Health inspection·March 22, 2023

F689 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. California Code of Regulations, Title 22, Section 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (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. On 2/3/2023 at 1:45 pm, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a Facility Reported Incident regarding quality of care and treatment of Patient 1.   As a result of the investigation, the CDPH determined the facility failed to provide care and services to prevent a fall for Patient 1 by failing to: 1. Provide supervision and a functioning sensor pad alarm (an assistive electronic device that makes a loud sound to warn caregivers when the Patient attempts to stand up from the bed or the wheelchair) to prevent a fall for Patient 1, who was assessed at high risk for falls as required by the care plan for falls. 2. Ensure Licensed Vocational Nurse 1 (LVN 1) and Certified Nursing Assistant 1 (CNA 1) monitored the working condition of Patient 1's sensor pad alarm on 1/22/2023 while Patient 1 was sitting on the wheelchair per the facility's policy titled "Personal Alarm," and Patient 1's "Care Plan for Fall." 3. Ensure CNA 1 kept Patient 1 within her visual field (area of space that a person can see) on 1/22/2023 per Patient 1's nursing intervention in Patient 1's "Care Plan for Fall." As a result, on 1/22/2023, at 1:55 pm, Patient 1 got up from the wheelchair unnoticed by staff, fell from the wheelchair, and sustained a fracture (broken bone) on the left hip. Patient 1 required transfer to a General Acute Care Hospital (GACH) via emergency services where Patient 1 underwent surgery on 1/23/2023 to repair a left hip fracture. A review of Patient 1's Admission Record indicated the facility admitted an eighty-nine-year-old-female on 11/1/2016, and readmitted Patient 1 on 9/12/2022, with diagnoses that included dementia (loss of memory and other mental abilities severe enough to interfere with daily life), and hypertension (the force of blood flowing through the blood vessels, is consistently too high). A review of Patient 1's Care Plan for Fall, dated 10/5/21, indicated Patient 1 required the use of a sensor pad alarm when Patient 1 was sitting in a wheelchair and in bed to alert staff of unassisted transfer (moves between surfaces including to or from bed, chair, wheelchair) to prevent a fall incident. The nursing interventions included to use a sensor pad alarm, keep Patient 1 within visual field, monitor the alarm for good working condition, proper placement, and to respond promptly to Patient 1 once the alarm activated. A review of Patient 1's Fall Risk Assessments, dated 9/12/2022 and 12/15/2022, indicated Patient 1 was at high risk for falls due to having a history of falls in the last twelve months, unsteady gait, poor sitting or standing balance, and inability to stand without assistance. A review of Patient 1's Physician Orders, dated 10/13/2022, timed at 10:05 am, indicated to apply a pad alarm when Patient 1 was on a wheelchair and in bed to alert staff of unassisted transfers. A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/15/2022, indicated Patient 1 had severely (very seriously) impaired cognition (ability to think and reason). The MDS indicated Patient 1 required extensive assistance (staff provide weight bearing support) with transfers, and with locomotion on the unit (how the Patient moves between locations in his/her room and adjacent corridor on the same floor) with one-person physical assist. A review of Patient 1's Change of Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) Assessment notes, dated 1/22/2023, at 1:55 pm, indicated a C(unidentified) reported Patient 1 fell out of the wheelchair onto the floor in the hallway. The notes indicated Patient 1 cried out in pain that the left hip was injured. The notes indicated LVN 2 notified Patient 1's physician (MD 1) of Patient 1's fall incident. The notes indicated MD 1 ordered a STAT (immediately) x-ray (a test that produces images of the structures inside the body such as the bones) of the left femur (thigh bone) and left hip. A review of Patient 1's Radiology Results Report (official record of medical images that contains the interpretations and images), dated 1/22/2023, timed 8:15 pm, indicated Patient 1 sustained a left femoral intertrochanteric fracture (broken thigh bone). A review of Patient 1's Licensed Nurse Progress Notes, dated 1/22/2023, timed at 9:28 pm, indicated the facility transferred Patient 1 via "911," (paramedic transport) to a GACH due to left femur fracture and pain (unrated). A review of Patient 1's Orthopedic Operative Report from GACH, dated 1/23/2023, indicated Patient 1 sustained a ground level fall (begins when a person has his or her feet on the ground) and was found to have an intertrochanteric left hip fracture. The report indicated Patient 1's operative limb (leg) was slightly abducted (away from the midline) and internally rotated (rotation towards the center of the body) and had longitudinal traction (leg by contact between the skin and adhesive tape, to maintain the proper alignment of a leg fracture) placed to achieve a satisfactory reduction (surgery of the bone). The report indicated Patient 1 underwent a general endotracheal anesthesia (introduction of a gaseous mixture to keep the Patient from felling pain through a tube inserted into the trachea [windpipe]) for intramedullary nailing (a metal rod is inserted into the innermost part of the bone) of left intertrochanteric hip fracture operation on 1/23/2023. During an observation and interview on 2/3/2023 at 2:35 pm, Patient 1 was awake and had difficulty standing up. Patient 1 stated she did not remember how she sustained a left hip fracture. During an interview on 2/3/2023 at 3:32 pm and a concurrent review of the facility's Investigation of Incident/Accident, dated 1/26/2023, the Director of Nursing (DON) stated she conducted the investigation of Patient 1's fall incident on 1/22/2023. The DON stated CNA 1 reported Patient 1 had a sensor pad alarm in the wheelchair, but the sensor pad alarm did not go off when Patient 1 stood up then fell onto the floor in the hallway. The DON stated there was no documented evidence that the facility's nursing staff monitored and checked Patient 1's sensor pad alarm for proper functioning every day and on 1/22/2023. During an interview on 2/3/2023 at 3:40 pm, LVN 1 stated on 1/22/2023, at 1:55 pm, CNA 1 reported to her that Patient 1 fell out of the wheelchair in the hallway. LVN 1 stated CNA 1 informed LVN 1 Patient 1's sensor pad alarm did not go off when Patient 1 attempted to stand up unassisted from the wheelchair. LVN 1 stated CNA 1 told LVN 1 that her (CNA 1's) back was turned away from Patient 1 since she was monitoring other Patients (unidentified). LVN 1 stated she did not check Patient 1's sensor pad alarm for proper functioning on 1/22/2023. During a telephone interview on 2/3/2023 at 4:25 pm, CNA 1 stated on 1/22/2023 from 1:45 pm through 2 pm, she was assigned to monitor ten Patients (unidentified) including Patient 1. CNA 1 stated Patient 1 was sitting in the wheelchair in the hallway. CNA 1 stated after she checked Patient 1's sitting position, she turned her back and walked away from Patient 1 to check other Patients (unidentified). CNA 1 stated while she was walking towards another Patient (unidentified) who was sitting in the wheelchair across the nursing station, five feet away from Patient 1, she heard a loud yelling and groaning sound of pain. CNA 1 stated when she turned around, she saw Patient 1 was already down on the floor. CNA 1 stated she was not aware Patient 1 had attempted to stand up from the wheelchair because Patient 1's sensor pad alarm did not go off. CNA 1 stated she did not check Patient 1's sensor pad alarm for proper functioning on 1/22/2023. CNA 1 stated, "I should be looking at the Patients the whole time to prevent a fall from the wheelchair." A review of the facility's undated policy and procedure titled, "Personal Alarm," indicated nursing staff will monitor proper functioning and positioning of personal alarm and check the alarm system every day for proper functioning. The policy indicated the facility would use a sensor pad alarm that would sound an audible alarm when the sensor detects a Patient was rising out of the bed or wheelchair reminding the Patient to return to a safe position while alerting staff to a potential fall. As a result of the investigation, the CDPH determined the facility failed to provide care and services to prevent a fall for Patient 1 by failing to: 1. Provide supervision and a functioning sensor pad alarm to prevent a fall for Patient 1, who was assessed at high risk for falls. 2. Ensure LVN 1 and CNA 1 monitored the working condition of Patient 1's sensor pad alarm on 1/22/2023 while Patient 1 was sitting on the wheelchair per the facility's policy on "Personal Alarm," and Patient 1's "Care Plan for Fall." 3. Ensure CNA 1 kept Patient 1 within her visual field on 1/22/2023 per Patient 1's nursing intervention in Patient 1's "Care Plan for Fall." As a result, on 1/22/2023, at 1:55 pm, Patient 1 got up from the wheelchair unnoticed by staff, fell from the wheelchair and sustained a fracture on the left hip. Patient 1 required transfer to a GACH via emergency services where Patient 1 underwent a surgery on 1/23/2023 to repair a left hip fracture. The above violations jointly, separately, or in any combination, 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.