Other·June 12, 2023

Code of Federal Regulations, Title 42, Section 483.21(b) Comprehensive Care Plans   §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each patient, consistent with the patient rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a patient's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following —   (i) The services that are to be furnished to attain or maintain the patient's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40 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. 42 CFR §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: (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. (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. California Code of Regulations, Title 22, Section 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 5/4/2023, the California Department of Public Health conducted an unannounced visit at the facility to investigate a Facility Reported Incident regarding Patient 1’s fall (unintentionally coming to rest on the ground) on 4/27/23 at 4:45 a.m. As a result of the investigation, the Department determined the facility failed to: 1) Develop and implement a patient-centered comprehensive care plan by the Interdisciplinary Team (IDT) to prevent a fall for Patient 1 who was assessed as high risk for falls, had a history of falls, and had a history of turning off the bed pad alarm in accordance with the facility’s policies and procedures titled “Fall Management System” dated 6/2021 and “Comprehensive Patient Centered Care Plan”. 2) Develop and implement a plan of care to address Patient 1’s behavior of turning off the bed pad alarm (a device with a sensor and monitor to alert staff when a patient attempts to leave the bed), in accordance with the facility’s Policy and Procedure titled “Comprehensive Patient Centered Care Plan” and “Fall Management System.” As a result of these failures on 4/27/2023 at 4:45 am Patient 1 fell and sustained a right hip fracture (break in the bone) and was subsequently transferred on 4/27/2023 at 7:05 pm, to General Acute Care Hospital 1 (GACH 1) for medical management due to Patient 1’s right hip fracture. During a review of Patient 1’s Admission Record, the Admission Record indicated the facility admitted Patient 1, an 81 year old male, on 5/6/2022, with diagnoses including cerebral infarction (stroke, sudden death of brain cells in a localized area due to inadequate blood flow), and generalized muscle weakness. During a review of Patient 1’s Physician’s Order, dated 10/3/2022, the Physician’s Order indicated for staff (in general) to “apply a pad alarm when in bed to alert staff if getting out of bed unassisted, due to poor safety awareness.” During a review of Patient 1’s Fall Risk Assessment, dated 11/10/2022, the Fall Risk Assessment indicated, Patient 1 was assessed as high risk for falls due to intermittent confusion, history of fall on 10/3/2022, and required assistance with bowel/bladder elimination (toileting). During a review of Patient 1’s Facility Incident Report, dated 11/19/2022, and timed at 8:25 am, the Facility Incident Report indicated, on 11/19/2022 at 6:40 am, Licensed Vocational Nurse 2 (LVN 2) found Patient 1 lying on the floor on Patient 1’s right side, at the end of Patient 1’s bed, facing the closet. The report indicated, Patient 1 stated Patient 1 tried to go to the bathroom and lost his balance. During a review of Patient 1’s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/15/2023, the MDS indicated, Patient 1 had severely impaired cognition (unable to think and process information). The MDS indicated, Patient 1 required extensive assistance (patient involved in activity while staff provide weight bearing support) with one-person physical assistance for bed mobility (how patient moves to and from lying position, turns to side and positions body while in bed), transfers (how patient moves between surfaces including to and from bed, chair, and wheelchair), toilet use, and personal hygiene. The MDS indicated, Patient 1 required the use of walker and wheelchair for ambulation (walking). During a review of Patient 1’s Care Plan titled, “Patient at Risk for Fall or Injury due to Generalized Weakness,” initiated on 2/15/2023, the care plan indicated interventions including for nursing staff to apply a pad alarm in bed and to check for placement of the bed pad alarm for proper functioning every shift. During a review of Patient 1’s Progress Notes, dated 4/27/2023, at 4:45 am, the notes indicated, LVN 1 saw Patient 1 lying on the floor next to Patient 1’s bed. LVN 1 reported the incident to Registered Nurse Supervisor 2 (RN2) and RNS 2 assessed Patient 1. The notes indicated Patient 1 stated he turned off the bed pad alarm because he (Patient 1) did not want to hear the noise from the bed pad alarm while getting up to get his wheelchair. During a review of Patient 1’s Progress Notes, dated 4/27/2023 at 10:29 am, the notes indicated, LVN 3 notified Patient 1’s Medical Doctor 1 (MD 1) regarding Patient 1’s complaint of uncontrolled pain (unrated). During a review of Patient 1’s Progress Notes, dated 4/27/2023, at 4:21 pm, the notes indicated, LVN 3 observed Patient 1 guarding (protecting) Patient 1’s right hip and Patient 1 complained of 10 out of 10 (10/10) pain (a pain scale from 0 to 10; 10 being the worst pain and 0 for no pain) on the right hip. The notes indicated LVN 3 called MD 1 and MD 1 ordered STAT (immediate) X-rays (digital image of an internal part of the body) of the right hip and right knee. During a review of Patient 1’s X-ray result of the right hip, dated 4/27/2023, the X-ray result indicated, Patient 1 had a displaced (not aligned) subcapital (fracture occur in the neck of the thighbone) fracture of the right femoral (relating to the thigh bone) neck and the shaft (part of the long bone) of the femur (thigh bone) was displaced laterally (sideways). During a review of Patient 1’s Physician’s Order, dated 4/27/2023, and timed at 4:59 pm, the Physician’s Order indicated, to transfer Patient 1 to GACH 1 due to right hip fracture. During a review of Patient 1’s GACH 1’s Orthopedic (medical specialty focuses on treating injuries/deformities of the bones or muscles) Consultation Notes, dated 4/27/2023, at 11:14 pm, the notes indicated, MD 2 discussed with the medical team and considered a surgical plan for Patient 1’s right hemiarthroplasty (surgical procedure that involves replacing part of the hip). During a review of Patient 1’s GACH 1’s Computed Tomography (CT- detailed internal images of the body) Scan without contrast (a dye, substance to add color that helped show abnormal areas inside the body) of the pelvis (lower part of the trunk between abdomen and thighs) result, dated 4/27/2023, at 11:35 pm, the CT result indicated, Patient 1 had an acute displaced angulated (end of bone fragments are at an angle of each other) subcapital fracture of the right femoral neck. During an interview on 5/5/2023 at 1:30 pm, with the facility’s Director of Nursing (DON), the DON stated, Patient 1 had an order for bed alarm and the alarm needed to be turned on and kept in place for Patient 1’s safety. During an interview on 5/5/2023, at 2:01 pm, with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated, Patient 1 was alert and had a history of turning off Patient 1’s bed pad alarm from time to time (unspecified dates). CNA 2 stated, this was not a new behavior for Patient 1. CNA 2 stated, she would turn on Patient 1’s bed pad alarm, each time she observed Patient 1 turned off the bed pad alarm. During an interview on 5/5/2023, at 2:18 pm, with RNS 1, RNS 1 stated, she was aware Patient 1 had a history of “disabling the alarm” by removing the cord from the bed pad alarm. During an interview on 5/5/2023, at 2:33 pm, with the facility’s DON, the DON stated, prior to Patient 1’s fall on 4/27/2023, there was one incident (unspecified date) she (DON) saw Patient 1 turned off Patient 1’s bed pad alarm. The DON stated, she did not develop a care plan to address Patient 1’s behavior of turning off the bed pad alarm. During an interview on 5/5/2023, at 2:43 pm, with LVN 1, LVN 1 stated, on 4/27/2023 at “approximately” 2 am, she observed Patient 1 held the bed pad alarm on Patient 1’s right hand. LVN 1 stated, she took the bed pad alarm away from Patient 1 and instructed Patient 1 not to touch the bed pad alarm. LVN 1 stated, on 4/27/2023 at 4:45 am, she found Patient 1 lying on the floor. During an interview on 5/5/2023, at 3:23 pm, with the facility’s DON and a concurrent review of Patient 1’s all care plans, the DON stated, there was no care plan developed and implemented to address Patient 1’s behavior of turning off or removing Patient 1’s bed pad alarm. The DON stated, the facility did not have a policy on Bed Pad Alarm. During a phone interview on 5/9/2023, at 7:43 am, with RNS 2, RNS 2 stated, Patient 1 had an order for the bed pad alarm due to Patient 1 had a history of getting out of bed without calling for assistance. RNS 2 stated on 4/27/2023, before 4:45 am (unspecified time), LVN 1 reported to her (RNS 2) Patient 1 turned off Patient 1’s bed pad alarm “around 2 to 3 am.” RNS 2 did not answer when the surveyor asked what were RNS 2’s interventions/instructions when LVN 1 reported to her (RNS 2) that Patient 1 turned off Patient 1’s bed pad alarm. RNS 2 stated, she was aware Patient 1 “always turn the alarm off.” During an interview on 5/10/2023, at 6:04 am, with CNA1, CNA 1 stated, on 4/26/2023 at “around” 11 pm, she saw Patient 1 lying on Patient 1’s bed, and the bed pad alarm was off. CNA 1 stated, she (CNA 1) changed Patient 1’s adult brief (disposable underwear), then turned Patient 1’s bed pad alarm back on. CNA 1 stated, on 4/27/2023 at “around” 4:45 am, LVN 1 informed her (CNA 1) Patient 1 was lying on the floor in Patient 1’s room. CNA 1 stated, she ran to Patient 1’s room and saw Patient 1’s bed pad alarm was off. CNA 1 stated, Patient 1 told CNA 1 Patient 1 got up from the bed and Patient 1 turned off his bed pad alarm because the pad alarm would make too much noise. CNA 1 stated, Patient 1 had a history of turning off the bed pad alarm “from time to time (unspecified dates).” During an interview on 5/16/2023, at 3:16 pm, with the DON, the DON, stated there were no care plans developed nor Interdisciplinary Team (IDT- a group of health care professionals who work together toward the goals of their patients) meeting conducted to address Patient 1’s behavior of turning off Patient 1’s bed pad alarm. The DON stated Patient 1’s behavior of turning off the bed pad alarm needed to be communicated so the issue can be addressed by the IDT. During a review of the facility’s Policy and Procedure titled, “Fall Management System,” dated 6/2021, indicated, “Patients with high risk factors identified on the Fall Risk Evaluations 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 risk factors and will consider the particular elements of the evaluation that put the patient at risk. Interventions for fall prevention may include but not limited to sensor pads/alarms, low bed, floor mat, toileting program, etc.” During a review of the facility’s Policy and Procedure titled, “Comprehensive Patient Centered Care Plan,” revised 2/2023, indicated, “The care plan is developed by the IDT which may include, but is not limited to the following professionals: Attending Physician, Registered Nurse responsible for the patient, Nursing Assistants responsible for patient care and others as necessary.” As a result of the investigation, the Department determined the facility failed to: 1) Develop and implement a patient-centered comprehensive care plan by the Interdisciplinary Team to prevent a fall for Patient 1 who was assessed as high risk for falls, had a history of falls, and had a history of turning off the bed pad alarm in accordance with the facility’s policies and procedures titled “Fall Management System” dated 6/2021 and “Comprehensive Patient Centered Care Plan”. 2) Develop and implement a plan of care to address Patient 1’s behavior of turning off the bed pad alarm, in accordance with the facility’s Policy and Procedure titled “Comprehensive Patient Centered Care Plan” and “Fall Management System. As a result of these failures on 4/27/2023 at 4:45 am Patient 1 fell and sustained a right hip fracture and was subsequently transferred on 4/27/2023 at 7:05 pm, to General Acute Care Hospital 1 for medical management due to Patient 1’s right hip fracture. The above violation 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 Patient 1.