Other·March 10, 2023

T22 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. 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. F689 §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. An unannounced visit was conducted by California Department of Public Health on 12/13/22 at 10:30 AM to investigate a facility reported incident regarding patient safety. The facility failed to supervise Patient 1 preventing the patient from rolling out from the transportation van onto the pavement, while in his wheelchair causing the wheelchair’s footrest to retract and pushing against the patient’s legs while the patient was being transported from the facility to the doctor’s office. This deficient practice resulted to Patient 1‘s accident on 12/8/2022, sustaining a right tibial (along the length of the bone, below the knee and above the ankle) fracture (a complete or partial bone break). A review of Patient 1’s admission record indicated the patient is a 60- year- old male patient admitted at the facility on 05/30/2021 with diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning), contracture (a fixed tightening of muscle, tendons, ligaments, or skin. It prevents normal movement of the associated body part) of right and left hip, muscle weakness and other lack of coordination. A review of Patient 1’s history and physical, dated 11/16/2022, indicated, the patient did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/20/2022 indicated Patient 1 was totally dependent (needs full staff performance) with transferring from bed to wheelchair or wheelchair to bed and needs extensive assistance (patient involved in activity but staff provides maneuvering of limbs) to move around when in wheelchair. On 12/13/2022 at 11:09 AM, during an interview with Administrator (ADMIN), he stated Patient 1 was scheduled for a doctor’s appointment on 12/08/2022 at 2:15 pm. The patient was accompanied to his doctor’s appointment by Transport Company Driver (TC 1) and Restorative Nurse Assistant (RNA). The ADMIN stated during his investigation of the incident, when Patient 1 was unbuckled from his wheelchair and TC 1 released patient’s wheelchair from the vehicle’s wheelchair locks, the patient’s wheelchair rolled out of the vehicle, causing injury to Patient 1’s legs. On 12/13/2022 at 12:08 PM, during an observation and interview with Patient 1, the patient was observed lying in bed (with head of bed slightly elevated) wearing a leg immobilizer (removable devices that maintain stability of the knee. Knee immobilizers are typically used for injuries that benefit from immobilization but can tolerate brief periods without immobilization and thus do not require casting) and splint (supportive device that protects a broken bone or injury) on patient’s right leg and purplish discoloration (bruise) on patient left knee and lower shin. Patient 1 stated, he had a fall when he went to his doctor’s appointment on 12/08/2022. Patient 1 stated, while TC 1 was unbuckling his seatbelt (from the vehicle) and releasing the wheelchair strap (used to secure the wheelchair in place) from the van, the patient’s wheelchair rolled out from the van. Patient 1 stated he stuck both legs out to brace his fall and hurt his legs. Patient 1 stated, the other staff (RNA) was outside the van when it happened and was not able to catch him to prevent him from falling. On 12/22/2022 at 12:44 PM, during an interview with RNA, he stated he was the staff member who accompanied Patient 1 to the doctor’s office on 12/08/2022. RNA stated on the day of the incident (Patient 1 rolled out the van), TC 1 was releasing the patient’s wheelchair from the vehicle, and after releasing the wheelchair from the strap Patient 1 rolled out from the van RNA was waiting outside of the transport vehicle for the patient. On 12/22/2022 at 2:15 PM, during a telephone interview, TC 1 staff stated when transporting patients from the facility to their doctor’s appointment, it involves safely picking up the patient and taking the patient to their destination. TC 1 staff stated on 12/8/2022 (afternoon) he was unbuckling Patient 1’s wheelchair from the van, Patient 1 fell out of his wheelchair and hurt his legs when he fell onto the ground. TC 1 staff stated he was unable to remember if the patient’s wheelchair was on brake and when he unlatched the wheelchair lock (strap from the vehicle to secure the wheelchair in place) from inside the transport vehicle and unbuckled the patient from his safety belt (from the vehicle); the wheelchair began to roll, and he did not have a good grip on the wheelchair. TC 1 stated the escort staff (RNA) was not inside the van to assist him with the patient. On 12/22/2022 at 2: 45 PM, during an interview with the Director of Nursing (DON), she stated when patients are transferred to their doctor’s appointment and require additional assistance or monitoring to ensure safety due to their physical limitations, such as with Patient 1 who has dementia and muscle weakness, a staff from the facility must go with the patient. The DON stated if the facility staff goes with the patient they must always remain beside the patient and should help assist the driver (TC 1) to transport the patient to the doctor’s appointment, including making sure patient is safe while in the vehicle. On 12/29/2022 at 1:25 PM, during an interview with the Assistant Administrator (AAdmin), stated there was no specific policy to address safety and monitoring of patients during transportation to outside services and appointments. The AAdmin stated, there should be a written policy to address this because patients in the facility regularly visit outside services such as doctor’s appointments and to ensure their safety during that process, and that facility staff are responsible for the patient’s safety while in the vehicle and transfer to the patient’s appointment. A review of Patient 1’s Interdisciplinary Team (IDT, comprised of a primary care physician, nurse, social worker, dietician, personal care attendant and other professionals discusses the patient’s condition and coordinate a person- centered care plan) progress notes dated 12/09/2022 1:25 PM, indicated on 12/8/2022 when the patient went to his doctor’s appointment, TC 1 released Patient 1’s the seat belt (not specified), and patient’s wheelchair wheeled down, TC 1 and staff (RNA) tried to stop the wheelchair, but it rolled out from the car and the footrest made contact to the concrete which cause the footrest to retract, pushing against patient’s legs. Patient 1 was assessed, and the physician ordered for the patient to be transferred to hospital. A review of report titled “Radiology Report” from the facility’s contracted radiology services Radiology Clinic 1, dated 12/08/22 indicated the patient had a right tibial fracture. A review of Patient 1’ Physician’s order dated 12/09/2022 indicated to transfer the patient to the hospital due to acute fracture. A review of Patient 1’s “Radiology Report” from General Acute Care Hospital 1 (GACH 1), dated 12/09/22 indicated computed tomography (CT, medical imaging technique used to obtain detailed internal images of the body) of both legs was done and indicated the patient had an acute nondisplaced (broken bones but the pieces did not move far enough) right tibial medial malleolus (bony projection with a shape likened to a hammer head) fracture. A review of Patient 1’s Emergency Department History and Physical from GACH date 12/08/22, indicated the patient was placed in right knee immobilizer and right posterior (back part of the body) leg splint. A review of the facility policy titled “Patient Safety” dated 4/15/2021, indicated, the purpose to provide a safe and hazard free environment. To ensure safety of a patient, any facility staff member who identifies an unsafe situation, practice or environment risk factor should immediately notify their supervisor or charge nurse. The facility failed to supervise Patient 1 preventing the patient from rolling out from the transportation van onto the pavement, while in his wheelchair causing the wheelchair’s footrest to retract and pushing against the patient’s legs while the patient was being transported from the facility to the doctor’s office. This deficient practice resulted to Patient 1‘s accident on 12/8/2022, sustaining a right tibial (along the length of the bone, below the knee and above the ankle) fracture (a complete or partial bone break). The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.