Other·February 21, 2024

F689 Code of Federal Regulations,Title 42, Section 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. 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. (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. 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. On 1/3/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding resident safety and falls. As a result of the investigation, the CDPH determined the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) provided care and services to prevent a fall for Resident 1 by failing to: 1. Ensure CNA 1 provided two-person physical assistance (help from two person) when CNA 1 turned Resident 1 to one side to change the resident's adult brief on the bed as indicated in Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/18/2023. 2. Ensure CNA 1 notified Licensed Vocational Nurse 4 (LVN 4) or Treatment Nurse 1 (TXN 1) to set Resident 1's Low Air Loss mattress (LAL, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) on static mode (firm surface set in place and unlikely to move) before CNA 1 turned Resident 1 to one side to change the resident's adult brief on the LAL mattress. These violations resulted in Resident 1’s fall from Resident 1’s bed to the floor. Resident 1 sustained acute displaced fracture (bone breaks into two or more pieces and move out of alignment) at the neck of the right humerus (upper arm bone) and acute nondisplaced fracture (fracture in which the bone cracks or breaks but remains in proper alignment) at the neck of the right femur (thigh bone) and the sacrum (a structure located at the base of the spine). Resident 1 was transferred and admitted to the General Acute Care Hospital (GACH) 1 on 1/3/2024 at 1:00 AM for further evaluation. A review of Resident 1's Admission Record (AR) indicated, the facility admitted Resident 1, a 94-year-old female, on 9/16/2016 and readmitted Resident 1 on 12/6/2023, with diagnoses of functional quadriplegia (the complete inability to move all extremities due to severe disability), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue) of muscles on both arms and legs, and dementia (memory loss which interferes with daily functioning). A review of Resident 1's MDS dated 8/18/2023 indicated, Resident 1 had severely impaired cognition, and required extensive assistance from two or more persons with physical assist for bed mobility. A review of Resident 1’s Admission/Readmission Assessment (AA) dated 12/6/2023 indicated, Resident 1 was at risk for falls due to Resident 1 had on and off confusion, balance problem while standing and sitting, decreased muscular coordination, and poor vision with or without glasses. A review of Resident 1's Activities of Daily Living (ADL) Self Care Performance Deficit Care Plan (ADL CP), initiated on 12/6/23 indicated, for staff to assist with ADL and functional mobility as needed. A review of Resident 1's Situation, Background, Appearance, Review Communication Form (SBAR, a verbal or written communication tool that helps provide essential, concise information, usually during crucial situations), dated 1/2/2024 indicated, on 1/2/2024, CNA 1 changed Resident 1's brief, rolled Resident 1 onto Resident 1's right side, and Resident 1 slid off the bed. The SBAR indicated, Resident 1's Primary Physician (PP) was notified, and the PP recommended for Resident 1 to have X-ray (pictures of the inside of the body) on the right side of the body. A review of Resident 1's X-ray report dated 1/2/2024, timed at 6:24 PM indicated, Resident 1 sustained acute displaced fracture at the neck of the right humerus and acute nondisplaced fracture at the neck of right femur. A review of Resident 1's Progress Notes (PN) dated 1/3/2024, timed at 1:00 AM indicated, the facility transferred Resident 1 to GACH 1. A review of Resident 1's GACH 1 Emergency Department Provider Note (ED PN), dated 1/3/2024, timed at 7:25 AM indicated, Resident 1 would be admitted to GACH 1 for treatment and would be seen by an orthopedist (a doctor who specializes on injuries and diseases affecting the bones, muscles, and joints). A review of Resident 1's GACH 1 Computed Tomography scan (CT scan, medical imaging technique used to obtain detailed internal images of the body) of the right hip report dated 1/3/2024, timed at 7:58 AM, indicated Resident 1 had suspicion of an acute nondisplaced fracture of the sacrum. A review of Resident 1's GACH 1 X-ray of right shoulder report (X-ray report) dated 1/3/2024, timed at 9:58 AM indicated, Resident 1 had fracture of the surgical neck of the right humerus. A review of Resident 1's GACH 1 Orthopedist Consultation (OC) dated 1/4/2024, timed at 8:56 AM indicated, the plan of care included nonoperative management, sling for comfort, follow up with new x-rays in six weeks, pain control, and non-weight bearing on right upper extremity. During an interview on 1/4/2024 at 4:20 PM with the Director of Nursing (DON), the DON stated Resident 1 fell on 1/2/2024 at 11:40 AM when CNA 1 was changing Resident 1's brief and turning Resident 1 to Resident 1's right side. The DON stated X-ray was done on the same day and showed Resident 1 sustained a right humerus fracture. The DON stated Resident 1's PP ordered to transfer Resident 1 to GACH 1. The DON stated Resident 1 was on a LAL mattress. During an interview on 1/5/2024 at 9:30 AM with TXN 1, TXN 1 stated LAL mattress had to be set on static mode when turning and/or working with Resident 1 on the LAL mattress. TXN 1 stated Resident 1 was unable to move in bed "by herself." TXN 1 stated nursing staff had to assist Resident 1 with bed mobility. During an interview on 1/5/2024 at 11:15 AM with LVN 4, LVN 4 stated, on 1/2/2024, a CNA (unable to identify) called LVN 4 into Resident 1's room. LVN 4 stated when LVN 4 entered Resident 1's room, LVN 4 saw Resident 1 on the floor lying on Resident 1's right side. LVN 4 stated Resident 1 had contractures in all limbs (arms and legs) and required full assistance from staff for cleaning, eating, and turning. LVN 4 stated the safest way to turn or clean Resident 1 and avoid a fall was to have another staff help when providing care to Resident 1. During an interview on 1/5/2024 at 12:04 PM with CNA 1, CNA 1 stated CNA 1 provided Resident 1 a bed bath on 1/2/2024 at 11:05 AM. CNA 1 stated after finishing the bed bath, CNA 1 turned Resident 1 to Resident 1's right side to put a brief on Resident 1. CNA 1 stated Resident 1 slipped off the bed and fell to the floor. CNA 1 stated she did not ask for another staff to assist in turning Resident 1 because she had taken care of Resident 1 without assistance in the past. CNA 1 stated Resident 1 had contracture on both legs. CNA 1 stated the safest way to change, clean, or reposition Resident 1 was with two staff. CNA 1 stated Resident 1's fall could have been prevented by having another staff to assist when repositioning, cleaning, or changing Resident 1. During an interview on 1/5/2024 at 2:30 PM with the Director of Staff Development (DSD), the DSD stated CNAs were instructed to team up as partners and automatically had another staff to work with in providing care for Resident 1, who needed assistance or dependent on CNAs for care. The DSD stated the expectation would be to have CNA 1 team up with another CNA (any CNA) when providing care to Resident 1. The DSD stated, Resident 1 was dependent on staff for care, turning, and repositioning in bed because Resident 1 had contractures. The DSD stated Resident 1 needed to be assisted by two staff. The DSD stated CNA 1 needed to ask for assistance from another staff (any CNA) before CNA 1 turned Resident 1 on the bed to prevent the fall. During an interview on 1/5/2024 at 3:25 PM with CNA 1, CNA 1 stated she did not notify LVN 4 or TXN 1 to set the LAL mattress on static mode before providing care to Resident 1. CNA 1 stated the facility trained her that the control panel for the LAL mattress was specifically for the charge nurses (LVNs) or treatment nurses (TXNs) to adjust the setting for LAL mattress. CNA 1 stated CNAs (in general) were not allowed to touch or adjust the setting for the LAL mattress. During an interview on 1/5/2024 at 5:12 PM with the DON, the DON stated the facility's expectation was for CNA 1 to notify the licensed nurses (LVNs or TXNs) to set the LAL mattress on static mode when providing care to Resident 1, so the LAL mattress would not move (air inside the LAL mattress would not shift). The DON stated when the LAL mattress was not on static mode, the mattress could move, and the distribution of the resident's weight would not be even and could cause the resident to fall out of the LAL mattress. During an interview on 1/5/2024 at 5:49 PM with the DSD, the DSD stated, CNA 1 received special mattress training (on 10/14/2023) which included having the licensed nurse (LVN or TXN) set the LAL mattress on static mode during bed bath or when providing care for any residents (in general) on the LAL mattress. The DSD stated setting the LAL mattress on static mode prevented the LAL mattress from making sudden movements which could cause a fall. During a review of the facility's policy and procedure (P&P) titled, "Fall and Fall Risk, Managing," revised in 3/2018, the P&P indicated "the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling." During a review of the Manufacturer's Manual (MM) titled, "DynaRest Airfloat 100, Air Mattress with Pump," undated, the MM indicated in static mode, the LAL mattress provided a firm surface for the patient to transfer or reposition. The facility failed to ensure CNA 1 provided care and services to prevent a fall for Resident 1 by failing to: 1. Ensure CNA 1 provided two-person physical assistance when CNA 1 turned Resident 1 to one side to change the resident's adult brief on the bed as indicated in Resident 1's MDS, dated 8/18/2023. 2. Ensure CNA 1 notified Licensed Vocational Nurse 4 (LVN 4) or TXN 1 to set Resident 1's Low Air Loss mattress on static mode before CNA 1 turned Resident 1 to one side to change the resident's adult brief on the LAL mattress. These violations resulted in Resident 1’s fall from Resident 1’s bed to the floor. Resident 1 sustained acute displaced fracture at the neck of the right humerus and acute nondisplaced fracture at the neck of the right femur and the sacrum. Resident 1 was transferred and admitted to the GACH 1 on 1/3/2024 at 1:00 AM for further evaluation. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.