Other·October 6, 2022

F689- §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. § 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. Title 22 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 7/27/2022 at 9:30 am, the California Department of Public Health conducted an unannounced visit at the facility to investigate a Facility Reported Incident regarding quality of care and fall of Patient 1. On 7/20/2022 at 9 PM, Certified Nurse Assistant 3 (CNA 3) left Patient 1 unsupervised and Patient 1 fell from her bed, sustained a refracture [a break along the line of a previous fracture (break in the continuity of a bone)] of a healing right hip fracture. As a result of the investigation, the Department determined that the facility failed to: 1. Ensure Patient 1 received one on one supervision (1:1, one staff supervising 1 patient) to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) on 7/20/2022 as indicated in Patient 1's Fall Care Plan when CNA 3 left patient 1 unsupervised on the bed to go to the bathroom. 2. Follow the facility's policy and procedure on Fall Management System when CNA 3 failed to implement interventions to prevent a fall for Patient 1. As a result of these failures, Patient 1 fell from her bed and sustained a refracture of a healing right hip fracture. The patient was transferred to a General Acute Care Hospital (GACH) and underwent a removal of right hip deep hardware (device used to hold broken bone), a deep bone biopsy (remove a bone sample), intramedullary nail fixation (long rod inserted inside the bone) of the right hip fracture, intertrochanteric (top end of the thigh bone) closed reduction (procedure to set a broken bone without cutting the skin open) and nailing of right femur shaft (long part of the thigh bone) fracture. A review of Patient 1's Face Sheet indicated the facility admitted an 88-year-old female on 7/11/2022 with diagnoses that included a fracture of the right femur (thigh bone) and dementia (loss of memory, language, and other thinking abilities). A review of Patient 1's Fall Risk Evaluation on Admission, dated 7/11/2022, indicated the patient was assessed as high risk for falls. A review of Patient 1's Comprehensive Care Plan, titled "At Risk for Falls Related to a Past History of Falls Requiring Right Hip Open Reduction and Internal Fixation Surgery (ORIF, a type of surgery used to stabilize and heal a broken bone)" dated 7/11/2022, indicated the interventions were for staff to provide a call light within reach, bed in low position, floor mats at the bedside, and to ensure the needed items were within the patient's reach. A review of Patient 1's Licensed Nursing Admission Note, dated 7/11/2022, at 8:27 PM, indicated the patient was admitted to the facility after sustaining a fracture on the right hip from a fall from an assisted living facility (housing for elderly) where she lived. A review of Patient 1's Licensed Nursing Note, dated 7/12/2022, at 7:54 AM, indicated the patient attempted to get out of bed twice and was reoriented and educated on the proper use of her call light. A review of Patient 1's Licensed Nursing Note, dated 7/13/2022, at 2:51 PM, indicated the patient was confused, forgetful, and was found sitting on the edge of the bed with the bed alarm on. The note indicated the patient verbalized wanting to use the restroom. A review of Patient 1's Social Services Note, dated 7/13/2022, at 5:34 PM indicated the patient lived in a memory care unit of the assisted living facility due to dementia. A review of Patient 1's Change of Condition (COC, a sudden clinically important deviation from the patient's baseline in physical, cognitive, behavioral, or functional domains) note, dated 7/14/2022 at 2:45 AM, indicated the patient fell and complained of right rib pain. The COC indicated an x-ray (a photographic or digital image) of the right ribs and right hip were ordered, and no fracture was found. A review of Patient 1's Licensed Nursing Note, dated 7/14/2022 at 2:58 AM, indicated an unidentified Certified Nursing Assistant (CNA) heard Patient 1's bed alarm went off and found the patient sitting on the edge of the bed. The note indicated Patient 1 asked to be changed and the CNA went to get supplies, turned around and saw Patient 1 stood up, lost her balance, and fell. The note indicated Patient 1 was assessed by Charge Nurse 1 without injury. A review of Patient 1's Licensed Nursing Note, dated 7/15/2022 at 1:13 AM, indicated on 7/14/2022 at 11:40 PM the patient's bed alarm sounded, and a "loud thud" was heard as Registered Nurse Supervisor 1 (RNS 1) entered the room. The note indicated the patient was found on the floor by the foot of the bed with both legs flexed towards the foot of the bed and head towards the wall. The note indicated the patient had a hematoma (pool of clotted blood in a body space) to the back, left side, of the head with minimal bleeding. The note indicated Patient 1 complained of pain on the right thigh. The note indicated the patient was transferred to the Emergency Room (ER) via 911 (an emergency number for police, fire, or medic). A review of Patient 1's Licensed Nursing Note, dated 7/15/22, at 8:50 AM indicated the patient returned to the facility on 7/15/22 at 8:45 AM. A review of Patient 1's Comprehensive Care Plan, titled "At risk for falls related to an actual fall secondary to impulsive behavior, poor safety awareness and perceived independence," created on 7/15/2022, untimed, indicated two interventions to be implemented to prevent falls including assigning the patient a 1:1 sitter and 1:1 activity for social and sensory stimulation. A review of Patient 1's Minimum Data Set (MDS, a standardized assessment tool) dated 7/17/2022, indicated the patient required extensive assistance (patient involved in activity, staff provide weight bearing support) with toileting, bathing, bed mobility, and transfers. The MDS indicated Patient 1 had moderately impaired cognitive skills (ability to understand and process information) for daily decision making. A review of Patient 1's Fall Committee Interdisciplinary Team (IDT, a group of health care professionals who work together toward the goals of their patients) Note, dated 7/18/2022, at 1:14 PM, indicated the patient was to be placed on 1:1 supervision with 1:1 activity for social and sensory stimulation. A review of Patient 1's Licensed Nursing Note, dated 7/20/2022, timed at 9:35 PM, indicated at 9 PM, RNS 1 heard Patient 1's bed alarm went off and found the patient on the floor by the foot of the bed with the right leg inverted inward. The note indicated the patient tried to reach out for something and fell from the bed. The note indicated 911 was called and the patient was transferred to the GACH. A review of Patient 1’s GACH ER Physician's Note, dated 7/20/2022, at 9:56 PM, indicated the patient was diagnosed with a new right hip fracture. A review of Patient 1's GACH right hip x-ray, dated 7/20/2022, indicated the patient had a proximal right (next to the right) femoral shaft (long part of the thigh bone) completely displaced (gap between pieces of bone) fracture, with moderate angulation (bent at an angle as opposed to straight). A review of Patient 1’s GACH Operative Procedural Documentation, dated 7/21/2022, at 3:32 PM, indicated the patient underwent an intertrochanteric fix with a nail two weeks prior to repair of the right hip fracture and required another surgery to repair the second fracture. The documentation indicated the surgery was risky and "no guarantee could be made" about the outcome. The patient underwent removal of right hip deep hardware, a deep bone biopsy, intramedullary nail fixation of the right hip fracture, intertrochanteric closed reduction and nailing of right femur shaft fracture. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 8/1/2022, at 3:16 PM, she stated she was assigned to care for Patient 1 on 7/20/2022. LVN 1 stated CNA 3 was the assigned 1:1 sitter for Patient 1. LVN 1 stated a 1:1 sitter was assigned for Patient 1 due to the patient had fallen two times prior and was very impulsive and would try to get out of bed. LVN 1 stated on 7/20/2022 at around 9 PM, after Patient 1 fell, RNS 1 called LVN 1 to help RNS 1. LVN 1 stated she was instructed by RNS 1 to stay with Patient 1 and to immobilize the patient's leg. LVN 1 stated CNA 3 was not in Patient 1's room at the time of the fall and had walked out into the facility hallway to find someone to relieve her for a restroom break. LVN 1 stated CNA 3 should not have left the patient unsupervised. LVN 1 stated CNA 3 should have asked for help, by sending a text message or pushing the call light in Patient 1's room to ask for a staff member to relieve her and not leave the patient unsupervised. During an interview on 8/1/2022 at 4:30 PM, RNS 1 stated on 7/20/2022 at around 9 PM, RNS 1 walked towards the Nurse's Station and heard Patient 1's bed alarm went off and then heard Patient 1 yell. RNS 1 entered Patient 1's room and found the patient on the floor at the foot of the bed with the patient's leg "twisted inward". RNS 1 stated, she immobilized the patient's leg and yelled out for LVN 1. RNS 1 stated Patient 1 had been assigned a 1:1 sitter due to two prior fall incidents. RNS 1 stated, CNA 3, the 1:1 sitter for Patient 1. was not in the room with the patient when Patient 1 fell. RNS 1 stated CNA 3 only showed up when RNS 1 called for help. RNS 1 stated CNA 3 had left Patient 1 unsupervised to go to the restroom. RNS 1 stated CNA 3 should have called and asked another staff to cover/relieve her. RNS 1 stated Patient 1 liked to get up and that was why "we" have a sitter there to make sure the patient did not get up by herself and fall. During an interview on 8/1/2022 at 6:03 PM, CNA 3 stated she was assigned as the 1:1 sitter for Patient 1 on 7/20/2022 from 3 PM to 11 PM. CNA 3 stated a 1:1 sitter was supposed to always stay with the patient and made sure the patient did not fall. CNA 3 stated the facility did not assign anyone to cover her for the 15-minute breaks and her lunch break. CNA 3 stated she asked RNS 1 who was going to cover for her breaks and RNS 1 told her "I don't know." CNA 3 stated on 7/20/2022 at around 9 PM she left Patient 1's room to look for a staff member to cover for a restroom break but no one was around. CNA 3 stated at that point, she decided to walk towards the restroom and then she heard RNS 1 called out for help. CNA 3 stated Patient 1 was found on the floor by the foot of the bed and 911 was called. During a concurrent interview and review of Patient 1's Fall Care Plan, on 8/2/2022, at 1:35 PM, the Director of Nursing (DON) stated after Patient 1 fell twice on 7/14/2022, the facility implemented a 1:1 sitter for the patient. The DON stated a physician's order was not obtained for the 1:1 intervention because "nursing interventions", do not need a physician order. The DON stated the 1:1 sitter was expected to always stay with the patient. The DON stated on 7/20/2022, CNA 3 left Patient 1's room to use the restroom, the patient was left unattended and fell. The DON stated Patient 1's fall could have been prevented. A review of the facility’s Policy and Procedure, titled "Fall Management System," with a revised date of 2/2022, indicated "Each patient is assisted in attaining or maintaining their highest practicable level of function through providing the patient adequate supervision to prevent accidents." The policy indicated "It is the policy of this facility to provide each patient with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs." The policy indicated "Patients with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the patient at risk". As a result of the investigation, the Department determined that the facility failed to: 1. Ensure Patient 1 received one on one supervision to prevent a fall on 7/20/2022 as indicated in Patient 1's Fall Care Plan when CNA 3 left patient 1 unsupervised on the bed to go to the restroom. 2. Follow the facility's policy and procedure on Fall Management System when CNA 3 failed to implement interventions to prevent a fall for Patient 1. As a result of these failures, Patient 1 fell from her bed and sustained a refracture of a healing right hip fracture. The patient was transferred to a GACH and underwent a removal of right hip deep hardware, a deep bone biopsy, intramedullary nail fixation of the right hip fracture, intertrochanteric closed reduction and nailing of right femur shaft fracture. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.