Other·February 24, 2023

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 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. 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: (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 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: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 2/7/2022 at 2:45 pm, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a Facility Reported Incident regarding quality of care/treatment, patient safety, and falls. As a result of the investigation, the Department determined the facility failed to ensure Patient 1 who had a diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life), received care and services to prevent a fall by failing to: 1. Assess and monitor Patient 1 for causes leading to episodes of restlessness (the inability to rest or relax) and constantly trying to climb out of Patient 1's bed and as indicated by the facility’s Falls and Fall Risk Managing policy and procedure. 2. Identify appropriate interventions to reduce the number of repetitive falls for Patient 1 who was not able to verbalize her needs and as indicated by the facility’s Falls and Fall Risk Managing policy and procedure. 3. Document patterns or triggers that caused Patient 1 to climb out bed during multiple previous incidents and on 1/20/2023, the facility failed to document behaviors and possible triggers affecting Patient 1 who was exhibiting signs of restlessness and agitation and as indicated in the facility’s Routine Resident Checks policy and procedure. As a result of these failures, on 1/20/2022, at 4:35 am, Patient 1 climbed out of her bed unnoticed by Certified Nurse Assistant 1 (CNA 1), fell, and sustained a right femoral trochanteric (one of the bony prominences toward the near end of the thighbone/the femur) fracture (broken hip bone). Patient 1 required transfer to a General Acute Care Hospital (GACH) via 911 (emergency services) where Patient 1 underwent surgery on 1/22/2022 to repair the hip fracture. A review of Patient 1's Admission Record indicated the facility admitted Patient 1 on 12/26/2021, with diagnoses that included dementia, schizoaffective disorder (a mental disorder), syncope (fainting resulting from certain stressful triggers), abnormalities of gait (the way a person walks), and mobility (how a person moves). A review of Patient 1's Admission/Readmission Data Tool -Fall Risk Assessment, dated 12/26/2021, indicated Patient1 had a history of falls and was at risk for falls. A review of Patient 1's Medication Administration Record (MAR), dated 12/26/2021 to 12/31/2021, indicated Patient 1 had 14 episodes of constantly trying to get out of bed from 12/29/2021 to 12/31/2021. A review of Patient 1's History and Physical Examination, dated 12/29/2021, 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 comprehensive assessment and care screening tool), dated 12/31/2021, indicated Patient 1 had severe impaired cognition (when a person has very hard time remembering things, making decisions, concentrating, or learning). The MDS indicated Patient 1 required extensive assistance (patient involved in activity, staff provide weight-bearing support) from staff with two plus people physically assisting for bed mobility (how patient moves to and from lying position, turns to side to side, and positions body while in bed) and transfers. A review of Patient 1's MAR, dated 1/1/2022 to 1/31/2022, indicated Patient 1 had 45 episodes of constantly trying to climb out of bed from 1/1/2022 to 1/4/2022. A review of Patient 1's untitled Care Plan, dated 1/5/2022, indicated Patient 1 had the potential to demonstrate physical behaviors of getting out of bed unassisted, related to dementia. The care plan indicated the nursing interventions included to assess and anticipate Patient 1's needs, food, thirst, toileting needs, comfort level, body positioning, and pain. The care plan indicated the nursing interventions also included to analyze key times, places, circumstances, triggers, what deescalates Patient 1's behavior, and document the nursing interventions. A review of Patient 1's Change of Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains), dated 1/20/2022, timed at 4:35 am, indicated Patient 1 had an unwitnessed fall and Licensed Vocational Nurse 1 (LVN 1) observed Patient 1 lying on the floor. The COC indicated LVN 1 noted Patient 1's right thigh swollen, and Patient 1 had pain. The COC indicated LVN 1 notified Patient 1's physician and sent Patient 1 to the GACH for evaluation of Patient 1's right thigh. A review of Patient 1's Progress Notes, dated 1/20/2022, timed at 7:30 am, indicated LVN 1 observed Patient 1 awake in bed on 1/20/2022 at 2 am. The notes indicated Patient 1 removed her adult brief (disposable adult underwear) and tried to get out of her (Patient 1's) bed unassisted. The notes indicated CNA 1 assisted Patient 1 by putting Patient 1's brief on, and as CNA 1 turned her back, Patient 1 removed her brief once again. The notes indicated, LVN 1 saw Patient 1 at 3 am, awake with continued episodes of trying to climb out of Patient 1's bed on both sides. LVN 1 noted Patient 1 was "agitated" (feeling or appearing troubled or nervous). The notes indicated LVN 1 "encouraged" (gave support and advice), CNA 1 to monitor Patient 1 closely (close surveillance or supervision, especially of people liable to suffer a sudden and dangerous deterioration in health). The notes indicated at 4:35 am, LVN 1 saw Patient 1 lying down on the floor mat (used to reduce force and reduce injury), and Patient 1's head was next to the foot of Patient 1's bed. The notes indicated LVN 1 observed Patient 1 awake with Patient 1's right lower extremity (lower leg) swollen and painful to touch. The notes indicated Patient 1's physician ordered to transfer Patient 1 to the GACH via 911 at 4:55 am. The notes indicated LVN 1 called 911 at 5 am. and the paramedics (emergency staff) transferred Patient 1 to the GACH on 1/20/2022, at 5:25 am. A review of Patient 1's GACH Progress Notes, dated 1/20/2022, timed at 9:55 pm, indicated Patient 1 was confused, had a past medical history of dementia, and had a fall from her bed. The notes indicated the GACH admitted Patient 1 with a diagnosis of a right femoral trochanteric (one of the bony prominences toward the near end of the thighbone/the femur) fracture (broken hip bone). A review of Patient 1's GACH Progress notes, dated 1/22/2022, timed at 3:48 pm, indicated Patient 1 underwent surgery that involved GACH to intubate (insertion of a tube either through the mouth or nose and into the airway to aid with breathing) Patient 1, antegrade (moving or extending forward) nailing of the right intertrochanteric (between the bone bumps at the top of the thigh bone) hip fracture. During a telephone interview on 7/13/2022 at 9:16 am, CNA 1 stated she was assigned to Patient 1 on 1/20/2022, the date when Patient 1 fell. CNA 1 stated she reported to LVN 1, more than once, that Patient 1 was restless and tried to climb out of Patient 1's bed. CNA 1 stated LVN 1 told CNA 1 to get a chair and sit outside of Patient 1's room. CNA 1 stated she explained to LVN 1 that she could not sit outside of Patient 1's room because she was assigned to care for 15 other patients. CNA 1 stated she told LVN 1 that she would continue to visually check on Patient 1. CNA 1 stated she was in another patient's room (unidentified) when she heard LVN 1 call for her help. CNA 1 stated LVN 1 found Patient 1 on the floor, inside Patient 1's room, next to Patient 1's bed. During a telephone interview on 7/21/2022 at 10:16 am, LVN 1 stated at the start of her shift (11pm-7am) on 1/19/2022, Patient 1 was sitting in a wheelchair at the nursing station. LVN 1 stated she received a report from the previous shift (3 pm – 11 pm) nurse that Patient 1 had been having episodes of trying to get out of Patient 1’s bed and chair; therefore, the nurse placed Patient 1 by the nursing station to monitor and prevent Patient 1 from falling. LVN 1 stated she could not remember if there was a method used to ensure close monitoring was being done by CNA 1 for Patient 1 who was agitated and restless. LVN 1 stated she observed CNA 1 outside of Patient 1’s room, but she did not know if CNA 1 was outside Patient 1’s room the entire shift. LVN 1 stated CNA 1 during the 11pm - 7am shift was assigned to care for 13-14 patients. LVN 1 stated she herself was also responsible for monitoring Patient 1. LVN 1 stated when she returned from her break, she observed Patient 1 lying on the floor mat in Patient 1's room next to the bed. During a telephone interview on 7/29/2022 at 9:47 am, Director of Nursing 2 (DON 2) stated it was the responsibility of LVNs and CNAs to divide their time amongst each other and monitor Patient 1 who was showing signs of agitation and restlessness. DON 2 stated staff (CNA 1 and LVN 1) needed to monitor Patient 1. DON 2 stated an option would have been for LVN 1 to sit outside Patient 1's room and complete her charting while monitoring Patient 1. DON 2 stated it was the responsibility of the LVN to document behaviors and possible triggers that may be affecting Patient 1 who was exhibiting signs of restlessness and agitation. During an interview on 11/3/2022, at 3:46 pm and a record review of Patient 1's MAR dated 12/26/2021 to 12/31/2021, DON 2 stated Patient 1 had 14 episodes of trying to get out of bed from 12/29/2021 to 12/31/2021. DON 2 stated there was no evidence at the time of the interview that an interdisciplinary meeting (IDT, a group of diverse health care professionals from different fields) was done to analyze Patient 1's behaviors of trying to get out of bed. DON 2 stated there was no documented evidence of any nursing interventions done regarding 1's behaviors of trying to get out of bed. DON 2 stated the patients with diagnosis of dementia, could not verbalize their needs and stated something was bothering Patient 1. DON 2 stated it was a way for Patient 1 to communicate her needs to nursing staff by attempting to get out of bed. A review of the facility’s Care Planning - Interdisciplinary Team (IDT) policy and procedure, revised on September 2013, indicated the team is responsible for the development of an individualized comprehensive care plan for each resident. The care plan is based on the resident’s comprehensive assessment and is developed by the IDT which includes, the registered nurse who has responsibility for the patient, the DON (as applicable), the charge nurse and nursing assistant responsible for the resident’s care, and others as appropriate or necessary to meet the needs of the resident. A review of the facility's Dementia-Clinical Protocol, dated November 2018, indicated facility's staff would review the current physical, functional, and psychosocial status of individuals with dementia, and would summarize the individual's condition, related complications, and functional abilities and impairments. The policy indicated the staff would monitor the individual with dementia for changes in condition and declining function and would report these findings to the physician. A review of the facility's policy titled, "Routine Resident Checks," dated July 2013, indicated staff shall make routine patient checks to help maintain patient safety and well-being. The Policy indicated routine patient checks involve entering the patient's room and/or identifying the patient elsewhere in the unit to determine if the patient's needs are being met, identify any change in the patient's condition, identify whether the patient has any concerns, and see if the patient is sleeping, needs toileting assistance. The policy indicated the person conducting a routine check shall report promptly to the nurse supervisor/charge nurse any changes in the patient's condition and medical needs. The policy indicated the nursing supervisor/charge nurse shall keep documentation related to these routine checks, including the time, identity of the person making checks, and any outcomes of each check. A review of the policy titled, "Falls and Fall Risk Managing," dated December 2007, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident’s specific risks and causes to try to prevent the resident from falling. The policy indicated the staff with the input of the attending physician, would identify appropriate interventions to reduce the risk of falls. If a systemic evaluation of a patient's fall risk identifies several possible interventions, that staff may choose to prioritize interventions. The policy indicated the staff would monitor and document each patient's response to interventions intended to reduce falling or the risks for falling. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. As a result of the investigation, the Department determined the facility failed to ensure Patient 1 who had a diagnosis of dementia, received care and services to prevent a fall by failing to: 1. Assess and monitor Patient 1 for causes leading to episodes of restlessness and constantly trying to climb out of Patient 1's bed and as indicated by the facility’s Falls and Fall Risk Managing policy and procedure. 2. Identify appropriate interventions to reduce the number of repetitive falls for Patient 1 who was not able to verbalize her needs and as indicated by the facility’s Falls and Fall Risk Managing policy and procedure. 3. Document patterns or triggers that caused Patient 1 to climb out bed during multiple previous incidents and on 1/20/2023, the facility failed to document behaviors and possible triggers affecting Patient 1 who was exhibiting signs of restlessness and agitation and as indicated in the facility’s Routine Resident Checks policy and procedure. As a result of these failures, on 1/20/2022, at 4:35 am, Patient 1 climbed out of her bed unnoticed by CNA 1, fell, and sustained a right femoral trochanteric fracture. Patient 1 required transfer to a GACH via 911 where Patient 1 underwent surgery on 1/22/2022 to repair the hip fracture. 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 Patient 1.