Health inspection·March 23, 2023

F 656 Code of Federal Regulations §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. §483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (iii) Be culturally competent and trauma informed. California Code of Regulations, Title 22 § 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. (1) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. On 2/6/23, at 9:30 AM, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint and an entity reported incident regarding quality of care and treatment of Patient 1. As a result of the investigation, the CDPH determined the facility failed to develop and implement a patient-centered comprehensive care plan to prevent a fall for Patient 1, who had blindness on both eyes (visual impairment/unable to see) and a history of falls by failing to: Ensure the Interdisciplinary Team (IDT, a team of health care professionals who work together to establish plans of care for the patients) met and updated Patient 1's Fall Care Plan as indicated in the facility's policy and procedure, titled "Falls - Assessing Falls and Their Causes," after Patient 1 fell on 12/26/2023, 1/6/2023, and 1/13/2023. As a result, Patient 1 sustained multiple falls (12/26/2023, 1/6/2023, 1/13/2023, and 1/15/2023,) in the facility and was hospitalized due to injuries sustained from the falls. On 1/15/2023, the facility transferred Patient 1 to General Acute Care Hospital (GACH) 1's Emergency Department (ED) due to head trauma (damage to the scalp, skull, or brain caused by injury) and cephalohematoma (an accumulation of blood under the scalp). A review of Patient 1's Admission Record indicated the patient was a 79 year-old female and was admitted to the facility on 12/21/2022 with diagnoses that included unsteadiness on feet, muscle weakness, blindness on both eyes, and a history of falling at home. A review of Patient 1's Physician Progress Notes, dated 12/22/2022, at 9:01 PM, indicated Patient 1 had a fall with head injury from the previous admission (10/25/2022). The note indicated Patient 1 lost 80 percent of her eyesight. A review of Patient 1's Falls Care Plan, initiated on 12/22/2022, indicated Patient 1 was at high risk for falls related to unsteady (unable to stabilize without staff assistance) gait (walk), decreased mobility (ability to move), and activity intolerance. The goal was for Patient 1 to not sustain serious injury. The nursing interventions included to anticipate Patient 1's need and provide prompt response to all requests for assistance, provide appropriate footwear when walking, ensure the call light was within reach and encouragement for Patient 1 to use it. A review of Patient 1's Care Conference (IDT meeting note), dated 12/23/2022, indicated Patient 1 had unsteady gait and remained a fall risk due to visual impairment. There was no indication that the IDT discussed falls and interventions to prevent falls due to unsteady gait and visual impairment. A review of Patient 1's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 12/27/2022, indicated Patient 1 had severe impaired cognition (ability to think and process information). The MDS indicated Patient 1 had impaired vision. Patient 1 required extensive physical assistance during toilet use and limited physical assistance from one person when walking in the room. The MDS indicated Patient 1 was not steady when moving from seated to standing position and when walking with a walker. A review of Patient 1's Morse Fall Risk Assessments (MRS, the Morse Fall Scale is a rapid and simple method of assessing a patient's likelihood of falling), dated 12/26/2022, indicated the Patient 1 was at high risk for falls due to a history of falling, use of walker, weakness when walking, and overestimating or forgets her limits. Patient 1 scored 80 points (a score of 45 or higher means high risk for falls). A review of Patient 1's Progress Note - Change in Condition, dated 12/26/2022, timed at 4:15 PM, indicated Patient 1 experienced an unwitnessed fall and was found sitting on the floor next to the patient's walker. The note indicated Patient 1 required frequent visual monitoring due to periods of confusion and forgetfulness. Patient 1 required encouragement to use the call light, and prompt anticipation to attend to the patient's needs. A review of Patient 1's Situation Background Assessment and Recommendation (SBAR, communication record between members of the health care team) Communication Form, dated 1/6/2023, untimed, indicated Patient 1 sustained a fall. The form indicated Patient 1 had activity intolerance but overestimated her own limits. Patient 1 did not use the walker and used furniture to hold on while walking. Patient 1 was unable to walk more steps to the bathroom and decided to sit down slowly on the floor. Patient 1 complained of lower back pain (not rated). The form indicated Patient 1 required more assistance (not indicted type of assistance) with activities of daily living (ADL, activities related to personal care such dressing, eating and personal hygiene). A review of Patient 1's Actual Fall Care Plan, initiated on 1/6/23, indicated Patient 1 had an actual fall related to an unsteady gait, poor balance, and activity intolerance. The goal was for Patient 1 to resume usual activities. Nursing interventions included to monitor Patient 1 for changes in mental status and to determine and address causative factor of the fall. A review of Patient 1's SBAR Communication Form, dated 1/13/2023, timed at 12:03 AM, indicated Patient 1 was found lying on the floor, on her right side, next to the patient's bed and walker. Patient 1 reported that she slid off her bed and lost balance when trying to get up to go to the bathroom. Patient 1 complained of body pain (unrated). Licensed Vocational Nurse 2 (LVN 2) notified Patient 1's Physician (MD 1, Doctor of Medicine), MD 1 ordered STAT (rush/immediate) X-rays (image study of the bones and soft tissue) of the right shoulder and hip to rule out fractures (breaking). The X-ray results were negative for fractures. A review of Patient 1's SBAR Communication Form, dated 1/15/2023, timed at 11:44 PM, indicated Patient 1 was found sitting on the floor with bleeding on the left ring finger, hematoma (a collection of blood outside of the vessels, a bad bruise) on the back of the head, and bruising on both buttocks. Patient 1 was sent out to the hospital via ambulance (911, phone number to call for emergency services). A review of Patient 1's GACH 1's Emergency Documentation, dated 1/16/2023, timed at 12:22 AM, indicated Patient 1 was admitted from the facility after sustaining a fall with a cephalhematoma to the left occiput (back of the head or skull). Patient 1 stated, she was walking with her walker and had a fall. The documentation indicated Patient 1 had several falls in the past, was on blood thinner medication, and had an obvious head injury. The Computed Tomography (CT, medical imaging used to obtain detailed internal images of the body) result was negative for a brain bleed. The diagnoses included head injury and cephalohematoma. A review of Patient 1's Nurse Progress Notes, dated 1/16/2023, at 10:02 AM, indicated Patient 1 returned to the facility from GACH 1 after sustaining a fall. The note indicated Patient 1 was stable with diagnosis of cephalohematoma on the left parietal (forming part of the top and side of the head) area. The note indicated Patient 1's skin was intact, had multiple bruises on the lower back, and multiple discolorations on both legs. A review of Patient 1's Admission Discharge Census List, dated 2/6/2023, indicated Patient 1 was discharged from the facility at 8:40 PM. During an interview on 2/8/2022, at 8:50 AM, the Director of Nursing (DON) stated the IDT did not meet after Patient 1's falls. The DON stated the fall care plan had to be updated after each fall and stated care plans were a guide for nurses to follow. The DON stated care plans had to be specific, detailed, and not be generalized due to every patient being unique. During a concurrent interview on 2/8/2023, at 9:06 AM, with the DON and a review of Patient 1's Fall Care Plans, dated 12/22/2022, 1/6/2023, and the IDT meeting note, dated 12/23/2022, the DON stated Patient 1 was admitted to the facility with a history of multiple falls and was legally blind (20/200 visual acuity, a person can see at 20 feet, what a person with 20/20 vision sees at 200 feet). The DON stated Patient 1's Fall Care Plan and IDT note did not include interventions to prevent recurrent falls. The DON stated the IDT did not meet after Patient 1 fell on 12/26/2023, 1/6/2023, and 1/13/2023. The DON stated the IDT had to meet after every fall to discuss and find the root cause of the falls. The DON stated if the IDT met and addressed the falls, future falls could have been prevented for Patient 1. The DON stated Patient 1's Actual Fall Care Plan, created on 1/6/2023, did not include person-centered interventions to address the root cause of the fall. A review of the facility's policy and procedure, titled, "Care Planning - Interdisciplinary Team," revised 3/2022, indicated the IDT is responsible for the development of patient care plans. Comprehensive, person-centered care plans are based on patient assessments and developed by the IDT. A review of the facility's policy and procedure, titled, "Care Plan, Comprehensive Person-Centered," revised 3/2022, indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the patient's physical, psychosocial, and functional needs is developed and implemented for each patient. The policy indicated assessments of patients are ongoing and care plans are revised as information about the patient's condition changes. The IDT reviews and updates the care plan when there has been a significant change in the patient's condition. A review of the facility's policy and procedure, titled, "Falls - Managing Fall Risk," dated 10/1/2022, indicated fall risk factors included: cognitive impairment, lower extremity (legs) weakness, and visual deficits. A review of the facility's policy and procedure, titled, "Falls - Assessing Falls and Their Causes," dated 10/01/2022, indicated the purpose of the policy was to provide guidelines for assessing a patient after a fall and to assist the staff in identifying causes of the falls. As a result of the investigation, the CDPH determined the facility failed to develop and implement a patient-centered comprehensive care plan to prevent a fall for Patient 1, who had blindness on both eyes and a history of falls by failing to: Ensure the IDT met and updated Patient 1's Fall Care Plan as indicated in the facility's policy and procedure, titled "Falls - Assessing Falls and Their Causes," after Patient 1 fell on 12/26/2023, 1/6/2023, and 1/13/2023. As a result, Patient 1 sustained multiple falls in the facility and was hospitalized due to injuries sustained from the falls. On 1/15/2023, the facility transferred Patient 1 to GACH 1's ED due to head trauma and cephalohematoma. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.