Other·April 5, 2023

F744 Code of Federal Regulations, Title 42, Section 483.40 (b)(3) Treatment/Service for Dementia §483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. California Code of Regulation, Tittle 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 Regulation, Tittle 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. (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. (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. On 2/7/2023 at 11:30 am., the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding quality of care and treatment of Patient 1. As a result of the investigation, the CDPH 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) and history of falling, received care and services to prevent a fall (unintentionally coming to rest on a lower-level surface) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) redirected (changed direction or focus) Patient 1 to stay calm and remain by Patient 1's bedside when Patient 1 was confused (unable to think clearly), restless (inability to rest or relax), and tried to fight/hit CNA 1 on 1/17/2023 as indicated on Patient 1's care plan titled, " Falling Star Program," and policies titled, "Falling Star Program," "Resident Care Plan," "Dementia Care." 2. Ensure CNA 1 provided two-person physical assistance (help from two persons) during dressing (putting on and changing pajamas and housedresses) and personal hygiene (combing hair, brushing teeth, washing, and drying face and hands) for Patient 1 as indicated in Patient 1's care plan titled "Protect our Patient (POP)," and Patient 1's Minimum Data Set (MDS, a standardized comprehensive assessment and care screening tool). As a result, on 1/17/2023, at 12:00 pm, Patient 1 fell out of her bed, Patient 1 experienced severe left leg pain (pain that interferes with some or all activities of daily living), and a left hip fracture (complete or partial bone break). The facility transferred Patient 1 to General Acute Care Hospital 1's (GACH 1) Emergency Department (ED) via ambulance (911, phone number to call for emergency services). Patient 1 had a surgery on 1/19/2023 to repair the acute (sudden) left intertrochanteric (bony protrusions of the thighbone) hip fracture. A review of Patient 1's Admission Record indicated Patient 1 was a 89 year-old female and the facility originally admitted Patient 1 on 9/28/2017 and readmitted the patient to the facility on 1/25/2023. Patient 1's medical diagnoses included history of falling with a displaced fracture (a fracture with the end of the bone has come out of alignment) of the neck of the left femur (thigh bone), osteoporosis (condition where bones become weak and brittle), and dementia. A review of Patient 1's Care Plan titled, "Falling Star Program," revised on 6/23/2022, indicated Patient 1 was at risk for falls and injuries secondary to cognitive (ability to understand and process information) impairment, poor safety awareness, a history of falls, balance deficit (loss/absence), and impaired mobility (ability to move freely). The goal was for Patient 1 to have no falls or injuries. The nursing interventions included to observe Patient 1 for restlessness and redirect the patient as needed/indicated. A review of Patient 1's untitled Care Plan, revised on 6/23/2022, indicated Patient 1 had self-care deficits related to cognitive deficits and poor safety awareness. The goal was for Patient 1 to be clean, and well-groomed daily. The nursing interventions included to assist Patient 1 with activities of daily living (ADLs, activities related to personal care such dressing, eating and personal hygiene), and if the patient resisted (avoid/repel) care, nursing staff should try to provide care again later or have another staff approach the patient. A review of Patient 1's Care Plan titled, "Protect our Patient/POP," revised on 6/23/2022, indicated the goal was to prevent Patient 1 from sustaining bone fractures. The nursing interventions included for staff to provide Patient 1 with assistance from two persons during bed mobility, transfers, and ADL care. A review of Patient 1's History and Physical (H&P), dated 7/19/2022, indicated Patient 1 did not have the capacity to make decisions due to dementia. A review of Patient 1's MDS, dated 12/2/2022, 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 physical assistance (patient involved in activity, staff provide weight bearing support) from two-persons with dressing and personal hygiene. A review of Patient 1's Fall Risk Assessment, dated 12/2/2022, indicated Patient 1 was assessed at high risk for falls due to Patient 1 being disoriented (lost sense of direction), unable to stand without assistance, had unsteady gait, and poor sitting or standing balance. Patient 1 scored 18 on the fall risk assessment (a score of 18 or more represents high risk for fall). The assessment indicated to initiate a falling star program and implement useful interventions to reduce falls and injuries for Patient 1. A review of Patient 1's Change of Condition (COC, a sudden clinically important deviation from the patient's baseline in physical, cognitive, behavioral, or functional domains) Note, dated 1/17/2023, at 12:04 pm, indicated at 7 am, Patient 1 was confused and disoriented, and at 12 pm, Patient 1 fell from the patient's bed. Licensed Vocational Nurse (LVN) 1 heard Patient 1 yells and went into Patient 1's room. The note indicated Patient 1 showed signs of pain (level not rated) with grimacing, crying out, and guarding of the left leg. A review of Patient 1's Licensed Nurse Note, dated 1/17/2023, indicated CNA 1 tried to get Patient 1 up for lunch, then CNA 1 left Patient 1's bedside to get clean linen. The note indicated CNA 1 returned a few seconds later and saw Patient 1 lost balance and fell onto the patients' knees. The note indicated CNA 1 ran over to Patient 1 and called for help. LVN 1 went into Patient 1's room and found Patient 1 on her knees, continued to strike out, hit, spit, and cursed at CNA 1. LVN 1 and CNA 1 attempted to lift Patient 1 off the floor, but Patient 1 cried out in pain (level not listed) and guarded her left leg. The note indicated Patient 1's physician (MD 1, Medical Doctor) ordered STAT (urgent or rush) X-rays (a photographic or digital image of the inside of the body) of the left hip, femur, tibia (shin bone), and fibula (calf bone) due to pain. The note indicated at 2:35 pm, the X-ray results showed Patient 1 sustained a left hip fracture. MD 1 ordered to transfer Patient 1 to GACH 1's ED. A review of Patient 1's GACH 1 H&P, dated 1/18/2023, at 3:20 pm, indicated Patient 1 had a fall and sustained a left hip fracture. The H&P indicated Patient 1 complained of bilateral (both) hip and left leg pain (level not rated). A review of Patient 1's GACH 1 X-Rays Report, dated 1/18/2023, timed 6:46 pm, indicated Patient 1 had an acute (sudden) left intertrochanteric (bony protrusions of the thighbone) hip fracture. A review of Patient 1's GACH 1 Progress Note, dated 1/22/2023, indicated Patient 1 had a hip surgery on 1/19/2023. A review of Patient 1's GACH 1 Progress Note, dated 1/25/2023, indicated Patient 1 had an intramedullary nailing (IM nailing, a surgery done to repair a broken bone) of left intertrochanteric hip fracture. During an observation of Patient 1 in Patient 1's room on 2/7/2023, at 11:57 am, Patient 1 was lying in bed awake. Patient 1 had an abductor pillow (a foam pillow placed between the thighs and strapped onto the patient's leg to keep the leg stable and prevent pain or further injury after a hip surgery) between Patient 1's legs and the patient was not able to move her legs. During an interview on 2/7/2023, at 12:12 pm, CNA 1 stated Patient 1 did not "like" when staff changed the patient's clothes or incontinent pads. CNA 1 stated Patient 1 fought/hit (violent struggle involving physical blows) staff when staff changed Patient 1's clothes or incontinent pads. CNA 1 stated, Patient 1 bit, kicked, and said bad words when staff provided ADL care to the patient. CNA 1 stated, Patient 1 was confused and would try to roll out of the patient's bed. CNA 1 stated Patient 1's behavior was the reason nursing staff had to keep their eyes on Patient 1 and monitor Patient 1 closely. CNA 1 stated, she (CNA 1) had to kneel on the floor mat when changing Patient 1's clothes and incontinent pads because Patient 1 would get combative (ready or eager to fight) during care. CNA 1 stated Patient 1 was "a fighter." CNA 1 stated on the day that Patient 1 fell (1/17/2023), she (CNA 1) attempted to change Patient 1's incontinent pad. CNA 1 stated she removed Patient 1's gown but Patient 1 got combative and hit CNA 1. CNA 1 stated she left Patient 1's bedside, walked out of Patient 1's room to get clean linen from the linen cart that was located outside of Patient 1's room. CNA 1 stated as she got the linen, she heard a "noise," turned around, and saw Patient 1 lying on the floor. During an interview on 2/7/2023, at 1:17 pm, CNA 1 stated on 1/17/2023, when she removed Patient 1's gown, Patient 1 fought/hit CNA 1. CNA 1 stated Patient 1 did not have a POP sign (a sign to remind staff to provide two-person physical assistance) on the wall by the patient's bed. CNA 1 stated she was not aware that Patient 1 required assistance from two-persons during ADL care. CNA 1 stated she knew how to change Patient 1 by herself. During an interview on 2/7/2023, at 1:34 pm, the Director of Nursing (DON) stated the POP program was for patients who required assistance from two persons during ADL care. The DON stated patients who had diagnosis of osteoporosis or were combative during care would be placed on the POP program. The DON stated Patient 1 was on the POP program and the patient had a POP sign posted on the wall above Patient 1's bed. During an interview with the Director of Staff Development (DSD) on 2/7/2023, at 1:48 pm, and a concurrent review of the POP sign, the DSD stated, "POP meant Protect our Patients from Pathological (caused by the nature of a physical or mental disease) Fractures." The POP sign indicated to provide two-person physical assistance, gentle handling of the patients, and following the patients' plan of care. During an observation of Patient 1's room on 2/7/2023, at 1:53 pm, and a concurrent interview with the DON, there was no POP sign posted on Patient 1's wall. The DON stated Patient 1 "probably had a room change," that was why the POP sign was not posted on the wall inside Patient 1's room. During an interview on 2/7/2023, at 2:01 pm, CNA 2 stated Patient 1 was in the POP program before the patient's fall (1/17/2023). CNA 2 stated Patient 1 did not have a POP sign posted on Patient 1's bedroom wall on 1/17/2023. CNA 2 stated the POP sign indicated Patient 1 required assistance from two-persons during ADL care. CNA 2 stated Patient 1 did not have the POP sign posted on Patient 1's wall, and nursing staff could miss Patient 1 required assistance from two-persons during ADL care. During an interview on 2/7/2023, at 2:06 pm, LVN 2 stated Patient 1's ADL care should be provided by two-persons due to Patient 1's combative behavior during ADL care. During an interview on 2/7/2023, at 2:32 pm, the DON stated the POP program was an intervention in Patient 1's POP Care Plan. The DON stated it was important to have the POP sign in Patient 1's room for nursing staff to know Patient 1 required two-person assistance during ADL care. The DON stated Patient 1 was assessed as being high risk for falls, pathological fractures due to osteoporosis, and the patient needed the assistance from two-persons during ADL care. The DON stated nursing staff needed to follow Patient 1's plan of care. A review of the facility's undated policy and procedure titled, "Dementia Care," indicated the facility would develop and implement person-centered care plans with useful interventions to include and support the care needed identified in the comprehensive assessment for patients with dementia. A review of the facility's undated policy and procedure titled, "The Resident Care Plan," indicated the patients' care plan shall be implemented for each patient on admission and developed throughout the assessment process. The policy indicated the care plan included facility's staff responsible to implement nursing interventions to meet the patient's care plan goals. A review of the facility's undated policy and procedure titled, "Falling Star Program," indicated facility's staff would utilize the patients' Fall Risk Assessment form and provide appropriate nursing interventions to the patients. A review of the facility's undated POP sign, indicated to protect the patients from pathological fractures by: 1. Providing physical assistance from two persons to the patients. 2. Handle the patients gently. 3. Follow the patients' plan of care. As a result of the investigation, the CDPH determined the facility failed to ensure Patient 1, who had a diagnosis of dementia and history of falling, received care and services to prevent a fall by failing to: 1. Ensure CNA 1 redirected Patient 1 to stay calm and remain by Patient 1's bedside when Patient 1 was confused, restless, and tried to fight/hit CNA 1 on 1/17/2023 as indicated on Patient 1's care plan titled, " Falling Star Program," and policies titled, "Falling Star Program," "Resident Care Plan," "Dementia Care." 2. Ensure CNA 1 provided two-person physical assistance during dressing and personal hygiene for Patient 1 as indicated in Patient 1's care plan titled "Protect our Patient," and Patient 1's MDS. As a result, on 1/17/2023, at 12 pm, Patient 1 fell out of her bed, Patient 1 experienced severe left leg pain, and a left hip fracture. The facility transferred Patient 1 to GACH 1 ED via ambulance. Patient 1 had a surgery on 1/19/2023 to repair the left 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.