Other·March 10, 2023

F688 Code of Federal Regulations, Title 42, §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 Code of Federal Regulations, Title 42, §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. Code of Federal Regulations, Title 42, §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. California Code of Regulations, Title 22, §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. California Code of Regulations, Title 22, §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. California Code of Regulations, Title 22, §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 1/17/2023 to 1/20/2023, the California Department of Public Health (CDPH) conducted an unannounced recertification survey visit to the facility. As a result of the recertification survey, the CDPH determined that the facility failed to ensure that appropriate treatment and services were provided to prevent further decline in range of motion (ROM, full movement potential of a joint) and mobility (ability to move) for Patient 35, 6, and 13 by failing to: 1. Provide ROM exercises to Patient 35 after the interdisciplinary team (IDT, a team of health care professions who work together to establish plans of care for patients) identified the service was needed on 11/2/2022. 2. Provide ROM exercises to Patient 6 for multiple days on 8/2022 and on 9/2022. 3. Provide ROM exercises to Patient 13 for multiple days on 8/2022. These failures had the potential to result in ROM decline and development of contractures (chronic loss of joint motion associated with deformity and joint stiffness) for Patient 35, 6, and 13. 1. A review of Patient 35's Face Sheet (admission record) indicated the facility originally admitted a 92-year-old female on 6/22/2022 and re-admitted on 10/17/2022. Patient 35's diagnoses included but were not limited to palliative care (specialized medical care that focuses on providing patients relief from pain and other symptoms of a serious illness), non-ST elevation myocardial infarction (NSTEMI, type of heart attack that happens when a part of your heart is not getting enough oxygen), and a history of falling. A review of the Admission Orders, dated 10/11/2022, indicated Patient 35 was admitted after right hip surgery. A review of the Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation, dated 10/12/2022, indicated Patient 35 sustained a right hip fracture, requiring right hip surgery on 10/6/2022. Patient 35 was readmitted to the facility on 10/11/2022. A review of the Interdisciplinary Notes, dated 10/13/2022, at 9:36 PM, indicated Patient 35 complained of chest pain. The Interdisciplinary Note indicated emergency services were called, and Patient 35 was admitted to the general acute care hospital due to elevated troponin (protein in blood, high levels of troponin is a sign of a recent heart attack) levels. A review of Patient 35's initial certification for hospice (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible), dated 10/14/2022, indicated a hospice admission date of 10/14/2022. A review of the Interdisciplinary Notes, dated 10/17/2022, at 10:56 PM, indicated Patient 35 was re-admitted to the facility under hospice care. A review of Patient 35's Minimum Data Set (MDS, a comprehensive care plan used as a care planning tool), dated 10/24/2022, indicated Patient 35 required extensive assistance (patient involved in activity with staff providing support) for bed mobility, transfers between surfaces, and dressing. The MDS indicated Patient 35 had a ROM impairment in one leg. A review of the Resident Care Conference, dated 11/2/2022, indicated to consider a Restorative Nursing Aide (RNA, nursing aide program that helps patients to maintain their function and joint mobility) program for passive range of motion (PROM, movement of a joint through the ROM with no effort from patient). During a concurrent observation on 1/17/2023, at 12:52 PM, Patient 35 was sitting up in a wheelchair asking the nurse for assistance to the restroom. On 1/17/2023, at 1:16 PM, Patient 35 was sitting in a wheelchair at the nursing station asking to call a family member. During an interview and record review on 1/20/2023, at 9:35 AM, the Director of Rehabilitation (DOR) reviewed Patient 35's clinical record. The DOR stated ROM after hip surgery would be beneficial to Patient 35. The DOR stated therapy staff did not evaluate Patient 35 after readmission on 10/17/2022 due to the patient's hospice status. During an interview and record review on 1/20/2023, at 10:04 AM, the Director of Social Services (DSS) reviewed the Resident Care Conference, dated 11/2/2022. The DSS stated the IDT and the family discussed the possibility of Patient 35 receiving RNA services for ROM. The DSS stated this request was communicated to the hospice company. The DSS stated the facility did not follow up on this request for ROM services with Patient 35's hospice provider because the facility did not have a hospice coordinator. 2. A review of Patient 6's Face Sheet (admission record) indicated the facility originally admitted an 82-year-old female on 6/27/2019 and re-admitted the patient on 6/29/2022. Patient 6's diagnoses included but were not limited to dysphagia (difficulty swallowing). A review of the physician's order, dated 7/1/2022, indicated for the Restorative Nursing Aide (RNA, nursing aide program that helps patients to maintain their function and joint mobility) to provide active assistive ROM (AAROM, use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) to both arms and both legs, five times a week to the patient's tolerance. A review of Patient 6's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 1/4/2023, indicated Patient 6 was totally dependent for bed mobility, transfers between surfaces, dressing, eating, toileting, hygiene, and bathing. The MDS indicated Patient 6 had ROM impairments to one arm and both legs. A review of Patient 6's RNA record for 8/2022, indicated blank portions on the record (no initial to indicate the service was done) for the following dates: 8/3/2022, 8/7/2022, 8/10/2022, 8/11/2022, 8/12/2022, 8/13/2022, 8/27/2022, and 8/28/2022. A review of Patient 6's RNA record for 9/2022 indicated blank portions on the records for the following dates: 9/8/2022, 9/14/2022, 9/15/2022, 9/16/2022, 9/17/2022, 9/18/2022, and 9/24/2022. During an observation on 1/19/2023, at 2:43 PM, Patient 6 was lying in bed with the head-of-bed elevated to 45 degrees. Restorative Nursing Aide 1 (RNA 1) assisted Patient 6 with AAROM to the right arm, right leg, and left shoulder. RNA 1 then performed passive ROM (PROM, movement of a joint through the ROM with no effort from patient) to the left elbow, left wrist, left hand, and left leg. During an interview and record review on 1/20/2023, at 2:04 PM, the Director of Staff Development (DSD) stated RNA services were important to maintain or improve the patients' overall mobility and to prevent contractures. The DSD reviewed Patient 6's RNA records for 8/2022 and 9/2022 and confirmed there were blank dates. The DSD stated blank dates indicated the RNA treatment for Patient 6 was not completed. The DSD stated it was possible the RNA was pulled to perform direct patient care as a Certified Nursing Assistant. A review of the facility's policy titled, "Restorative Nursing Program," revised 2/2009, indicated the purpose of the program was to assist each patient "to reach and maintain their highest practicable level of functioning." 3. A review of Patient 13's Face Sheet (admission record) indicated the facility originally admitted a 75-year-old male on 2/15/2015 and re-admitted on 5/19/2017. Patient 13's diagnoses included but were not limited to dementia (decline in mental ability severe enough to interfere with daily life), Parkinson's disease (a progressive disease of the nervous system resulting impaired movement), and abnormal posture. A review of Patient 13's physician's order, dated 12/20/2021, indicated for the Restorative Nursing Aide (RNA, nursing aide program that helps patients to maintain their function and joint mobility) to provide passive ROM (PROM, movement of a joint through the ROM with no effort from patient) exercises to both legs five times per week. A review of Patient 13's physician's order, dated 4/13/2022, indicated RNA for PROM exercises to both arms five times per week and as tolerated by Patient 13. A review of Patient 13's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 12/29/2022, indicated Patient 13 was totally dependent for bed mobility, transfers between surfaces, dressing, eating, toileting, hygiene, and bathing. The MDS indicated Patient 13 had ROM impairments to one arm and both legs. A review of the Patient 13's RNA record for 8/2022 indicated blank portions on the records for the following dates: 8/3/2022, 8/4/2022, 8/5/2022, 8/6/2022, 8/7/2022, and 8/10/2022. During an observation on 1/19/2023, at 1:53 PM, Patient 13 was lying in bed with the head-of-bed slightly elevated. Restorative Nursing Aide 1 (RNA 1) performed PROM to both of Patient 13's arms and legs. During an interview and record review on 1/20/2023 at 2:04 PM, the Director of Staff Development (DSD) stated RNA services were important to maintain and improve the patients' overall mobility and to prevent contractures. The DSD reviewed Patient 13's RNA record for 8/2022 and confirmed there were blank dates. The DSD stated blank dates indicated the RNA treatments for Patient 13 were not completed. The DSD stated it was possible the RNA was pulled to perform direct patient care as a Certified Nursing Assistant. A review of the facility's policy titled, "Restorative Nursing Program," revised 2/2009, indicated the purpose of the program was to assist each patient "to reach and maintain their highest practicable level of functioning." As a result of the recertification survey, the CDPH determined that the facility failed to ensure that appropriate treatment and services were provided to prevent further decline in range of motion and mobility for Patient 35, 6, and 13 by failing to: 1. Provide ROM exercises to Patient 35 after the interdisciplinary team identified the service was needed on 11/2/2022. 2. Provide ROM exercises to Patient 6 for multiple days on 8/2022 and on 9/2022. 3. Provide ROM exercises to Patient 13 for multiple days on 8/2022. These failures had the potential to result in ROM decline and development of contractures for Patient 35, 6, and 13. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 35, 6 and 13.