Health inspection·September 28, 2022

F580 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is— (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); T22 § 72311 Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (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. (3) 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. (C) An unusual occurrence, as provided in Section 72541, involving a patient. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section72301(g). T22 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 7/15/2022 at 12:20 pm, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care. On 6/17/2022, Patient 1 complained of right hip pain. The facility’s licensed nursing staff did not inform Physician 1 of Patient 1's pain until 6/20/2022 (three days later) at 10:39 am. Patient 1's X-ray of the right hip result dated 6/21/2022, indicated a right hip fracture (broken bone). Patient 1 remained in the facility until 6/29/2022, when the patient was transferred to an Orthopedic (medical provider who specializes in disorders of the bones) Surgeon’s (Physician 2’s) office for an orthopedic consultation, Physician 2 called 911 (emergency services) to transfer the resident to a General Acute Care Hospital 1 (GACH 1). As a result of the investigation the Department determined that the facility failed to: 1. Promptly notify Patient 1’s attending physician (Physician 1) for three (3) days, in accordance with the facility’s policy and procedures, regarding Patient 1’s change in condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) that started on 6/17/2022. 2. Assess and monitor, in accordance with the facility’s policy and procedures, Patient 1's complaint of right hip pain on 6/17/2022. 3. Transfer Patient 1 to GACH 1 in a timely manner for a medical evaluation after Patient 1 's X-ray (a test that produces images of the body structures) of the right hip result dated 6/21/2022, which indicated a right hip fracture (broken bone). These failures resulted in the delayed medical evaluation and treatment for Patient 1’s right hip fracture that was left untreated for at least 12 days from Patient 1’s initial complaint of right hip pain. Furthermore, the facility took nearly eight (8) days after an x-ray identified the right hip fracture before Patient 1 was seen by an orthopedic surgeon who then contacted 911 to transfer Patient 1 to a GACH. Patient 1 was admitted to GACH 1 and underwent an open reduction internal fixation (ORIF, surgery to fix severely broken bone) of his right hip on 7/2/2022. A review of Patient 1’s Admission Record indicated the facility admitted a seventy-nine-year-old male patient on 4/13/2022, with diagnoses including diabetes mellitus (a medical condition characterized by the body’s inability to regulate blood sugar levels), dementia (loss of cognitive function such as thinking, remembering, and reasoning) with behavioral disturbance, and Schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). A review of Patient 1’s untitled Care Plan, dated 4/14/2022, indicated the patient was at risk for pain and the nursing interventions were to assess the resident’s pain level, document and notify the resident’s physician of increasing and/or unrelieved pain. A review of Patient 1's History and Physical dated 4/16/2022, indicated Patient 1 did not have the capacity to understand and make decisions. A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/20/2022, indicated Patient 1 was sometimes able to make his needs known and had severely impaired cognition (ability to make decisions). The MDS indicated Patient 1 required extensive to total assistance with activities of daily living (ADL). A review of Patient 1's untimed Occupational Therapy (OT, a form of therapy that encourages rehabilitation through the performance of activities required in daily life) Treatment Encounter Note, dated 6/17/2022, untimed, indicated Patient 1 complained of constant right hip pain with movement to the right lower extremity. The note indicated Occupational Therapist 1 (OT 1) recommended a right hip X-ray and notified the charge nurse (unidentified). A review of Patient 1's Physical Therapy (PT, form of therapy that uses exercises and physical activities to help condition muscles and restore strength and movement) Discharge Summary dated 6/23/2022, indicated Patient 1 refused therapy on 6/17/2022 due to right hip pain. The discharge summary indicated Physical Therapist 1 (PT 1) communicated the change in Patient 1’s condition and recommended an X-ray to the nursing staff (unidentified). . The discharge summary indicated to discontinue therapy until X-ray results and Physician 1's order. A review of Patient 1's late entry Progress Note dated 6/20/2022, timed at 9:05 am, indicated the Director of Rehabilitation (DOR) reported Patient 1’s right hip pain to the nursing staff (unidentified). The DOR indicated in the notes per nursing staff (unidentified), still waiting for Physician 1's instructions and order. A review of Patient 1's Situation Background Assessment and Recommendation (SBAR) Communication Form dated 6/20/2022, timed at 10:35 am, indicated Patient 1 was noted with increased weakness and generalized body pain. The SBAR documentation indicated Patient 1 verbalized that his pain was 3 out of 10 (a pain scale wherein 0 means no pain and 10 means worst pain possible). Patient 1 had no redness, swelling, or discoloration. The SBAR documentation indicated Physician 1 was notified on 6/20/2022 at 10:39 am and Physician 1 ordered blood tests. The SBAR indicated the x-ray was requested/suggested. A review of Patient 1's X-ray of the right hip result dated 6/21/2022, indicated the patient had a fracture of the intertrochanteric (bony protrusions on the femur or thighbone) portion of the right hip with osteoporosis (a condition in which bones become weak and brittle). A review of Patient 1's Progress Note dated 6/21/2022, timed at 11:58 am, indicated Patient 1's X-ray result was reported to Physician 1. The note indicated Physician 1 gave new orders. A review of Patient 1's Physician Order dated 6/21/2022, timed at 8 pm, indicated the following orders: 1. May have an orthopedic consult for fracture of the right hip with osteoporosis. 2. Hold PT and OT services until orthopedic consult. 3. Non-weight bearing (no weight can be placed) to right lower extremity until orthopedic consult. 4. Start Fosamax (medication used to prevent and treat certain types of bone loss) 70 milligrams (mg, unit of measurement), give one tablet by mouth in the morning every Saturday for osteoporosis. A review of Patient 1's physician order dated 6/24/2022, indicated for the patient to have an orthopedic consult with Physician 2 on 6/29/2022, at 10 am. A review of Patient 1's Progress Note dated 6/29/2022, timed at 3:47 pm, indicated Physician 2's staff (unidentified) informed the facility’s staff (unidentified) Patient 1 would be transferred to GACH 1 for evaluation of right hip fracture. The note indicated Physician 1 was aware. A review of Patient 1's Emergency Department (ED) Documentation from GACH 1 dated 6/29/2022, indicated Patient 1 was found to have a right hip fracture. The ED documentation indicated Patient 1 had an orthopedic follow-up appointment, had X-ray done, and was directed to come to ED for evaluation. The ED documentation indicated Patient 1 made grimaces upon log roll (a maneuver used to move a person without flexing the spinal column) of right lower extremity. The ED documentation indicated to admit Patient 1 for surgery within 24 hours. A review of Patient 1's Orthopedic Consultation Note from GACH 1 dated 6/29/2022, indicated Patient 1's right lower extremity was shortened and in externally rotated position (rotation away from the center of the body). Patient 1 with pain with log roll (to maintain alignment of the spine while turning and moving). The note indicated Patient 1 required fracture stabilization and surgical fixation. A review of Patient 1's Discharge Documentation from GACH 1 dated 7/8/2022, indicated Patient 1 reported right hip pain and inability to walk. The documentation indicated Patient 1’s X-ray of the right hip (dated 6/29/22) showed moderately displaced comminuted (bone that is broken in at least two places) right intertrochanteric fracture. The documentation indicated Patient 1 underwent an ORIF of the right proximal femur (the bone of the thigh, extending from the hip to the knee) on 7/2/2022. Patient 1 was discharged back to the facility on 7/11/2022. During an interview on 7/15/2022 at 10:05 am, Physician 2 stated Patient 1's treatment was delayed. Physician 2 stated any individual with any kind of hip fracture needed to be evaluated in an emergency setting and with an emergency physician due to high mortality (the state of being subject to death) and morbidity (the condition of suffering from a disease) rates. Physician 2 stated often time, individuals with hip fractures also have comorbidities (existence of more than one disease or condition at the same time) that needed to be addressed. During an interview on 7/15/22 at 12:40 pm., the Assistant Director of Nursing (ADON) stated on 6/20/22, Patient 1 complained of generalized body pain and needed increased assistance with ADL. The ADON stated Physician 1 was notified and ordered a blood test and X-ray. Patient 1's X-ray (dated 6/21/2022) showed right hip fracture with osteoporosis. The ADON stated Physician 1 was notified and was aware of the new fracture. The ADON stated Physician 1 ordered to start Patient 1 on Fosamax and orthopedic consultation. The ADON stated Patient 1 went for his orthopedic consultation with Physician 2 (on 6/29/2022). The ADON stated Physician 2 informed the facility that he called 911. The ADON stated Physician 2 stated Patient 1's fracture required further evaluation and needed to be seen at the hospital. The ADON stated Patient 1 was readmitted to the facility from GACH 1 on 7/11/2022, after ORIF surgery. During an observation in Patient 1’s room and concurrent interview on 7/15/2022 at 1:38 pm, Patient 1 did not respond to his name and kept his eyes closed. During an interview on 7/15/2022 at 1:50 pm, Registered Nurse 1 (RN 1) stated Patient 1's X-ray result (dated 6/21/2022) showed displaced (a gap from where the bone breaks) hip fracture. RN 1 stated the ADON was the one who notified Physician 1. RN 1 stated any patient with displaced fracture, the physician (in general) would order to transfer to the hospital but for Patient 1, Physician 1 ordered an orthopedic consultation. During an interview on 7/15/2022 at 2:52 pm, Physician 1 stated for a patient (in general) with hip fracture, the patient required to go out to the hospital to be evaluated. During a concurrent telephone interview and a review of Physician 1's orders dated 6/21/2022, Physician 1 stated the facility’s staff did not notify him of Patient 1’s fracture. Physician 1 stated the Fosamax was not his order. Physician 1 stated if the facility notified him of Patient 1's hip fracture, he would have ordered for Patient 1 to be transferred to the hospital for evaluation. Physician 1 stated if the fracture was old then orthopedic consultation will be fine. Physician 1 stated the orthopedic consultation was not his order. Physician 1 stated hip fracture required to be taken care of right away. During an interview on 7/15/2022 at 3:04 pm, the Director of Rehabilitation (DOR) stated on 6/17/22, PT 1 notified her, and the nursing department staff (unidentified) that Patient 1 complained of right hip pain. The DOR stated this was the first time Patient 1 complained of right hip pain. The DOR stated she followed up with the nursing department staff (unidentified) on 6/20/2022 (3 days later). During a telephone interview on 8/22/2022 at 1:48 pm, OT 1 stated PT 1 informed him of Patient 1's complaint of right hip pain and recommendation for an X-ray of the hip. OT 1 stated on 6/17/2022, Patient 1 also complained to him of pain to the right hip with right leg movement. OT 1 stated he informed the charge nurse (unidentified) and recommended to get an X-ray of the hip. OT 1 stated he worked with patient 1 in bed and only performed upper body gentle range of motion exercises at that time. OT 1 stated he assisted Patient 1 with his dinner meal. OT 1 stated prior to 6/17/2022, Patient 1 did not complain of pain during therapy. During a telephone interview on 8/23/22 at 8:40 am, PT 1 stated on 6/17/2022, Patient 1 complained of right hip pain and would get combative when PT 1 tried to touch Patient 1's right leg. PT 1 stated she informed the charge nurse (unidentified), RN 2, and the ADON. PT 1 stated she recommended to get an order for an X-ray and hold therapy until further orders from Patient 1’s Physician. During an attempted telephone interview on 8/24/2022, at 10:05 am, RN 2 was not available and did not return the call. During a follow-up telephone interview on 8/24/2022, at 11:55 am, Physician 1 stated he did not recall if the facility notified him of Patient 1’s complaint of right hip pain on 6/17/2022. Physician 1 stated if the patient (in general) complained of pain or has possible injury after a fall, he would order an X-ray to check for fracture or send the patient to the hospital for evaluation depending on the severity of the injury. Physician 1 stated he did not recall the facility notifying him about patient 1's right hip fracture. Physician 1 stated, “I don’t think they notified me about the fracture.” Physician 1 stated if the facility notified him, he would have ordered to send Patient 1 to the hospital for evaluation. During a follow-up telephone interview and concurrent review of Patient 1's medical record on 8/24/2022, at 1:45 pm, the ADON stated she was not aware of Patient 1’s complaint of right hip pain on 6/17/2022. The ADON stated on 6/20/2022, the CNA (unidentified) notified her of Patient 1's complaint of generalized pain and weakness for the last three days. The ADON stated Physician 1 was notified of Patient1's change in condition on 6/20/2022 at 10:39 am. Physician 1 ordered blood tests and an X-ray of the right hip. The ADON stated on 6/21/2022 at 11:58 am, she notified Physician 1 of Patient1's x-ray results via text message regarding the x-ray showed right hip fracture with osteoporosis. The ADON stated Physician 1 ordered for orthopedic consultation, to hold PT and OT services, no weight bearing to right lower extremity and start medication for osteoporosis. The ADON stated any change in pa