Other·February 9, 2023

F688 CFR §483.25(c)(1) The facility must ensure that a patient who enters the facility without limited range of motion does not experience reduction in range of motion unless the patient’s clinical condition demonstrates that a reduction in range of motion is unavoidable; and CFR §483.25(c)(2) A patient 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. CFR §483.25(c)(3) A patient 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. CCR§72301. Required Services. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. 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. (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. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. CRR 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 11/18/2022 at 10:07 am, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding resident neglect. As a result of the investigation, the Department determined that the facility failed to provide range of motion exercises (activities aimed at improving movement of a specific joint, a point where two bones make contact) for Patient 1 as indicated in the physician’s order and the facility's policy for “Patient Mobility and Range of Motion (ROM, full movement potential of a joint).” As a result of these failures Patient 1 experienced pain and declined in ROM, that caused stiffness (inability to move easily and without pain) and contractures (deformity and joint stiffness) on Patient 1’s right hand and right arm. A review of Patient 1’s Admission Record indicated the facility admitted a 70 year old female, on 6/12/22, with diagnoses that included cerebral infarction (brain damage due to a loss of oxygen to the area, also known as a stroke) and difficulty in walking. A review of Patient 1’s Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Admission Evaluation & Plan of Treatment, dated 6/13/22, indicated Patient 1’s right and left upper extremity (arm) ROM were within functional limits (WFL, sufficient joint movement) and no contracture. The OT evaluation indicated Patient 1 had no pain. A review of Patient 1’s Plan of Care for Risk for Decline in ROM initiated on 8/9/22, indicated for Restorative Nursing Aide Program (RNA, nursing aid program that helps patients to maintain their function and joint mobility) to provide passive range of motion (PROM, therapist or equipment moves the joint through the range of motion with no effort from the patient) to both arms and both legs. A review of Patient 1’s Physician Order dated 8/9/22, indicated for RNA to initiate PROM to both arms for Patient 1 five times a week or as tolerated. A review of Patient 1’s RNA Flow Sheet (record of RNA treatment sessions) from 8/9/22 to 11/18/22, indicated ROM exercises to both arms was not provided five times a week according to physician’s order. Patient 1’s RNA Flow Sheet for September 2022 was blank for the following dates: 9/2/22, 9/4/22, 9/9/22, 9/11/22, 9/12/22, 9/18/22, 9/21/22, 9/25/22 and 9/26/22. Patient 1’s RNA flow sheet for October and November 2022 were blank and unsigned from 10/17/22 to 11/18/22. A review of Patient 1’s Minimum Data set (MDS, a standardized assessment and care planning tool) dated 9/16/22, indicated the patient usually understands and able to make herself understood. The MDS indicated Patient 1 required extensive assistance (the individual would not be able to perform or complete the activity of daily living without another person to aid in performing the complete task, by providing weight-bearing assistance) with bed mobility, transfers between surfaces, dressing, toilet use and personal hygiene and was totally dependent with eating. During an observation and concurrent interview with Patient 1 in Patient 1’s room on 11/18/22 at 11:16 am, Patient 1 stated she “has no therapy here,” and she wanted “therapy.” Patient 1’s right side of the body had limited movement and the right hand appeared contracted (limited movement, decrease in size and or range). During an observation of Patient 1 in Patient 1’s room and interview on 11/18/22 at 1:53 pm, Patient 1 was awake, lying-in bed. Patient 1 was unable to lift her right arm and right hand. Patient 1 stated, “no nurse exercises with me, they have not come to do exercises with me in a long time.” Patient 1 was unable to specify how many days she did not receive ROM exercises. During an interview on 11/18/22 at 4:02 pm, the Director of Rehabilitation Services (DOR) stated, Patient 1 was last seen by the OT in July 22 (7/15/22). During an observation of Patient 1’s Therapy Screening by the DOR and a concurrent interview on 11/18/22 at 4:50 pm, the DOR assessed Patient 1’s arms and legs. Patient 1’s right hand was in closed position (like a fist). The DOR attempted to open Patient 1’s right hand but was unable to extend the fingers due to stiffness. Patient 1 complained of pain while the DOR attempted to open her right hand. The DOR stated Patient 1’s right arm could not raise above 80 degrees (approximately shoulder height) due to Patient 1’s complaints of pain. The DOR stated Patient 1’s right arm had 80 degrees of shoulder flexion (raising the arm in front of the body and overhead, normal range is 0-180 degrees) and 80 degrees of shoulder abduction (raising the arm to the side and overhead, normal range is 180 degrees). A review of Patient 1’s Therapy Screening Form dated 11/18/22, indicated the patient had stiffness on the right hand and fingers, painful right shoulder on flexion 0-80 degrees and abduction 0-80 degrees. There was a recommendation for an OT evaluation to determine appropriate splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) and to continue with RNA program. During an interview on 11/18/22 at 5:25 pm and a review of Patient 1’s OT Admission Evaluation and Treatment (OT Evaluation) dated 6/13/22, the DOR stated during the initial OT evaluation (6/13/22), the ROM in Patient 1’s right arm was WFLs. The DOR defined WFLs as having no limitations in ROM, even when performing PROM. During an interview on 11/18/22 at 5:45 pm, and a review of Patient 1’s OT Discharge Summary, dated 7/15/22, the DOR stated Patient 1 did not receive PROM exercise after the patient was discharged from OT services (7/15/22). The DOR stated, Patient 1 should be screened for ROM quarterly. During an interview on 11/18/22 at 6:21 pm and a review of Patient 1’s OT Evaluations, the Medical Records Director (MRD) and the DOR stated Patient 1 did not have any quarterly screening for ROM since Patient 1 was discharged from OT services on 7/15/22. During an interview on 11/18/22 at 6:30 pm, the DOR stated, Patient 1’s right arm ROM could have been maintained had PROM exercise been provided consistently (in every case or on every occasion). The DOR stated PROM exercise were not provided as ordered after the OT Department discharged the patient from OT services on 7/15/22. The DOR stated Patient 1 had decreased ROM on right shoulder, right hand, right fingers and right thumb and the patient complained of pain when performing PROM exercises to the patient’s right arm. The DOR stated Patient 1 would not have right arm pain if ROM exercises were consistently provided. The DOR stated, Patient 1’s decline in ROM to the right arm was avoidable and preventable. During an interview on 11/18/22 at 7:28 pm and a review of Patient 1’s RNA Flow Sheet dated from 8/9/22 to 11/18/22, the Director of Nursing (DON) stated when the RNA Flow Sheet was blank, unsigned, and not documented, then “it was not done.” During an interview on 12/8/22 at 1:39 pm, Restorative Nursing Aide 1 (RNA 1) stated, she was the only RNA at the facility. RNA 1 stated, when she could not provide PROM exercise for some patients that she was assigned to perform RNA exercises, she gave them (the patients) “off days.” During an interview with the facility’s Administrator on 1/10/23 at 4:15 pm, the facility did not have a policy for monitoring the patients’ ROM and mobility. The Administrator stated the facility monitored the patients’ ROM and mobility using the quarterly MDS. A review of the facility’s contracted Rehabilitation Agency’s Policy and Procedure updated 9/5/17, indicated all patients identified needing an assessment of functional status and potential to benefit from rehabilitation services be evaluated in order to determine an appropriate plan of care. Therapeutic goals must meet at least one of the following characteristics to prevent deterioration and sustain function; provide interventions that enable the patient to live at their highest level of independence in the case of a chronic or progressive disability. A review of the facility’s Policy and Procedure tiled “Patient Mobility and Range of Motion”, revised July 2017, indicated patients with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The policy indicated the patients will not experience an avoidable reduction in range of motion. As a result of the investigation, the Department determined that the facility failed to provide range of motion exercises for Patient 1 as indicated in the physician’s order and the facility's policy for “Patient Mobility and Range of Motion.” As a result of these failures Patient 1 experienced pain and declined in ROM, that caused stiffness and contractures on Patient 1’s right hand and right arm. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.