk by herself and was steady." LVN 2 stated Resident 1 was able to ambulate independently. LVN 2 stated Resident 1 never pressed the call light when Resident 1 went to the bathroom. LVN 2 stated during the night of the fall (8/23/24 at 9 pm), LVN 2 heard a thud while passing medications and immediately checked Resident 1. LVN 2 stated LVN 2 found Resident 1 lying on the floor. LVN 2 stated Resident 1 told LVN 2 that Resident 1 tripped on the footrest of the wheelchair while walking from the closet to the bed. LVN 2 stated it was not the nurses' practice to refer to the PT EN. LVN 2 stated LVN 2 did not know Resident 1 required CGA with ambulation. During an interview on 9/5/24 at 11:20 am, CNA 3 stated the licensed nurses (in general) needed to communicate to the CNA (assigned CNA) whether residents needed assistance or not with ambulation. During a concurrent interview with PT 1 and a record review on 9/5/24 at 12:20 pm, the PT EN dated 8/21/24 was reviewed. The PT EN indicated Resident 1 required CGA with gait on level surfaces and standby assistance with transfers. PT 1 stated Resident 1 had slight weakness to both lower extremities (legs). PT 1 stated the PT EN dated 8/21/24 indicated Resident 1 was unsteady with transfers and gait and had decreased safety awareness. PT 1 stated PT 1 would not consider Resident 1 independent (able to ambulate by oneself). During a follow-up interview on 9/5/24 at 12:39 pm, the DOR stated when licensed nurses (all licensed nurses) or CNAs (all CNAs) asked regarding Resident 1's mobility, the DOR would verbally inform them (licensed nurses and CNAs) whether the resident required assistance from staff or an assistive device. The DOR stated the safety report and any changes in the resident's condition would be discussed during huddle meeting (a short meeting where a team comes together to address residents' goals and challenges). The DOR stated the PT EN were available in Resident 1's chart (medical record) for the nurses' reference. During an interview on 9/5/24 at 12:50 pm, LVN 1 stated Resident 1 was not considered at risk for fall. LVN 1 stated Resident 1 had a slight limp and would take small, steady steps while walking inside the room and the resident would use the wheelchair to move around the facility. LVN 1 stated LVN 1 did not refer to the PT notes/assessments in Resident 1's medical record. LVN 1 stated CGA meant staff needed to be close to Resident 1 to guide and redirect Resident 1 when the resident was unsteady. During a concurrent interview and record review on 9/5/24 at 1 pm with RN 1, Resident 1's care plan for fall dated 7/22/24 was reviewed. The care plan did not indicate that Resident 1 required CGA with ambulation. RN 1 stated RN 1 did not speak to PT 1 about Resident 1 requiring CGA. RN 1 stated CGA required staff to be close to Resident 1 so staff could grab or guide Resident 1 when Resident 1 was unsteady. RN 1 stated Resident 1's fall risk care plan indicated no documentation that Resident 1 required CGA with ambulation. During a concurrent record review and interview with the Director of Nursing (DON) on 9/5/24 at 3:07 pm, the MDS dated 7/25/24, PT DS dated 8/21/24, and Resident 1's fall care plan dated 7/22/24, were reviewed. The MDS indicated Resident 1 required CGA with toilet transfer and to walk 10 feet. The PT DS indicated Resident 1 required CGA with ambulation on level surfaces using a two-wheeled walker. The DON stated Resident 1 required CGA with ambulation. The DON stated Resident 1 told staff she could "do things by herself." The DON stated, "this resident (Resident 1) will do whatever she wants to do." The DON stated the care plan did not indicate any interventions based on the PT assessments of Resident 1's level of functional mobility and level of assistance required. The facility's Policy and Procedure (P&P) titled, "Fall Management Program," dated 11/1/2017 indicated, "it is the policy of this facility to provide the highest quality of care in the safest environment for the residents residing in the facility." The P&P indicated, "based on the information gathered from the history and assessment of the resident, the nursing staff, and Interdisciplinary Team (IDT, a group of health care professionals working collaboratively to accomplish a common goal), with input from the Attending Physician, will identify and implement interventions to reduce the risk of falls." As a result of the investigation, the Department determined the facility failed to provide care and services to prevent a fall for Resident 1 who was assessed as needing contact guard assistance with ambulation, by failing to: 1. Ensure CNA 1, CNA 2, LVN 1, and LVN 2, who were assigned to take care of Resident 1, were made aware by PT 1 that Resident 1 required touching assistance with ambulation on level surfaces and when walking ten feet. 2. Provide touching assistance to Resident 1 while Resident 1 walked in the room, from the closet to Resident 1's bed. As a result of these failures, on 8/23/24 at "around" 9 pm, Resident 1 fell while walking from the closet to Resident 1's bed. Resident 1 experienced 10/10 pain on the right groin area. The facility transferred Resident 1 to GACH 1 for further evaluation. At GACH 1, Resident 1 was found to have a fracture through the transcervical region of the right femoral neck. Resident 1 was hospitalized at the GACH 1 for 20 days. On 8/26/24, Resident 1 underwent a partial right hip arthroplasty. The above violations jointly, separately, or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.