Other·November 3, 2022

FCR- §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. 22 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. (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. (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. 22 CCR §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 10/13/2021, the California Department of Public Health conducted an unannounced visit at the facility to investigate a Facility Reported Incident regarding quality-of-care and patient safety related to falls. The Facility Reported Incident indicated that on 10/2/2021, at 11 :25 pm, Patient 1 fell from the wheelchair and sustained a fracture of the right hip. As a result of the investigation, the Department determined that the facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) provided interventions, to calm Patient 1 while the patient was agitated and had been self-propelling her wheelchair throughout the facility, for licensed nurse and certified nursing assistant staff (in general) to monitor Patient 1 during all out of bed activities and visually check patient every 2 hours and as necessary, for Patient 1 to use a silent wheelchair alarm (chair sensor and operate through detecting a reduction of pressure that allows a caregiver to monitor the activity of a sitting patient), and to have the patient sit at the nursing station as indicated in Patient 1’s Care Plan Interventions. 2. Follow the facility’s policy and procedure on Fall Management when LVN1 failed to implement interventions to prevent the fall for Patient 1. 3. Ensure Certified Nursing Assistant 2 (CNA 2) checked Patient 1’s wheelchair alarm and supervised the patient while the patient was using the wheelchair as indicated in the patient’s Fall Care Plan. As a result of these failures, on 10/2/2021, Patient 1 sustained a fall, and was admitted to a General Acute Care Hospital (GACH) due to right hip pain after falling from the wheelchair. Patient 1 had a fracture of the proximal (closer to body) right femur (hip or thigh bone). On 10/5/2021, Patient 1 underwent surgery with closed reduction and screw fixation to the right hip. A review of Patient 1’s Admission Record indicated the facility initially admitted the patient on 10/19/2012 and readmitted the patient on 10/06/2021. Patient 1 was an 86-year-old female with diagnoses of heart failure (condition where the heart cannot pump enough blood to meet the body's needs), chronic obstructive pulmonary disease (COPD, a progressive lung disease that makes it hard to breathe), dementia (loss of intellectual functioning), and bipolar disorder (a mental condition marked by alternating periods of elation and depression). A review of Patient 1’s History and Physical (H&P), dated 5/02/2020, indicated the Patient 1 did not have the capacity to make decisions. A review of Patient 1’s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/06/2021, indicated Patient 1 has severely impaired cognition (ability to think and reason). Patient 1 required extensive assistance (staff provide patient with weight-bearing support) with one-person physical assist for bed mobility, transfer, toilet use, and was totally dependent with one-person physical assist for locomotion on unit (how patient moves between locations in her room and adjacent corridor on same floor) and locomotion off unit (how patient moves to and returns from off-unit locations (areas set for dining, activities, or treatments). The MDS indicated Patient 1 was using a bed and chair alarm (any physical or electronic device that monitors patient movement and alerts the staff when movement is detected) daily. A review of Patient 1’s Interdisciplinary Notes (IDN), dated 8/11/2021 through 10/2/2021, indicated Patient 1 was agitated or combative and scooting in the hallway or attempting to elope (go out of facility) on 8/11/2021, 8/13/2021, 8/14/2021, 8/19/2021, 9/06/2021, 9/11/2021, 9/22/2021, 9/25/2021, 9/29/2021, 9/30/2021, and 10/2/2021. A review of Patient 1’s Post Fall Assessment, dated 10/2/2021, indicated the patient’s mental status as wanders (walk without any clear purpose or direction), with behavior at time of fall as agitated, and fall prevention in place as bed/wheelchair alarm. A review of Patient 1’s Situation Background Assessment and Recommendation, dated 10/2/2021, indicated Patient 1’s mental status as worsening behavioral symptoms. A review of Patient 1’s Interdisciplinary Team Conference Record, dated on 10/2/2021, indicated prior to Patient 1’s fall, Patient 1 was agitated and pacing through the hallways via wheelchair. A review of Patient 1’s Falls Care Plan, with a revised date of 10/2/2021, indicated Patient 1 fell on 2/11/2021, 3/21/2021, 8/3/2021, 9/22/2021 and 10/2/2021. The Care Plan interventions included for licensed nurse and certified nursing assistant staff (in general) to monitor Patient 1 during all out of bed activities and visually check patient every 2 hours and as necessary. The care plan indicated for Patient 1 to use a silent wheelchair alarm (chair sensor and operate through detecting a reduction of pressure that allows a caregiver to monitor the activity of a sitting patient), and to have the patient sit at the nursing station. A review of Patient 1’s GACH Emergency Department Physician Notes, dated 10/2/2021, indicated Patient 1’s chief complaint was right hip pain after falling from her wheelchair and the X-ray of the right hip indicated right femur (thigh bone) fracture. A review of Patient 1’s GACH 1 Progress Notes, dated 10/5/2021, indicated Patient 1 underwent internal screw fixation to the right hip. A review of the facility’s Investigation Report, dated 10/6/21, indicated on the afternoon of 10/02/2021, Patient 1 was observed on the floor with her wheelchair positioned in front of her. Patient 1 complained of pain on her right side, facility called 911, and the paramedics came to assess the patient and transferred the patient to a GACH Emergency Room (ER). The X-ray showed Patient 1 had a hip fracture and was scheduled for surgery. On 10/6/21, the patient returned to the facility for rehabilitative services following right hip surgery. During a concurrent observation and interview with Patient 1, on 10/13/2021 at 10:13 PM, the patient was sitting on a wheelchair. Patient 1 was alert to name but was unable to answer simple questions. During an interview with CNA 1, on 10/13/2021, at 2:22 PM, CNA 1 stated Patient 1 was confused and a high risk for falls. CNA 1 stated Patient 1 had a behavior of scooting off on her wheelchair, back and forth, along the hallway when she was agitated. During an interview with the Assistant Administrator 2 (ADM 2), on 10/14/2021, at 2:22 pm, ADM 2 stated on 10/2/21 after 1 pm, Patient 1, was found lying on the floor beside her wheelchair. ADM 2 stated there was no one with the patient. ADM 2 demonstrated how the patient laid on the floor and stated Patient 1 was lying on the right side with her head toward the front door and feet toward the back of the building. During a telephone interview with CNA 2, on 10/14/2021, at 2:50 pm, CNA 2 stated on 10/2/2021, after 1 pm, she heard someone scream in the hallway. CNA 2 stated Patient 1 was lying on the floor with ADM 2 near the patient and there was no other staff beside ADM 2 at the scene. CNA 2 stated Patient 1 was lying on the floor, but she did not hear the alarm at the time of the fall. During an interview with LVN 1 on 10/14/2021 at 3:35 PM, LVN 1 stated she was not aware of Patient 1’s fall risk or that the patient had wandered in the facility in wheelchair until after Patient 1 fell on 10/2/2021. LVN 1 also stated Patient 1 was trying to get out of the facility because Patient 1 told LVN 1 earlier in the day that the facility tried to keep Patient 1 locked up. LVN 1 stated Patient 1 scooted away from the nursing station, she found Patient 1 in another patient's room, and took the patient 1 back to her room. During an interview with LVN 1 on 10/14/2021 at 3:40 pm, LVN 1 stated the wheelchair alarm did not go off at the nursing station. During an interview with the Registered Nurse Supervisor (RNS), on 10/14/2021, at 3:55 pm, the RNS stated she was aware of Patient 1's behavior of pacing up and down the hallway on her wheelchair. The RNS stated Patient 1 went back and forth from the nurses' station to her own room. The RNS stated Patient 1 conversed but was confused. During an interview with CNA 3, on 10/14/2021, at 4:50 pm, CNA 3 stated, when agitated, Patient 1, scoots in the wheelchair to the nursing station and through the hallway. CNA 3 stated on 10/2/21 after lunch, CNA 3 witnessed the fall while Patient 1 was scooting with her wheelchair in the hallway and Patient 1 slid off from the wheelchair in the hallway. During an interview with the Director of Nursing (DON), on 10/14/2021 at 5:15 pm, the DON stated Patient 1 often goes up and down the hallway with a wheelchair. The DON stated Patient 1 had a known behavior of wandering. The DON stated Patient 1 wanders when agitated. The DON stated there was no one in the hallway when Patient 1 fell, and ADM 2 may have been doing other responsibilities when Patient 1 came into the front lobby and fell. The DON stated that the wheelchair and bed pad alarms were checked and tested by the Restorative Nursing Assistant (RNA) daily and that it was important that the alarm functioned so when it goes off, staff will be alerted to check the patients. During a concurrent record review and an interview with the DON, on 10/19/2021 at 5:20 pm, a review of the facility’s “Function Check Wheelchair and Bed Alarm log”, dated September 2021 and October 2021, indicated Patient 1’s wheelchair alarm was checked on September 18, 2021, and October 1, 2021. The DON stated the alarm was not checked daily nor prior to being used on 10/2/2021. The DON stated Patient 1 fell out from the wheelchair. The DON stated the facility does not have a policy or procedure for staff to check pad alarms prior to each use. A review of the Bed Alarm Log indicated the alarm should be checked daily. A review of Patient 1's Physician Order Summary Report, dated 10/06/ 2021, indicated Patient 1 needed to use a silent bed and chair (sensor) alarm daily, floor mats on each side of bed to prevent falls or injury, and to keep the bed low when Patient 1 is in bed. A review of the facility Policy and Procedure (P&P) titled “Falls Management Program,” dated June 2016, indicated the facility was to use a multidisciplinary approach to falls, to monitor a patient’s risk of falling to reduce the frequency and severity of a fall, and to implement measures that will help reduce fall frequency and injury severity. The P&P also indicated staff to proactively assess and direct efforts toward implementing person-centered fall care planning. The Facility Reported Incident indicated that on 10/2/2021, at 11 :25 pm, Patient 1 fell from the wheelchair and sustained a fracture of the right hip. As a result of the investigation, the Department determined that the facility failed to: 1. Ensure LVN 1 provided interventions, to calm Patient 1 while the patient was agitated and had been self-propelling her wheelchair throughout the facility, for licensed nurse and certified nursing assistant staff to monitor Patient 1 during all out of bed activities and visually check patient every 2 hours and as necessary, for Patient 1 to use a silent wheelchair alarm and to have the patient sit at the nursing station as indicated in Patient 1’s Care Plan Interventions, 2. Follow the facility’s policy and procedure on Fall Management when LVN1 failed to implement interventions to prevent the fall for Patient 1. 3. Ensure CAN 2 checked Patient 1’s wheelchair alarm and supervised the patient while the patient was using the wheelchair as indicated in the patient’s Fall Care Plan. As a result of these failures, on 10/2/2021, Patient 1 sustained a fall, and was admitted to the GACH due to right hip pain after falling from the wheelchair. Patient 1 had a fracture of the proximal right femur. On 10/5/2021, Patient 1 underwent surgery with closed reduction and screw fixation to the right hip. The above violations 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 Patient 1.