Other·June 2, 2023

F688 Code of Federal Regulations, Title 42, Section 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. California Cod of Regulations, Title 22, Section 72315. Nursing Services - 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. 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: (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. On 4/18/2023 at 7:30 am., the California Department of Public Health (CDPH) conducted an unannounced recertification survey. As a result of the investigation, CDPH determined that the facility failed to: 1. Assist Patient 43 with ambulation (walking) for 200 feet with contact guard assistance (physical steadying assistance) in accordance with the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) discharge recommendation on 11/10/22. 2. Report Patient 43's decline in mobility and increased need for physical assistance to the Rehabilitation Coordinator (RC). 3. Prevent Patient 43’s decline in mobility and increased need for physical assistance to the RC in accordance with the facility’s policy and procedure, "Activities of Daily Living (ADLs)," revised 9/2/22. As a result of these failures, Patient 43 had a substantial reduction in mobility from being able to walk for 200 feet with contact guard assistance to requiring maximum assistance (50-75 percent [%] of physical assistance) for sit to stand transfers and maximum assistance of two people to walk 20 feet. A review of Patient 43's Admission Record indicated Patient 43 is a 55-year-old male. Patient 43 was admitted to the facility on 3/24/22 and re-admitted on 8/13/22, with diagnoses including hemiplegia and hemiparesis (weakness and paralysis to one side of the body) following other nontraumatic intracranial hemorrhage (bleeding in brain tissue) affecting the left non-dominant side, muscle weakness, difficulty walking, and dysphagia (difficulty swallowing). A review of Patient 43's PT Evaluation and Plan of Treatment, dated 3/25/22, indicated Patient 43 was independent with bed mobility, transfers, and walking without an assistive device (a device to assist a person to perform a task) prior to admission to the facility. The PT Evaluation and Plan of Treatment indicated Patient 43 required maximum assistance for bed mobility and transfers between surfaces. The PT Evaluation and Plan of Treatment indicated Patient 43 was unable to walk at the time of the PT Evaluation upon admission. The PT treatment plan for Patient 43 included exercises, neuromuscular (relating to nerves and muscles) reeducation and gait (manner of walking) training therapy, five times a week for four weeks. A review of Patient 43's PT Evaluation and Plan of Treatment, dated 7/6/22, indicated Patient 43 required moderate assistance for bed mobility, transfers, and walking 50 feet with the use of a hemi-walker (assistive device that allows a person to lean on one side while walking for support). The PT treatment plan for Patient 43 included exercises, neuromuscular reeducation, and gait training therapy, four times a week for four weeks. A review of Patient 43's PT Discharge Summary, dated 7/28/22, indicated Patient 43 required contact guard assistance for bed mobility and transfers. The PT Discharge Summary also indicated Patient 43 required minimum assistance with walking 175 feet using a hemi-walker. The PT discharge recommendations indicated for Patient 43 to use a hemi-walker for safe mobility and an ankle foot orthosis (AFO, brace to hold the foot and ankle in the correct position). The discharge reason indicated a change in Patient 43's payer source. A review of Patient 43's PT Evaluation and Plan of Treatment, dated 8/3/22, indicated Patient 43 required minimum assistance for bed mobility and transfers. The PT Evaluation and Plan of Treatment indicated Patient 43 required moderate assistance to walk 100 feet using a hemi-walker. The PT treatment plan for Patient 43 included exercises, neuromuscular reeducation, and gait training therapy, five times per week for four weeks. A review of the PT Discharge Summary, dated 8/10/22, indicated Patient 43 was discharged to the hospital. A review of Patient 43's Census List (record of hospitalizations, room changes, and payer source changes) indicated Patient 43 was discharged to the hospital on 8/10/22 and was readmitted back to the facility on 8/13/22. A review of Patient 43's PT Evaluation and Plan of Treatment, dated 8/15/22, indicated Patient 43 had a decline in ambulation, mobility, and strength after Patient 43's hospitalization on 8/10/22. The PT Evaluation indicated Patient 43 was totally dependent (more than 75% physical assistance) for bed mobility and transfers. The PT Evaluation did not assess Patient 43's ability to walk. The PT treatment plan for Patient 43 included exercises, neuromuscular reeducation, and gait training therapy, five times per week for four weeks. A review of Patient 43's PT Discharge Summary, dated 11/10/22, indicated Patient 43 required contact guard assistance for bed mobility, minimum assistance for transfers, and contact guard assistance to walk 200 feet using a hemi-walker. The discharge reason indicated Patient 43 achieved the highest practicable level (upmost functioning and wellbeing). The PT discharge recommendations included a Restorative Nursing Program [RNP, nursing program that uses restorative nursing aides (RNAs) to help patients maintain their function and joint mobility] with the use of an assistive device for safe mobility. A review of Patient 43's Restorative Nursing Program care plan, initiated on 11/10/22, indicated interventions for Patient 43 to walk 200 feet with a hemi-walker and contact guard assistance, every day, five times per week or as tolerated. The care plan interventions included to monitor Patient 43 for any changes (decline/improvements) and to refer to nursing and/or rehabilitation staff nurse with any change of condition. A review of Patient 43's Documentation Survey Report (record of nursing assistant tasks) for 11/2022 indicated RNA (unidentified) assisted Patient 43 in walking 200 feet using a hemi-walker with contact guard assistance on 11/11/22, 11/14/22 to 11/18/22, and 11/21/22 to 11/25/22. A review of Patient 43's Census List indicated Patient 43 was discharged to the hospital on 11/25/22 for the treatment of Urinary Tract Infection and re-admitted back to the facility on 11/28/22. A review of Patient 43's PT Evaluation and Plan of Treatment, dated 11/29/22, indicated Patient 43 was seen for an evaluation only. The PT Evaluation indicated Patient 43 required contact guard assistance for bed mobility, minimum assistance for transfers, and contact guard assistance for walking 200 feet. The PT Evaluation indicated Patient 43 was referred to RNP for ambulation. A review of Patient 43's Documentation Survey Report for 11/2022 indicated the RNA (unidentified) assisted Patient 43 in walking 200 feet using a hemi-walker with contact guard assistance on 11/30/22. A review of Patient 43's Documentation Survey Report for 12/2022 indicated Patient 43 received RNA services five times per week to walk 200 feet using a hemi-walker with contact guard assistance. A review of Patient 43's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 12/27/22, indicated Patient 43 had clear speech, clearly expressed ideas, and wants, clearly understood others, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Patient 43 required extensive assistance (patient involved in activity while staff provide weight-bearing support) with bed mobility, transfers between surfaces, walking in room, walking in corridor, locomotion on unit (moving locations in room and nearby corridor, self-sufficient in wheelchair), locomotion off unit (other areas of the facility like the dining room and activity room), dressing, toileting, and personal hygiene. A review of Patient 43's Documentation Survey Report for 1/2023 and 2/2023 indicated Patient 43 received RNA services five times per week to walk 200 feet using a hemi-walker with contact guard assistance. A review of Patient 43's Documentation Survey Report for 3/2023 indicated Patient 43 received RNA services to walk 200 feet using a hemi-walker with contact guard assistance on 3/1/2/23, 3/2/23, 3/6/23, 3/7/23, and 3/8/23. A review of Patient 43's PT Evaluation and Plan of Treatment, dated 3/7/23, indicated Patient 43 was referred back to PT due to decreased mobility, decreased strength, limitation with ambulation, and increased need for assistance from others. The PT Evaluation indicated Patient 43 required maximum assistance for bed mobility and transfers. The PT Evaluation did not assess ambulation due to Patient 43's inability to walk. The PT treatment plan for Patient 43 included exercises, neuromuscular reeducation, therapeutic gait training therapy, and wheelchair management training, four times per week for four weeks. A review of Patient 43's Restorative Nursing Program care plan dated 3/8/23 indicated the RNP Program for walking 200 feet with a hemi-walker and contact guard assistance was resolved (discontinued) on 3/8/23. A review of Patient 43's MDS, dated 3/28/23, indicated Patient 43 transferred between surfaces only once or twice during the MDS assessment period. The MDS indicated Patient 43 did not walk in the room, did not walk in the corridor, did not participate in locomotion on unit, and did not participate in locomotion off unit during the MDS assessment period. During an observation and concurrent interview with Restorative Nursing Aide 1 (RNA 1) on 4/19/23 at 10:58 AM, RNA 1 stated RNA 1's job duties included the provision of RNA services and stocking the facility's central supply room. RNA 1 stated currently there were 21 patients in the facility requiring RNA services. RNA 1 observed and demonstrated the process of viewing each patient with RNA tasks and how to document RNA sessions on a computer screen mounted to the wall in the hallway. During a follow-up interview with RNA 1 on 4/19/23 at 2:39 PM, RNA 1 stated RNA 1 was the main RNA staff at the facility except on weekends. During an observation on 4/20/23 at 9:08 AM, Patient 43 sat up in a wheelchair to work with Physical Therapy Assistant 1 (PTA 1). Patient 43 was fully dressed and wore shoes. PTA 1 applied a sling to Patient 43's left arm and wheeled Patient 43 to the hallway. Patient 43's wheelchair was positioned with the facility's hallway railing on Patient 43's right side, which was Patient 43's stronger side. Patient 43 used the right arm to pull onto the railing to transfer from sitting to standing as PTA 1 stayed on Patient 43's left side. Patient 43 shifted Patient 43's body weight from the right leg to the left leg to practice stepping forward and backward with PTA 1's assistance. PTA 1 assisted Patient 43 to sit back in the wheelchair. PTA Student 1 (SPTA 1) stood in front of Patient 43 to assist PTA 1, who continued to be on Patient 43's left side, for the remainder of the PT treatment session. SPTA 1 and PTA 1 assisted Patient 43 in transferring from sitting in the wheelchair to standing. PTA 1 stated Patient 43 required maximum assistance to stand. PTA 1 physically moved Patient 43's left leg forward while the SPTA stood in front of Patient 43 while standing. Patient 43 then transferred Patient 43's body weight to the left leg to step forward with the right leg while holding on to the railing using the right arm. PTA 1 continued to physically lift and move Patient 43's left leg forward prior to Patient 43 stepping forward with the right leg in order to walk. Patient 43 walked with PTA 1 and SPTA 1's assistance for 10 feet. Patient 43 sat back down in the wheelchair and walked again another 10 feet with PTA and SPTA's physical assistance. During an interview with RNA 1 on 4/20/23 at 9:49 AM, RNA 1 stated the Rehabilitation Coordinator (RC) and RNA 1 met weekly to discuss any concerns with patients receiving RNA services, including if any patient experienced a decline. RNA 1 stated the PT staff reviewed Patient 43's RNP program for ambulation prior to Patient 43's discharge from PT. RNA 1 stated RNA 1 did not remember PT's recommended distance to walk with Patient 43. RNA 1 stated sometimes the complete RNA task was not visible on the computer screen including the distance to walk with the patient. RNA 1 stated RNA 1 assisted Patient 43 to walk an average of 25 feet. RNA 1 stated the farthest distance Patient 43 walked with RNA 1 was 50 feet. A review of the facility's RNP Caseload Review (records of the weekly RC and RNA meetings) indicated RC and RNA 1 met on 11/25/22, 12/2/22, 12/9/22, 12/22/22, 12/30/22, 1/4/23, 1/25/23, 2/8/23, 2/15/23, 3/1/23, 3/8/23, 3/17/23, 3/20/23, and 3/29/23. The RNP Caseload Review records did not indicate any concerns for Patient 43. During an interview with Patient 43 on 4/20/23 at 1:25 PM, Patient 43 stated Patient 43 used to walk the whole length of the facility's hallway with one person's assistance while using a hemi-walker with PT. Patient 43 stated Patient 43 never walked a whole hallway with RNA 1, did not walk with RNA 1 consistently, and did not walk with RNA 1 five times a week. Patient 43 admitted to having a bad memory but stated Patient 43 would have remembered working with RNA1 if RNA 1 walked Patient 43 five days a week. During a follow-up interview with Patient 43 on 4/20/23 at 1:35 PM, Patient 43 stated feeling scared to lose the ability to walk. During a review of Patient 43's clinical record and interview with PTA 1 on 4/20/23 at 1:55 PM, PTA 1 stated Patient 43 received PT services from 3/25/22 to 11/10/22. PTA 1 reviewed Patient 43's Treatment Encounter Note dated 11/9/22. PTA 1 stated Patient 43 required minimum assistance for sit to stand transfers, minimum assistance for transfers to the wheelchair, and contact guard assistance for walking, requiring verbal prompts and occasional physical assistance to walk. PTA 1 stated PTA 1 trained RNA 1 on Patient 43's RNP prior to discharge from PT on 11/10/22. PTA 1 stated RNA 1 was trained on the hemi-walker's placement and RNA 1's positioning to replicate the amount of assistance and distance Patient 43 achieved while walking with PT. PTA 1 stated PTA 1 expected RNA 1 to maintain Patient 43's mobility after working with PT, including assisting Patient 43 to walk from 125 to 200 feet using the hemi-walker. PTA 1 stated Patient 43 currently required maximum assistance for sit to stand transfers and maximum assistance of two people for walking. PTA 1 stat