Health inspection·November 18, 2022

F 689 FCR§ 483.25(d)(2) Accidents. The facility must ensure that each Patient receives adequate supervision and assistance devices to prevent accidents. 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: (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. (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. Title 22 72523 (a) 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. On 8/24/2022 at 10:30 am., the California Department of Public Health conducted an unannounced visit to the facility to investigate a facility reported incident regarding quality of care for Patient 1. On 8/19/2022, at 2 pm., Certified Nursing Assistant 1 (CNA 1) turned Patient 1 to one side to change the patient’s adult brief (disposable underwear) on the Low Air Loss mattress (LAL, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air), the LAL mattress shifted Patient 1 off the bed and Patient 1 fell from his bed to the floor. As a result of the investigation, the Department determined that the facility failed to: 1. Follow the manufacturer’s safety instructions for the use of the LAL, to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for Patient 1. 2. Ensure Certified Nursing Assistant 1 (CNA 1) notified Licensed Vocational Nurse 1 (LVN 1) to place Patient 1’s LAL mattress on a firm mode (set in place and unable or unlikely to move) setting, before CNA 1 turned Patient 1 to one side to change the patient’s adult brief on the LAL mattress. 3. Ensure Patient 1’s bed had bed rails (are adjustable metal or rigid plastic bars that attach to the bed) in a guard (raise to protect) position while turning and changing Patient 1’s adult brief. As a result of these failures, Patient 1 fell from his bed to the floor. Patient 1 was transferred via 911 (emergency services) and was admitted to the intensive care unit (ICU, a department of a hospital in which patients who are dangerously ill are kept under constant observation) at a General Acute Care Hospital (GACH). Patient 1 sustained a subarachnoid hemorrhage (bleeding between the brain and the tissue [flesh] covering the brain. The blood then builds up around the brain and inside the skull increasing pressure on the brain), scalp lacerations (deep cuts to the head), and was placed under hospice care (provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members). A review of Patient 1’s Admission Record, indicated the facility admitted an 86-year-old male on 5/17/2016, and readmitted the patient on 6/24/2016 with diagnoses of unspecified dementia (memory loss which interferes with daily functioning) and functional quadriplegia (the complete inability to move all extremities due to severe disability). A review of Patient 1’s Activity of Daily Living (ADL, term used in healthcare that refers to self-care activities) Care Plan, initiated on 5/17/22, indicated Patient 1 had an ADL deficit due to Alzheimer's Disease (progressive mental deterioration due to generalized degeneration of the brain), dementia, and impaired mobility (disability that affects movement). The goal was to keep Patient 1 well-groomed daily. The interventions included for staff to provide extensive to dependent assistance with turning and repositioning while in bed. A review of Patient 1’s Minimum Data Set (MDS, standardized assessment and care screening tool), dated 7/19/2022, indicated Patient 1's cognitive (ability to think and process information) status was severely impaired, and was total dependent (full staff performance every time) with toileting and personal hygiene with one staff member to assist. A review of Patient 1’s Nurses Progress Note dated 8/19/2022, timed at 3 pm, indicated CNA 1 was changing Patient 1 on the patient’s bed when the patient suddenly rolled out of the bed during care. The notes indicated nurses(unidentified) went to the patient’s room and saw Patient 1 face down on the floor and assisted the patient back to bed. The notes indicated the nurses applied pressure to Patient 1’s right eyebrow to stop the bleeding and applied an ice pack to reduce the swelling on the patient’s right side of his face. The notes indicated the facility informed the patient’s family and physician. The notes indicated Patient 1’s physician ordered to do x-rays (digital image) to the patient’s head and knees for further evaluation. A review of Patient 1’s Interdisciplinary Care Conference (meeting with multiple staff with different functional expertise), dated 8/19/2022, timed at 3:07 pm, indicated the team recommended for staff (in general) to apply bilateral (both) siderails to prevent further falls, and to have two nurses during “turning/care” for assistance. A review of Patient 1’s Change in Condition Progress Notes dated 8/19/2022, timed at 3:30 pm., indicated Patient 1’s fall could best be attributed to the LAL mattress being slippery. A review of the Paramedic (emergency services) Report, dated 8/19/2022, timed at 5:37 pm, indicated the paramedic team arrived at the facility at 5:42 pm. The report indicated Patient 1 fell from his bed at approximately 2 pm and sustained a traumatic blunt head injury (physical injuries caused by non-penetrating blows from dull objects or surfaces). The report indicated the paramedic team transferred Patient 1 to a GACH at 5:48 pm (over 3 hours later). A review of Patient 1’s Nurses Progress Notes dated 8/19/2022, timed at 5:53 pm, indicated the patient was sent out to the hospital via 911 as requested by Patient 1’s family. During an interview with the Social Services Director (SSD), on 8/24/2022 at 10:44 am, the SSD stated Patient 1 fell on 8/19/2022. The SSD stated CNA 1 reported Patient 1’s fall incident to the Director of Nursing (DON) when CNA 1 was providing care to Patient 1 on a low air loss mattress. The SSD stated the patient rolled off the bed, landed on the floor and sustained an injury to the forehead. A review of Patient 1’s GACH Progress Notes dated 8/26/2022, timed at 12:32 pm, indicated the GACH admitted the patient to the ICU on 8/19/2022. The notes indicated Patient 1 was found to have a traumatic (serious injury to the body) subarachnoid hemorrhage and scalp lacerations after a fall and his prognosis (prospects of recovery) was very poor. The notes indicated Patient 1 was placed in comfort care and hospice. During an interview on 8/29/2022 at 1:52 pm, the DON stated Patient 1’s fall could have been prevented with the use of an enabler (bed rails) or additional staff present during care. During an interview on 8/30/2022 at 5 pm, CNA 1 stated that on 8/19/2022 at approximately 1 to 2 pm during an adult brief change, CNA 1 turned Patient 1 away from CNA 1 and the LAL mattress shifted Patient 1 off the bed. CNA 1 stated the bed did not have the bed rails. CNA 1 stated Patient 1 sustained injuries to his right eyebrow and scrapings to his knees. During a telephone interview on 10/7/2022 at 2:08 pm, CNA 1 stated on 8/19/2022 he was standing on Patient 1’s left side and used a sheet to turn the patient by himself. CNA 1 stated Patient 1’s LAL mattress pumped more air on the left side and pushed the patient to the right side and the patient fell to the floor. During a telephone interview on 10/7/2022 at 2:23 pm, the Treatment Nurse (TXN) stated she and other licensed nurses (in general) were responsible to check the LAL mattress settings. The TXN stated that on 8/19/2022, she did not check Patient 1’s LAL mattress before CNA 1 provided care to Patient 1. The TXN stated CNA 1 did not call her to check Patient 1’s LAL mattress settings before CNA 1 provided care to Patient 1. The TXN stated CNA 1 needed to call her to change the LAL mattress settings to firm and stated Patient 1’s LAL mattress needed to be firm when staff are providing care to the patient. A review of the facility’s policy and procedure (P & P), titled “Accident and Incident Prevention,” with a revised date of 9/2007, indicated the facility would establish routine monitoring systems to assess, correct, and modify a safety risk factors. The policy indicated the administrators were responsible to assign an individual to perform safety inspection rounds. A review of the facility’s Ps & Ps indicated there was no policies for LAL mattress or fall prevention. A review of the LAL’s mattress User Manual with a copy right dated 2017, indicated the user of the LAL mattress needed to read the manual before using the LAL mattress. indicated to avoid injury from falling, the maximum firmness was recommended during patient turning or patient cleaning. The manual indicated to avoid risk of death or injury from entrapment (is an event in which a patient is caught, trapped, or entangled in the space in or about the bed rail) or falling, the manufacturer suggested the rails to be in the raised or guarded position whenever a patient is on the bed. The manual indicated health care professionals assigned to each case should make the final determination whether side or assist rails were warranted after assessing patients’ risks of entrapments and falls. As a result of the investigation, the Department determined that the facility failed to: 1. Follow the manufacturer’s safety instructions for the use of the LAL, to prevent a fall for Patient 1. 2. Ensure CNA 1 notified LVN 1 to place Patient 1’s LAL mattress on a firm mode setting, before CNA 1 turned Patient 1 to one side to change the patient’s adult brief on the LAL mattress. 3.. Ensure Patient 1’s bed has bed rails in a guard position while turning and changing Patient 1’s adult brief. As a result of these failures, Patient 1 fell from his bed to the floor. Patient 1 was transferred via 911 and was admitted to the ICU at a GACH. Patient 1 sustained a subarachnoid hemorrhage, scalp lacerations, and was placed under hospice care. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.