Health inspection·August 30, 2024

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. Code of Federal Regulations, Title 42, Section 483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be- (i)Developed within 7 days after completion of the comprehensive assessment. (ii)Prepared by an interdisciplinary team, that includes but is not limited to- (A)The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 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: (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. (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 7/19/2024, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care and treatment. As a result of the investigation, the CDPH determined that the facility failed to provide care and services to prevent a fall for Resident 1 as indicated in the facility's policies and procedures (P&P) titled, "Safety and Supervision of Residents," and "Falls and Fall Risk, Managing." The facility failed to: 1. Ensure Certified Nursing Assistant 1 and/or Licensed Vocational Nurse 1 provided supervision/monitoring to prevent a fall on 6/24/2024 at 1:20am when Resident 1, who was assessed as being high risk for falls, had increased agitation and confusion, repeated episodes of getting out of bed, and ambulating in Resident 1's room unassisted. 2. Ensure LVN 1 revised Resident 1's untitled care plan for falls and implemented new interventions to prevent Resident 1 from further falls and injuries. These violations resulted in Resident 1’s second fall on 6/24/2024 at 2:15 AM, about an hour after the first fall. As a result of the second fall, Resident 1 sustained a moderately displaced fracture (bone breaks into two or more pieces and move out of alignment) and mildly impacted fracture (occurs when the broken ends of the bone are jammed together by force of the injury) at the neck of the left subcapital femur (neck of the thigh bone). Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) 2 on 6/24/2024 at 3:08 AM for further evaluation and had a left hip hemiarthroplasty (a type of partial hip replacement surgery that involved replacing half of the hip joint) on 7/1/2024. A review of Resident 1's Admission Record (AR), indicated the facility admitted Resident 1, a 75-year-old female, to the facility on 6/7/2024, with diagnoses that included traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain due to injury) without loss of consciousness, Covid-19 (minor to severe respiratory illness caused by a virus and spread from person to person), fall (on)(from) other stairs and steps, and other abnormalities of gait and mobility. A review of Resident 1's Fall Risk Evaluation, dated 6/7/2024, the Fall Risk Evaluation indicated Resident 1 was at high risk for falls. A review of Resident 1's History and Physical Examination, dated 6/8/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's untitled Care Plan (CP), initiated on 6/7/2024, and revised on 6/9/2024, indicated Resident 1 was at high risk for falls due to confusion, gait/balance problems, psychoactive drug (medication that affects behavior, mood, thoughts, or perception) use, unawareness of safety needs, and history of falls. The CP interventions included for staff to anticipate and meet Resident 1's needs, review information on past falls and attempt to determine cause of falls, record possible root causes, and alter/remove any potential causes of falls if possible. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 6/11/2024, indicated Resident 1 had severely impaired cognition. The MDS indicated, Resident 1 normally used a walker and wheelchair. The MDS indicated Resident 1 required substantial/maximal assistance for toileting hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 1 required substantial/maximal assistance for rolling left and right on the bed, lying to sitting on side of the bed, sitting to standing, and walking 10 feet. The MDS indicated Resident 1 had a fall in the last month prior to admission to the facility. A review of Resident 1's Situation-Background-Assessment-Recommendation Summary for Providers (SBAR Summary), dated 6/24/2024, timed at 1:34 AM, indicated on 6/24/2024, untimed, CNA 1 found Resident 1 sitting on the floor (in Resident 1's room) in an upright position with her back against the wall and her legs straight out. The SBAR Summary indicated Resident 1 had no injuries and denied any pain. The SBAR Summary indicated two staff members (unidentified) assisted Resident 1 back to bed. The SBAR Summary indicated Resident 1's bed remained in the lowest position. The SBAR Summary indicated Resident 1's primary care provider recommended neurological checks (assesses level of consciousness, movement, hand grasp, pupil reaction, speech, and vital signs) and frequent visual checks. A review of Resident 1's Nursing Progress Notes (NPN), dated 6/24/2024, timed at 2:43 AM, indicated on 6/24/2024, at 1:20 AM, Resident 1 had an unwitnessed fall in Resident 1's room. The NPN indicated CNA 1 found Resident 1 sitting on the floor in front of Resident 1's bed with Resident 1's back against the wall and near the window. The NPN indicated Resident 1 could not say what happened. A review of the same NPN, dated 6/24/2024, timed at 2:43 AM, indicated on 6/24/2024, at 2:15 AM, Resident 1 had a second fall. The NPN indicated Resident 1's roommate (Resident 3) was calling for help. The NPN indicated CNA 1 found Resident 1 sitting on the floor in an upright position near Resident 3's bed. The NPN indicated Resident 1 had laceration on the left part of Resident 1's head and blood on her arm and gown. The NPN indicated Resident 1 stated Resident 1 fell on "something" but was unsure of what it was. The NPN indicated Resident 1 did not complain of any pain or discomfort. The NPN indicated LVN 1 called for emergency transport due to head injury. A review of Resident 1's GACH 2 Emergency Medicine Report (EMR), dated 6/24/2024, timed at 3:08 AM, indicated Resident 1was brought in by ambulance for contusion (injury to the soft tissue often produced by a blunt force such as a kick, fall, or blow) after falling out of the bed. The EMR indicated Resident 1 complained of six out of 10 pain (0 = no pain and 10 = the worst pain) to her left hip. The EMR indicated Resident 1 would be admitted to GACH 2 for further care and evaluation. A review of Resident 1's GACH 2 Hip and Pelvis X-ray Report of Resident 1's left hip, dated 6/24/2024, timed at 4:15 AM, indicated Resident 1 had a moderately displaced left femoral subcapital neck fracture. A review of Resident 1's GACH 2 Computed Tomography Scan Report of Resident 2's left hip, dated 6/24/2024, timed at 8:47 AM, indicated Resident 1 had a moderately displaced fracture and mildly impacted fracture at the neck of the left subcapital femur. A review of Resident 1's GACH 2 Discharge Summary, dated 7/9/2024, indicated Resident 1 had a left hip hemiarthroplasty for femoral neck fracture on 7/1/2024. During an interview on 7/19/2024 at 12:15 PM, the Director of Rehabilitation (DOR) stated Resident 1 was unsteady and used a walker for ambulation. The DOR stated Resident 1 required "a lot of cueing (to provide a hint or prompt for an action)," but able to follow directions. During a telephone interview on 7/19/2024 at 1:07 PM, CNA 1 stated on 6/23/2024, at 11 PM, Resident 1 was very confused and could not sleep. CNA 1 stated on 6/24/2024, unable to recall time, CNA 1 had to sit by Resident 1's room door because Resident 1 kept getting out of bed. CNA 1 stated on 6/24/2024, at "around 1:30 AM", CNA 1 found Resident 1 sitting on Resident 1's buttocks on the floor, close to Resident 1's bed. CNA 1 stated on 6/24/2024, after the first fall that occurred at 1:20 AM, unable to recall exact time, CNA 1 was in another resident's room, opposite Resident 1's room, when Resident 1 had a second fall. CNA 1 stated CNA 1 heard a loud sound and before CNA 1 entered Resident 1's room, CNA 1 saw Resident 1 on the floor by Resident 1's room door. CNA 1 stated CNA 1 notified LVN 1. CNA 1 stated LVN 1 did not provide CNA 1 with any specific instructions to increase supervision/monitoring of Resident 1 after Resident 1's first fall (on 6/24/2024 at 1:20 AM). On 7/22/2024 at 10:55 AM and 11:31 AM, attempts were made to contact LVN 1, however LVN 1 did not answer or return the call. During a follow-up telephone interview on 7/22/2024 at 12:21 PM, CNA 1 stated on 6/23/2024, at 11 PM, CNA 1 found Resident 1 walking unassisted to Resident 1's bathroom. CNA 1 stated CNA 1 assisted Resident 1 to the bathroom then put Resident 1 back to bed. CNA 1 stated a few minutes after, CNA 1 heard Resident 1 getting up from Resident 1's bed. CNA 1 stated CNA 1 asked Resident 1 what Resident 1 needed but Resident 1 did not say anything. CNA 1 stated Resident 1 was confused and CNA 1 redirected Resident 1 back to Resident 1's bed. CNA 1 stated (on 6/24/2024, at 1:20 AM), Resident 1 got up from Resident 1's bed unassisted for the third time and fell. CNA 1 stated CNA 1 was sitting in the hallway monitoring the call lights when Resident 1 fell the first time on 6/24/2024 at 1:20 AM. CNA 1 stated CNA 1 could not see inside Resident 1's room from the hallway where CNA 1 was sitting. During an interview on 7/22/2024 at 2:07 PM, the Director of Nursing (DON) stated (on 6/24/2024), Resident 1 was having increased confusion, agitation, and kept getting out of bed. The DON stated due to Resident 1's agitation and episodes of getting out of bed, the staff (CNA 1 and LVN 1) needed to increase supervision/monitoring of Resident 1 from every two hours to every hour, elevate to every 15 minutes, or have CNA 1 stay with Resident 1 as needed for Resident 1's safety. The DON stated LVN 1 needed to revise Resident 1's care plan and add new interventions after the first fall to help prevent the second fall and injuries. The DON stated CNA 1 needed to notify LVN 1 when CNA 1 had to help another resident so LVN 1 could have monitored Resident 1. On 7/30/2024 at 8:55 AM, an attempt was made to contact LVN 1, however LVN 1 did not answer or return the call. A review of the facility's P&P titled, "Safety and Supervision of Residents," revised 7/2017, indicated resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. The P&P indicated the facility's individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The P&P indicated the facility analyzed information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The P&P indicated the care team targeted interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P&P indicated implementing interventions to reduce accident risks and hazards included communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, and ensuring that interventions were implemented. The P&P indicated monitoring the effectiveness of interventions shall include ensuring that interventions were implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed and evaluating the effectiveness of new or revised interventions. The P&P indicated resident supervision was a core component of the systems approach to safety. The type and frequency of supervision may vary among residents and over time for the same residents. The P&P indicated for example, resident supervision may need to be increased when there was a change in the resident's condition. A review of the facility's P&P titled, "Falls and Fall Risk, Managing," revised 3/2018, indicated based on previous evaluations and current data, the staff identified interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P indicated if the resident continued to fall, staff re-evaluated the situation and whether it was appropriate to continue or change current interventions. The P&P indicated if falling recurred despite initial interventions, staff implemented additional or different interventions, or indicate why the current approach remained relevant. The facility failed to provide care and services to prevent a fall for Resident 1 as indicated in the facility's P&P titled, "Safety and Supervision of Residents," and "Falls and Fall Risk, Managing." The facility failed to: 1. Ensure Certified Nursing Assistant 1 and/or Licensed Vocational Nurse 1 provided supervision/monitoring to prevent a fall on 6/24/2024 at 1:20am when Resident 1, who was assessed as being high risk for falls, had increased agitation and confusion, repeated episodes of getting out of bed, and ambulating in Resident 1's room unassisted. 2. Ensure LVN 1 revised Resident 1's untitled care plan for falls and implemented new interventions to prevent Resident 1 from further falls and injuries. These violations resulted in Resident 1’s second fall on 6/24/2024 at 2:15 AM, about an hour after the first fall. As a result of the second fall, Resident 1 sustained a moderately displaced fracture and mildly impacted fracture at the neck of the left subcapital femur. Resident 1 was transferred and admitted to GACH 2 on 6/24/2024 at 3:08 AM for further evaluation and had a left hip hemiarthroplasty on 7/1/2024. 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.