Other·May 27, 2022

F689 42 CFR §483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The Patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each Patient receives adequate supervision and assistance devices to prevent accidents. T22 22 CCR §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. T22 22 CCR §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: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 8/18/2021 at 10 am, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a Facility Reported Incident (FRI) regarding quality of care Patient safety related to falls. The facility failed to ensure Patient 1, who was assessed at risk for falls, had impaired vision, and had a diagnosis of syncope (fainting) with a history of syncopal episodes (a temporary loss of consciousness [awareness] usually related to insufficient blood flow to the brain) and collapse (to fall), was free from fall accidents and injury, and was provided supervision. The facility failed to ensure: 1. All relevant staff who cared for Patient 1, including Certified Nursing Assistants (CNA) 1 and 2, were aware the patient was at risk for falls to ensure the patient was supervised during transfers, walking, and toileting to prevent falls. 2. The facility’s interdisciplinary team (IDT, group of diverse health care professionals from different fields) instituted strategies to safeguard the patient after a significant change in condition was noted, when Patient 1 presented with a decline in medical condition on 8/4/2021 and was diagnosed with a urinary tract infection (a common type of infection in the urinary system, which can cause confusion, and can involve any part of the urinary system; symptoms typically include needing to urinate often, having pain when urinating and feeling pain in your side or lower back) on 8/5/2021. As a result, Patient 1 sustained an unwitnessed fall on 8/8/2021 at 4:30 am and was found lying on the floor at the right side of the bed, facing down, and unresponsive. Patient 1 was transferred to a general acute care hospital (GACH) via 911 (emergency services), was intubated (tube placed in throat to help breathing), admitted to the Intensive Care Unit (ICU, a department of a hospital in which patients who are dangerously ill are kept under constant observation), and was diagnosed with a subdural hematoma (a buildup of blood on the surface of the brain), traumatic injury (physical injury which occurs suddenly) of the head, and brain compression (a condition in which something increases the amount of pressure pushing on the brain, which can damage brain tissue). On 8/9/2021, the patient died at the GACH with an immediate cause of death of a blunt force head trauma (a severe injury to the head). A review of Patient 1’s Admission Record indicated the facility admitted a ninety-four-year-old female Patient 1 on 12/29/2005, with diagnoses including unspecified dementia (loss of memory and other mental abilities severe enough to interfere with daily life), syncope, and collapse. A review of Patient 1’s History and Physical (H&P), dated 2/4/2021, indicated Patient 1 did not have the capacity to understand and make decisions. A review of Patient 1’s Fall Risk Assessment dated 3/28/2021, indicated the Patient was at risk for falls. Patient 1 scored 10 (a score over 9 is risk for fall). Patient 1 fall risk assessment was as follows: 1. Limited vision (2) 2. Elimination with assistance (2) 3. Ambulates without problem and with devices (1) 4. Not steady, but able to stabilize without human assistance (1) 5. Patient is 85 years old or older (2) 6. 1-2 medications taken currently or in the last 7 days (2). A review of Patient 1’s Care Plan initiated on 5/5/2021, indicated Patient 1 had a history of syncopal episodes. The care plan indicated a goal for the patient to have no further episodes and no injury from syncope with a target date of 8/19/21. The care plan interventions included for the nursing staff to monitor the patient for changes in level of mentation (mental activity), dizziness, and lethargy. A review of Patient 1’s Minimum Data Set (MDS, a patient assessment and care screening tool), dated 6/18/2021, indicated Patient 1 was assessed as having moderately impaired vision and required supervision for transfers, bed mobility (how a patient moves to and from lying position, turns side to side, and positions body while in bed), and walking in the room with one person to assist. A review of Patient 1’s Care Plan initiated on 6/30/2021, indicated Patient 1 was at risk for falls due to unsteady gait. The care plan goal was for Patient 1 not to have episodes of falls. Interventions included to assess and monitor the patient’s safety needs and awareness, assess other casual factors of falls such as dizziness, medication side effects, frequent visual checks for needs and safety, and provision of a hazard free environment. A review of Patient 1’s Care Plan initiated on 6/30/2021, indicated Patient 1 required assistance with activities of daily living (ADLs). The goal was for Patient 1 to continue with current functional status (not specified on the care plan). Interventions included to encourage the patient to get out of bed and assist her up on the wheelchair as tolerated, monitor the patient for decline in condition, to monitor for safety compliance, and provide verbal cues as needed. A review of Patient 1’s Care Plan initiated on 6/30/2021, indicated Patient 1 had impaired visual function related to cataracts (a medical condition in which the lens of the eye becomes progressively opaque, resulting in blurred vision). The goal was for Patient 1 not to have injuries related to visual impairment. Interventions included to alert the patient to necessary changes in environment and to assess visual function and consult as needed. A review of Patient 1’s Care Plan initiated on 6/30/2021, indicated the patient had episodes of refusing care and urinating on the floor. The interventions included for licensed nurses to assess the patient for pain, the need to void (to urinate), and acute changes such as acute/UTI. A review of Patient 1’s Progress Notes “Change of Condition,” dated 7/26/2021, timed at 7:25 am, indicated Licensed Vocational Nurse 2 (LVN 2) found the patient sitting on the floor next to her wheelchair. LVN 2 did a complete assessment and Patient 1 was able to move all extremities without difficulty and there was no visible injury noted. The physician was notified. A review of Patient 1’s Care Plan dated 7/26/2021, indicated Patient 1 was found sitting on the floor next to her wheelchair. The patient goals were for Patient 1 not to have falls and no serious complications. The approach plan included to assess and monitor safety needs, monitor casual factors that could attribute to fall incidents, frequent checks by staff, and assessment of Patient 1’s needs. A review of Patient 1’s Progress Notes, Change of Condition Note, dated 8/4/2021, timed at 2:37 pm, nine (9) days after the patient was found on the floor, indicated Patient 1 was sitting in her wheelchair feeling sleepy and was assisted back to bed. The patient’s physician was notified, and laboratory tests were ordered. A review of Patient 1’s Progress Notes dated 8/5/2021, timed at 12:28 pm, indicated the patient’s laboratory blood test results were reported to the patient’s physician and a new order for Bactrim DS (antibiotic medication) was given for a diagnosis of UTI. A review of Patient 1’s care plan titled “Actual infection: UTI,” dated 8/5/2021, indicated the interventions were for the licensed nurses to monitor for the presence of signs and symptoms of UTI, fever, pain in abdomen, change in mentation, “strong persistent urge to urinate, strong smell of urine, difficulty urinating and pain during urination.” A review of Patient 1’s Progress Notes dated 8/7/2021, timed at 2:20 pm, indicated Patient 1 “was still very weak,” the patient’s physician was notified, and the physician ordered for the patient to receive Rocephin (antibiotic) 1 gram (g, unit of measurement). A review of Patient 1’s untitled ADL sheet, dated 8/7/2021 indicated the patient used the toilet at 1:24 am, 1:26 pm, and at 6:55 pm. The form indicated the patient used the toilet on 8/8/2021, at 12:08 am. A review of Patient 1’s Progress Notes, dated 8/8/2021, timed at 4:30 am, indicated the patient was found beside her bed, face down with a laceration to her right forehead. The Notes indicated the patient’s blood pressure (the force of the blood pushing against the walls of the arteries, each time the heart beats, it pumps blood into the arteries), was elevated at 210/110 normal blood pressure for most adults is defined as a systolic pressure of less than 120 [first/top number] and a diastolic pressure of less than 80 [second/bottom number]) and was transferred to a GACH via 911. A review of Patient 1’s Progress Notes dated 8/8/2021 indicated at 4:30 am, a CNA (unidentified) found the patient on the floor on the right side of the bed, arousable to pain only without spontaneous eye-opening response. The notes indicated the patient had a laceration to the right side of her forehead, and some bleeding was observed from the laceration sustained from the unwitnessed fall. The notes indicated the paramedics (911 services) picked the patient up from the floor via stretcher to gurney. A review of Patient 1’s Prehospital Care Report, dated 8/8/2021, timed at 4:58 am, indicated Patient 1 was found lying on the “ground,” at the facility and had unequal pupils (black part in the center of the eye), swelling, a laceration, hematoma (pool of clotted blood formed in a tissue caused by a broken blood vessel damaged by injury) to her head, and an obvious deformity to the right side of her temple (the area just behind and to the side of the forehead and the eye). A review of Patient 1’s GACH record titled “ED [Emergency Department] Note Physician,” dated 8/8/2021, timed at 5:46 am, indicated Patient 1 presented to the ED after a traumatic fall at the facility and the patient was intubated due to severe head trauma. The note indicated there was significant trauma to the patient’s head especially on the right temporal frontal area with a 2 cm laceration and a low Glasgow Coma Scale (GCS, a 15-point scoring system used to describe the initial level of awareness). The note indicated the patient was admitted to the ICU with diagnoses of subdural hematoma and traumatic injury of the head. A review of Patient 1’s GACH records titled “Discharge Summary,” dated 8/9/2021, timed at 1:47 pm, indicated Patient 1 died with diagnoses of subdural hematoma, traumatic head injury, and brain compression. A review of Patient 1’s Certificate of Death, indicated the patient’s date of death was 8/9/2021, at 1:47 pm. Patient 1’s immediate cause of death was a blunt head trauma from an injury described as a “Ground level-fall” that occurred on 8/8/2021. During an interview on 8/18/2021 at 10:59 am, CNA 1 stated she was familiar with Patient 1. CNA 1 stated Patient 1 used a wheelchair as a walker to walk. CNA 1 stated she was not aware Patient 1 was at risk for falls. and that Patient 1 was able to go to the bathroom by herself. During an interview on 8/18/2021 at 12:30 pm, Registered Nurse 1 (RN 1) stated she worked the 11 pm shift on 8/7/2021 to 7:30 am 8/8/2021. RN 1 stated that around 4:30 am, LVN 1 informed her Patient 1 was on the floor. RN 1 stated she found Patient 1 laying on the right side of the bed and stated Patient 1 had a laceration on her right temple of approximal 2- 2.5 centimeters (cm, a unit of measurement) and the patient was unresponsive. During an interview on 8/18/2021 at 3:56 pm, the Director of Nursing (DON) stated Patient 1 was at risk for falls. During a telephone interview on 8/19/2021, at 10 am, CNA 2 stated he was working on the night Patient 1 fell. CNA 2 started his shift at 11 pm on 8/7/2021 and ended his shift at 7 am on 8/8/2021. CNA 2 stated Patient 1 did not have a roommate and her room was located at the end of the hallway from the nurse’s station. CNA 2 stated Patient 1 walked to the toilet alone and would not press the call light (device used by a Patient to signal his or her need for assistance from a professional staff), for help. CNA 2 stated he was not aware Patient 1 was at risk for falls. CNA 2 stated that during his shift on 8/7/2021, when he was walking down the hallway, he could see the patient sleeping on her bed. CNA 2 stated that he saw the patient at 11 pm, 1:30 am, 2 am, 2:30 am, 3 am, 4 am. CNA 2 stated that during these times, he did not enter the patient’s room to ask if she needed assistance with toileting. CNA 2 stated Patient 1 preferred to sleep with the lights on and the curtains and the door open and that made it easier for the staff to see the patient from the hallway. CNA 2 stated the last time he saw Patient 1 in bed was at 3 am on 8/8/2022. CNA 2 stated that at 4:15 am, he was performing an adult brief (disposable garment) change across Patient 1’s room and did not see the patient in bed. CNA 2 stated that as soon as he was done, he went to Patient 1’s room and found Patient 1 on the floor at 4:30 am, at the right side of her bed, facing down, and unresponsive. During an interview on 9/30/2021, at 6:36 am, LVN 1 (assigned to Patient 1) stated Patient 1 was able to go to the bathroom by herself (in general), using a four-wheel walker (FWW, walking aid device) and the patient could also transfer by herself from a FWW to the bed. LVN 1 stated she saw Patient 1 in bed on 8/8/2021 between 3:30 am and 4 am. LVN 1 stated when she was preparing for rounds at 4:30 am, CNA 2 called her to Patient 1’s room and when she got to Patient 1’s room, she found the patient lying face down on the floor. LVN 1 stated there was scant to moderate bleeding on head, the patient was not arousable, non-responsive to verbal or touch. LVN 1 stated she was aware that Patient 1 was being monitored for falls and stated they should have implemented safety precautions such as asking the patient if she needed anything every hour, assist her, and attend to her needs. LVN 1 stated that although she was aware Patient 1 was at risk for falls the staff did not assist the patient and the patient was not supervised to the bathroom. LVN 1 stated Patient 1 should have been supervised when going to the bathroom before the patient fell to prevent the patient from falling. LVN 1 stated Patient 1 got up on her own and the patient could have benefited from one-on-one staff supervision because she was weak after her change of condition. LVN 1 stated she did not request an order from Patient 1’s physician for one-on-one supervision and stated the patient should have been provided floor mats (used to reduce fall?related trauma if a patient gets up from bed, loses balance, and falls to the floor), on each side of her bed, and a bed alarm to alert the staff if the patient got out of bed. LVN 1 stated if these interventions had been provided by the facility, she was confident that this fall could have been prevented. During an interview and concurrent record review of the facility’s policy and procedures titled: “Safety and Supervision of Patients,” with the DON on 9/30/2021at 9:53 am, the DON stated that according to Patient 1’s Progress Notes dated 8/7/2021, Patient 1 was very weak. The DON stated Patient 1’s weakness was not specific; the Patient was ambulatory (walking around on her own) and then had a change of condition (a major decline in a Patien