Health inspection·March 12, 2024

Code of Federal Regulations, Title 42, Section 483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following — (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40. Code of Federal Regulations, Title 42, Section 483.25(d) Accidents The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident 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: (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. 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 (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 1/29/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding resident care, resident safety, and falls. As a result of the investigation, CDPH determined the facility failed to implement a resident-centered comprehensive care plan to prevent Resident 1’s fall by failing to ensure Certified Nursing Assistant (CNA) 1 provided two-person physical assistance when CNA 1 turned Resident 1 to one side while bathing the resident on the bed as indicated in Resident 1's Care Plan titled, "Activities of Daily Living (ADL)/Self-Care Deficits," initiated on 10/6/2023, and required in the facility's policies and procedures (P&P) titled, "Fall and Fall Risk, Managing," and "Care Plans, Comprehensive Person-Centered." This violation resulted in Resident 1 falling from the bed to the floor on 12/12/2023, at 10:30 AM. Resident 1 sustained a displaced fracture (bone breaks in two or more pieces and resulting misalignment) at the neck of the right subcapital femur (neck of the thighbone). Resident 1 was transferred and admitted to a General Acute Care Hospital (GACH) 1 on 12/12/2023, at 8:15 PM for further evaluation, had a right hip hemiarthroplasty (a type of partial hip replacement surgery that involved replacing half of the hip joint) on 12/14/2023, and remained in GACH 1 for five days. A review of Resident 1's Admission Record (AR) indicated, the facility admitted Resident 1, a 104-year-old female, on 10/3/2023, and readmitted Resident 1 on 12/19/2023, with diagnoses that included morbid obesity (more than 80 to 100 pounds over ideal body weight), muscle weakness, dementia (memory loss which interferes with daily functioning), lack of coordination, and osteoporosis (a condition in which the bones become weak and brittle). A review of Resident 1's Initial History and Physical (H&P) dated 10/3/2023, indicated Resident 1 did not have the capacity to understand or make decisions. A review of Resident 1's Care Plan titled, "ADL/Self Care Deficits (ADL CP)," initiated on 10/6/2023, indicated Resident 1 required physical assistance from two persons for bed mobility. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/7/2023, indicated Resident 1 had severely impaired cognition. The MDS indicated Resident 1 required substantial/maximal assistance for showering/bathing and personal hygiene. The MDS indicated, Resident 1 depended on staff for "rolling left and right." A review of Resident 1's Progress Notes (PN), dated 12/12/2023, timed at 10:45 AM, indicated at 10:30 AM, CNA 1 notified Licensed Vocational Nurse (LVN) 1 that Resident 1 fell on the floor during Resident 1's care. The PN indicated that CNA 1 instructed Resident 1 to turn to Resident 1's right side, but instead Resident 1 turned to Resident 1's left side and rolled down from the bed straight down to the floor. The PN indicated, Resident 1 complained of right hip pain. The PN indicated LVN 1 notified Resident 1's Primary Physician (PP) and the PP ordered for Resident 1 to have a stat (immediate) X-ray of the right hip. A review of Resident 1's Change in Condition Evaluation, dated 12/12/2023, timed at 11:15 AM, indicated on 12/12/2023, Resident 1 fell from the bed to the floor on Resident 1's right side while CNA 1 was providing care to Resident 1. A review of Resident 1's PN dated 12/12/2023, timed at 7:41 PM, indicated the x-ray provider had not arrived, and Resident 1 continued to complain of pain on Resident 1's right hip. The PN indicated that the facility transferred Resident 1 to GACH 1 via non-emergency transport. A review of Resident 1's Skilled Nursing Facilities to Hospital Transfer Form (SNF to Hosp Form), dated 12/12/2023, indicated the facility transferred Resident 1 to GACH 1 at 8:15 PM. A review of Resident 1's GACH 1 Emergency Department Provider Note (EDPN), dated 12/12/2023, timed at 8:20 PM, indicated Resident 1 arrived at GACH 1 for evaluation of right hip pain status post fall. The EDPN indicated that Resident 1 would be admitted to GACH 1 for further evaluation and care. A review of Resident 1's GACH 1 Computed Tomography scan of the right hip report, dated 12/12/2023, timed at 8:22 PM, indicated Resident 1 had a subcapital fracture of the right femur. A review of Resident 1's GACH 1 Orthopedist Consultation, dated 12/14/2023, timed at 2:06 PM, indicated the plan was to proceed with a right hip hemiarthroplasty on 12/14/2023. During a concurrent observation and interview on 1/29/2024, at 3:30 PM, with Resident 1 in Resident 1's room, Resident 1 was lying in bed. Resident 1 had an intact, clean, dry, and clear surgical incision on the right hip. Resident 1 was calm and had no signs of facial grimacing. Resident 1 said "Hi," but did not respond to any questions. During an interview on 1/30/2024, at 9:15 AM, Registered Nurse Supervisor (RNS) 1 who worked the night shift from 11 PM to 7 AM on 12/12/2023, stated Resident 1 required total care but was able to follow simple commands. RNS 1 stated Resident 1 was a "heavy" resident and required two-person physical assistance for repositioning, cleaning, and changing. RNS 1 stated before she ended her shift on 12/12/2023, RNS 1 specifically instructed CNA 1 that Resident 1 "always" needed assistance from two persons for repositioning, changing, and cleaning because Resident 1 was totally dependent on staff for care. RNS 1 stated Resident 1's fall could have been prevented if CNA 1 asked another staff to assist when providing care to Resident 1. During a telephone interview on 1/30/2024, at 11:25 AM, CNA 1 stated she provided Resident 1 a bed bath on 12/12/2023 at "around" 10:30 AM. CNA 1 stated after she washed Resident 1's back, CNA 1 asked Resident 1 to turn to Resident 1's right side towards CNA 1 but Resident 1 turned to Resident 1's left side away from CNA 1, and Resident 1 fell from Resident 1's bed 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 several times in the past. CNA 1 stated Resident 1 was able to understand simple commands and could turn with assistance. CNA 1 stated she received training on safe resident handling and caring for "heavyset" residents upon hire. 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 a phone interview on 1/30/2024, at 11:45 AM, LVN 1 stated on 12/12/2023, CNA 1 called LVN 1 into Resident 1's room. LVN 1 stated when LVN 1 entered Resident 1's room, she saw Resident 1 lying on the floor on Resident 1's right side. LVN 1 stated Resident 1 was lying on the left side of Resident 1's bed facing Resident 1's room door. LVN 1 stated Resident 1 was totally dependent on staff for care and required full assistance for cleaning, eating, and turning. LVN 1 stated Resident 1 could follow simple commands at times. LVN 1 stated Resident 1 had a heavyset body, was unable to move much, and needed two-person assistance for bathing, repositioning, and changing. LVN 1 stated the safest way to turn or clean Resident 1 and prevent a fall was to have another staff help when providing care to Resident 1. During an interview on 1/30/2024, at 2:34 PM, with the Director of Rehabilitation (DOR) in the facility's conference room, the DOR stated Resident 1 was "heavily built," weighed 183 pounds, had poor trunk control, and required two-person total assistance for transfer, repositioning, and changing. The DOR stated CNAs (all CNAs) were informed at the huddles (brief staff meeting) at the beginning of the shift which residents required two-person assistance when providing care. The DOR stated Resident 1 was one of the residents who needed two-person assistance. The DOR stated CNA 1 could have prevented Resident 1's fall if CNA 1 asked for another staff's assistance when CNA 1 turned Resident 1. During an interview on 1/31/2024, at 10:00 AM with the Director of Nursing (DON), the DON stated Resident 1 fell from Resident 1's bed to the floor on 12/12/2023, at 10:30 AM when CNA 1 asked Resident 1 to turn to Resident 1's right side towards CNA 1, but Resident 1 turned to Resident 1's left side away from CNA 1. The DON stated CNA 1 thought CNA 1 could manage Resident 1 by herself. The DON stated CNA 1 knew Resident 1 needed two-person assistance, but CNA 1 told the DON that CNA 1 had been providing care to Resident 1 without another staff in the past and did not have any issue. The DON stated CNA 1 could have prevented Resident 1's fall if CNA 1 had asked for another staff to assist before providing care to Resident 1. During an interview on 1/31/2024, at 10:30 AM, with the Director of Staff Development (DSD), the DSD stated all CNAs were instructed to have another staff to work with when providing care to Resident 1 who needed assistance or were dependent on CNAs for care. The DSD stated the expectation was to have CNA 1 team up with another 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 lack of coordination, muscle weakness, and was unable to move. 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 before CNA 1 turned Resident 1 on the bed to prevent the fall. A review of the facility's P&P titled, "Fall and Fall Risk, Managing," revised in 3/2018, indicated that based on previous evaluations and current data, staff shall identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling. The P&P indicated staff shall implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident. A review of the facility's P&P titled, "Care Plans, Comprehensive Person-Centered," revised in 3/2022, indicated facility's staff in conjunction with the resident and his/her family or legal representative, were to develop and implement a comprehensive, person-centered care plan for each resident. The facility failed to implement a resident-centered comprehensive care plan to prevent Resident 1’s fall by failing to ensure Certified Nursing Assistant (CNA) 1 provided two-person physical assistance when CNA 1 turned Resident 1 to one side while bathing the resident on the bed as indicated in Resident 1's Care Plan titled, "Activities of Daily Living (ADL)/Self-Care Deficits," initiated on 10/6/2023, and required in the facility's policies and procedures (P&P) titled, "Fall and Fall Risk, Managing," and "Care Plans, Comprehensive Person-Centered." This violation resulted in Resident 1’s fall from Resident 1's bed to the floor on 12/12/2023, at 10:30 AM. Resident 1 sustained a displaced fracture at the neck of the right subcapital femur. Resident 1 was transferred and admitted to GACH 1 on 12/12/2023, at 8:15 PM, for further evaluation, had a right hip hemiarthroplasty on 12/14/2023, and remained in GACH 1 for five days. The above violation 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 Resident 1.