Health inspection·April 28, 2023

F688 §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a Resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the Resident’s clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A Resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A Resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. CCR § 72315. Nursing Service - Patient Care. (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her professional licensure. 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 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. Based on observation, interview, and record review, the facility failed to provide treatment and services to Patient 62, 13 and 1 with mobility and range of motion [ROM, full movement potential of a joint (where two bones meet)] concerns. A. For Patient 62, the facility failed to: 1. Perform an annual Joint Mobility Assessment (JMA, brief assessment of a Patient’s range of motion in both arms and both legs) since 1/12/2022 (over one year) in accordance with the facility’s policy and 2. Provide passive range of motion (PROM, movement of a joint through the ROM with no effort from the patient) or any splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to both arms and both legs since 4/5/2022 (over 11 months) in accordance with the facility’s policy for Restorative Nursing Programs [RNP, nursing program that use a restorative nursing aide (RNA) to help Patients maintain their function and joint mobility]. These deficient practices had the potential for Patient 62 to experience a decline in range of motion, including the development and worsening of contractures (deformity and joint stiffness) in both arms and both legs, making it difficult to dress Patient 62 in normal clothes. These deficient practices also had the potential to cause Patient 62 to experience increased pain with movement and contribute to the development of pressure sores (injuries to the skin and underlying tissue caused by prolonged pressure on the skin). B. For Patient 13, the facility did not provide RNP services with the RNA for ambulation (walking) after discharge from Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) on 6/17/2022 (nine months). This deficient practice had the potential to cause a decline in Patient 13’s ability to walk. C. For Patient 1, the facility failed to provide ROM exercises to both arms and both legs in accordance with the facility’s policy for RNP since 3/9/2023. This deficient practice had the potential for Patient 1 to develop ROM limitations, including the development of contractures. 1ab. A review of Patient 62’s Admission Record indicated the facility admitted Patient 62, an 86-year-old female, to the facility on 3/10/2021. Patient 62’s diagnoses included unspecified atrial fibrillation (irregular and often very rapid heart rate), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one’s daily activities), and hypertension (abnormally high blood pressure). A review of Patient 62’s Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 3/17/2021, indicated Patient 62 had clear speech, sometimes expressed ideas and wants, sometimes understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Patient 62 required limited assistance (patient highly involved in activity) for eating and required extensive assistance (patient involved in activity while staff provide weight-bearing support) for dressing and personal hygiene. The MDS also indicated Patient 62 had functional ROM limitations in both arms and both legs. A review of Patient 62’s Occupational Therapy [OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)] Progress and Discharge Summary, dated 4/2/2021, indicated Patient 62 met a short-term goal to tolerate the application of a left-hand splint for three hours. The OT Progress and Discharge Summary also indicated Patient 62 met a long-term orthotic (splint) goal which indicated the RNP applied and removed the left-hand splint and monitored Patient 62’s skin condition for effective contracture prevention and joint protection. The OT Discharge Plan indicated Patient 62 was referred to the RNP for application of the left-hand splint and PROM program. A review of Patient 62’s Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Progress and Discharge Summary, dated 4/2/2021, indicated Patient 62 met short-term goals which included sitting upright in a chair/wheelchair with proper positioning for 60 minutes, reporting decreased pain in both knees and hip joints to moderate pain, and improved PROM of both knees to 60 degrees of flexion. The PT Progress and Discharge Summary also indicated RNP training included education to the nurses for proper positioning and techniques to inhibit extensor tone (prevent excessive straightening) in both of Patient 62’s legs. The PT Discharge Plan indicated Patient 62 was referred to RNP with an exercise program and to use a mechanical lift when transferring Patient 62 into the assigned wheelchair. A review of Patient 62’s Change of Condition JMA, dated 1/12/2022, indicated Patient 62 had limited ROM in the right ring finger and right little finger, left hand/finger, both knees, and both ankles. The JMA indicated Patient 62’s ROM in both shoulders was above shoulder height, the right elbow had full ROM, the left elbow had nearly full ROM, ROM in both wrists moved from a slightly bent position to a fully bent position, and both hips bent to hip height. A review of Patient 62’s Admission Order, dated 1/12/2022, indicated Patient 62 was admitted to hospice care with a diagnosis of Alzheimer’s disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life). Patient 62’s hospice Admission Order indicated Patient 62 may continue all routine medications and treatments. During an observation and interview on 3/15/2023 at 2:20 PM in Patient 62’s room, Patient 62 was awake, alert, and spoke in short sentences. Patient 62 was lying in bed with the head-of-bed (HOB) elevated almost upright and wore a hospital gown. Patient 62 reached forward with slight movement at the right shoulder joint and slight extension of the right elbow. Patient 62’s right wrist was completely bent downward, and Patient 62’s thumb and fingers on the right hand were bent around a rolled-up hand towel. Patient 62 did not have any active movement in the left arm. Patient 62’s left shoulder was positioned in neutral (arm positioned parallel to the body), the left elbow was slightly bent, the left wrist was bent in a downward position, and the left thumb and fingers were bent around a rolled-up hand towel. Patient 62 stated Patient 62 did not remember if any facility staff member provided any exercises to both arms and both legs. During an observation on 3/15/2023 at 2:27 PM in Patient 62’s room, Certified Nursing Assistant 8 (CNA 8) had Patient 62’s permission to remove the blanket over both legs. Patient 62 lifted the right leg very slightly at the hip joint but did not have any other active movement in the right leg and throughout the left leg. Both of Patient 62’s ankles were bent away from the body. During an interview on 3/15/2023 at 2:44 PM, the Director of Rehabilitation (DOR) stated the Patients on RNP did not have any physician’s orders for RNP services since the facility transitioned to paperless electronic documentation. The DOR stated RNP services were implemented in a patient’s care plan. The DOR stated the DOR and the MDS Assistant (MDSA) had RNP meetings once per month. During an interview on 3/15/2023 at 2:52 PM, the DOR and MDSA stated a patient’s RNP care plan included an RNP task in the electronic documentation system, which allowed the RNA to document the RNP session. The DOR and MDSA stated RNP services were important to maintain a patient’s ROM and to maintain a patient’s functional status. The DOR stated patients who did not move at all or had weakness were at risk for developing contractures. During an observation and interview on 3/16/2023 at 9:19 AM in Patient 62’s room, Patient 62 was awake, alert, and verbal. Patient 62 was lying in bed with the HOB elevated almost upright and wore a hospital gown. A rolled-up hand towel was resting on top of Patient 62’s left hand instead of inside the left palm. Patient 62 stated the hand towel sometimes came out of the left hand. Patient 62 continued to have minimal active movement in the right shoulder and right elbow to reach forward. Patient 62 was unable to move the right wrist, which was positioned in a completely bent position, and the right fingers, which were positioned into a fist. Patient 62 continued to have no movement in the left arm and both ankles were bent away from the body. Restorative Nursing Aide 1 (RNA 1) walked into Patient 62’s room. In a concurrent interview, RNA 1 stated Patient 62 did not receive RNA services for ROM but assisted Patient 62 with feeding. During a follow-up interview on 3/16/2023 at 9:35 AM, RNA 1 stated Patient 62 did not receive RNA for ROM since Patient 62 was on hospice. During an interview on 3/16/2023 at 10:50 AM, Restorative Nursing Aide 2 (RNA 2) stated RNA 2 did not work with Patient 62 since Patient 62 was on hospice. During an interview on 3/16/2023 at 11:47 AM, the Director of Nursing (DON) stated the facility’s nurses provided nursing care for hospice patients and the hospice company provided additional services. The DON stated patients on hospice were treated the same as any other patient in the facility. During a follow-up interview on 3/16/2023 at 4:15 PM, the DON stated patients on hospice received the same care provided to all other patients, including medication management, pain management, activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility), and RNA services for ROM. The DON stated some families did not want the patient on hospice to receive RNA services. The DON stated the facility coordinated care with the hospice company if the family did not want a patient to receive RNA services. During an interview and record review on 3/16/2023 at 3:09 PM, the DOR reviewed Patient 62’s PT Progress and Discharge Summary, dated 4/2/2021, which included recommendations for RNP exercises. The DOR reviewed Patient 62’s OT Progress and Discharge Summary, dated 4/2/2021, which included recommendations for a left-hand roll splint and RNP for PROM. The DOR stated Patient 62 received another OT evaluation on 1/12/2022 which included a recommendation for a right-hand roll splint. In a concurrent interview and observation, the Assistant Director of Rehabilitation (ADOR) provided a demonstration of an inflatable hand roll splint. The ADOR stated PROM should be performed prior to applying the splint. The ADOR brought out a blue colored splint which had an internal plastic air pocket that could be inflated. The ADOR connected a small manual pump to the plastic air pocket to inflate the splint. The ADOR stated the inflatable hand roll splint was secured to the hand with a Velcro strap. The ADOR stated the inflatable hand roll splint prevented further contractures to the hand and provided skin protection to the palm. During an interview and record review on 3/16/2023 at 5:09 PM, the DOR reviewed Patient 62’s JMAs, dated 3/11/2021 and 1/12/2022. The DOR stated Patient 62 did not receive another JMA after 1/12/2022 since Patient 62 was on hospice. The DOR stated the therapists did not perform any screening for ROM once a patient was placed on hospice services. During an observation and interview on 3/16/2023 at 5:46 PM in Patient 62’s room, the DOR observed Patient 62’s ROM. Patient 62 was lying in bed with the HOB elevated and wore a hospital gown. Patient 62 was awake, alert, and stated, “I want therapy for all my problems because I can’t move stuff.” The DOR asked Patient 62 to move both arms. Patient 62 slightly lifted the right arm at the shoulder joint and slightly extended the right elbow. Patient 62 was unable to move the left arm. The DOR lifted the blankets to observe both of Patient 62’s legs and stated, “Oh my God.” The DOR stated Patient 62 had contractures to both ankles into plantarflexion. The DOR walked out of Patient 62’s room and stated Patient 62 declined since the last JMA on 1/12/2022. The DOR stated Patient 62 had increased contractures in both ankles, both wrists, and both hands/fingers. The DOR stated the DOR could not touch Patient 62 since Patient 62 was on hospice services. The DOR stated the facility discontinued RNA services when patients were placed on hospice. During an interview and record review on 3/17/2023 at 7:37 AM, the DOR compared Patient 62’s JMA from 3/11/2021 and 1/12/2022. The DOR stated Patient 62 was discharged from PT and OT services on 4/2/2021 with recommendations for ROM with RNA and application of a left-hand splint. The DOR stated Patient 62’s ROM in the left shoulder, left elbow, left wrist, and left hand improved on the JMA, dated 1/12/2022, because Patient 62 received RNA services for ROM and application of the left-hand splint. The DOR stated Patient 62 currently had contractures to both ankles, both wrists, and both hands. The DOR did not know the reason for Patient 62’s decline in ROM and Patient 62’s contracture development. During an interview on 3/17/2023 at 9:33 AM, the Hospice Certified Nursing Assistant (CHHA 1) stated Patient 62 received a bed bath, oral care, nail care, body lotion application, and perineal care (genital and rectal cleaning). CHHA 1 stated providing ROM was not part of the assignment. CHHA 1 stated CHHA 1 moved Patient 62’s legs if Patient 62 did not complain of pain. CHHA 1 stated Patient 62 did lift the legs during care, and CHHA 1 would move Patient 62’s legs if Patient 62 wanted to move them for comfort. CHHA 1 stated CHHA 1 did not move Patient 62’s arms since Patient 62 was stiffer in both hands. During an interview on 3/17/2023 at 9:40 AM, Certified Nursing Assistant 7 (CNA 7) stated CNA 7 provided Patient 62 with ADL care, including dressing, bathing, changing the linen, changing positions every two hours, feeding, and oral care. CNA 7 stated Patient 62’s wrists, hands, and ankles were bent and did not move. CNA 7 stated both of Patient 62’s elbows and knees were very stiff. CNA 7