Other·January 10, 2021

T22 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. 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. The facility’s Certified Nursing Assistant 1 (CNA 1) failed to use a gait belt (an assistive device which can be used to help safely transfer a person from a bed to a wheelchair, assist with sitting and standing, and help with walking around) to assist Resident 1, who was at risk for fall, had unsteady balance, and required extensive assistance from staff during transfers and toilet use, from the wheelchair onto the shower chair in the resident’s bathroom. As a result, Resident 1 sustained a fall and required a transfer to General Acute Care Hospital (GACH). Upon admission to the GACH, Resident 1 was moaning, groaning, not answering questions, had pain on the knee and the urinary catheter site. Resident 1 had nondisplaced (type of fracture in which the bone cracks in only one place and doesn't move to change alignment) C5 (fifth neck bone) fracture (broken). Resident 1 was readmitted to the facility, on 9/29/20, and had to wear a hard-cervical collar (a device to prevent neck movement). Three days after readmission to the facility (10/2/20), Resident 1 developed left sided weakness and left lower extremity numbness (inability to feel), had difficulty with fine motor control of both hands and difficulty with gait. On 10/8/20, Resident 1 developed new onset left sided hemiparesis (muscle weakness or partial paralysis on one side of the body). A review of the Admission Record indicated Resident 1 was originally admitted to the facility, on 9/5/2015 with diagnoses that included hypertension (high blood pressure), osteoarthritis (most common form of arthritis, protective cartilage that cushions the ends of your bones wears down over time), age-related osteoporosis (bone disease that occurs when the body loses too much bone, makes too little bone, or both), and cognitive (ability to understand, learn, remember and make decisions) impairment. A review of Resident 1's At Risk for Injury from Falls Care Plan, dated 3/21/19, indicated the resident had unsteady balance, on cardiac (heart) medications (medication not indicated) and possible side effects that can lead to falls and requires extensive transfer to use toilet. A review of Resident 1’s At Risk for Injury from Falls Care Plan initiated 6/17/19 and revised 3/26/20, indicated Resident 1 was at risk for falls with a history of falls, was forgetful with poor safety judgment, had unsteady balance, on heart medications with falls as a possible side effect, and required extensive assistance from staff during transfers and toilet use. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 6/17/2020, indicated Resident 1 was cognitively (ability to understand, remember and make decisions) intact, uses a wheelchair (wc) for mobility, was able to make self-understood, able to understand others, and required extensive assistance with one person physical assistance for surface transfer and toilet use. The MDS indicated that Resident 1’s Care Area Assessment (CAA) Summary indicated Resident 1 triggered for fall. A review of Resident 1’s Physical Therapist Progress Notes, dated 7/19/20, indicated Resident 1 can be transferred from bed to and from chair 76 percent (%) to 99 % maximum assistance from staff. The resident and staff training included safety education and fall risk precautions. A review of the Fall Risk Assessment, dated 9/23/20, indicated Resident 1 scored 10 (score of 10 and greater indicates high risk for fall). The same form indicated Resident 1 had balance problems when sitting, standing or walking, on antihypertensive (medication for blood pressure), on anticoagulant (blood thinner medication) and has osteoporosis (weak and brittle bones). A review of the Situation, Background, Assessment, Recommendation (SBAR) communication form dated 9/24/20, indicated Resident 1's change of condition included assisted fall and hematuria (blood in urine). The SBAR indicated Resident 1 was found on the floor in the bathroom in a sitting position with head resting on the shower chair. CNA 1 was trying to transfer Resident 1 back onto the wheelchair. Resident 1 was holding onto a side rail and got tired. CNA 1 sat the Resident 1 on the floor. A review of Resident 1's Licensed Nurses Progress Notes, dated 9/24/20 at 11:40 a.m., indicated CNA 1 was pulling the wheelchair when she noticed the resident going down and assisted Resident 1 to the floor. A review of Resident 1's Fall Scene Investigation (FSI) Report, dated 9/25/20, indicated the root cause of fall was due to Resident 1's poor balance and unsteadiness. The FSI report indicated CNA 1 trying to transfer Resident 1 to the wheelchair while Resident 1 was holding on the rail but got tired. CNA 1 assisted Resident 1 to sit on the bathroom floor. A review of Resident 1’s Licensed Nurses Progress Notes, dated 9/25/20 at 8:00 am., indicated Resident 1 was confused, yelling but unable to describe the reason. Resident 1 was asked if he was in pain and responded with incomprehensible words. A review of Resident 1’s Physician Telephone Order, dated 9/25/20 at 9:40 am., indicated an order to transfer Resident 1 to GACH emergency room for evaluation of altered level of consciousness (ALOC, a change in mental status). A review of the GACH's Internal Medicine H&P, date of service on 9/25/20 at 3:20 p.m. indicated Resident 1's chief complaint was altered mental status, fall, and urinary catheter problem. The H&P indicated the facility reported Resident 1 was noted moaning, groaning, not answering questions, was more altered and complained of pain on the knee and urinary catheter. The H&P indicated Resident 1’s CT (Computed Tomography, a scan that provides detailed information about the bones of the spine) Cervical Spine result indicated Resident 1 has nondisplaced (bone crack that not move and maintains its proper alignment) C5 (fifth neck bone) vertebrae (interlocking bones that form the spine. The injury can result in some or total paralysis of wrists, hands, trunk, and legs) fracture. Resident 1 had very slight drift (slow movement away from the normal or original position) of right arm. A review of Resident 1's GACH CT Cervical Spine study, dated 9/25/20 at 1:16 p.m., indicated Resident 1 had nondisplaced (type of fracture in which the bone cracks in only one place and doesn't move to change alignment) C5 fracture. A review of Resident 1’s Physician Telephone Orders, dated 9/29/20, indicated the facility re-admitted Resident 1 with diagnoses that included C5 vertebral fracture. The physician order indicated Resident 1 to have a hard-cervical collar applied. The hard-cervical collar was to be kept in place on Resident 1’s neck at all times. A review of Resident 1's MRI (Magnetic Resonance Imaging, uses a large magnet and radio waves to look at organs and structures inside a body) dated 10/2/20 in comparison with CT C-spine performed on 9/25/20, indicated Resident 1 had C5 to C6 focal (limited to one part of body) spinal stenosis (narrowing of the spaces within your spine). A review of Resident 1's Video Visit- Neurosurgery (surgery of the nervous system) Consultation Progress Notes, dated 10/2/20, indicated Resident 1 had cervical fracture with evidence of possible cord (spinal cord) contusion (bruise) on the MRI. Resident 1 had left sided weakness and left lower extremity numbness (inability to feel) and was evaluated for cervical spine injury. Resident 1 had a decline in his functional status and required extensive assistance for daily activities. Resident 1 had difficulty with fine motor control of his hands and difficulty with gait. A review of Resident 1's Physician Progress Notes, dated 10/8/20, indicated Resident 1 developed new onset left sided hemiparesis (weakness or the inability to move on one side of the body) and was unable to lift the left arm and leg. MRI was negative for stroke. Resident 1 had focal spinal stenosis. The note indicated Resident 1 had some evidence of cord compression (causing an increase in pressure). On 10/13/20 at 2:16 p.m., during an interview, CNA 1 stated she assisted Resident 1 onto a shower chair in the bathroom, on 9/24/20. CNA 1 stated she instructed Resident 1 to grab the side rail and stand. CNA 1 stated Resident 1 started to fall slowly and did not have the strength to hold Resident 1. CNA 1 stated she guided Resident 1 to the floor, and Resident 1’s neck/head area ended up against the base of shower chair. CNA 1 stated she usually used a gait belt, when she transfers Resident 1 all by herself. CNA 1 stated, on 9/24/20, she did not use a gait belt, because she wanted to assist Resident 1 fast. On 10/13/20 at 3:02 p.m., during an observation, Resident 1 was in bed wearing a cervical collar. In a concurrent interview, Resident 1 stated CNA 1 was assisting him, could not hold him, fell on his butt and hit the floor hard. Resident 1 stated that he lost the strength on his legs. The Resident 1 stated he had fallen three times in the facility. Resident 1 complained of a headache. On 10/13/20 at 3:22 p.m., during an interview, CNA 2 stated that today Resident 1 required extensive assistance and cannot stand-up by himself. CNA 2 stated she used two persons and a gait belt to transfer the Resident 1 in the bathroom. CNA 2 stated Resident 1 complained of neck pain during care. On 10/21/20 at 4:34 p.m., during an interview, the Physical Therapist (PT) stated it was a judgement call to use a gait belt when transferring a resident. The PT stated Resident 1, "Is a big guy," and required a gait belt for transfers. The PT stated using a gait belt was important because, "That would be the safest way." A review of Resident 1's MDS, dated 10/24/2020, indicated Resident 1 had a significant change, had moderate cognitive impairment, used a wheelchair for mobility, was able to make self-understood, able to understand others, and required extensive assistance with two or more persons physical assistance for surface transfer and toilet use. On 10/26/20 at 1:40 p.m., during an interview, CNA 3 stated she was familiar with Resident 1. CNA 3 stated, as of today, Resident 1 had minimal movement to his arms and legs, moved just a little bit during transfers, and required two people for surface transfers. CNA 3 stated Resident 1 was not able to stand, move, or pull by himself. CNA 3 stated Resident 1 tried to help, but Resident 1 was not steady on his feet. Resident 1 required support from two persons all the time. Resident 1 was at risk for fall. On 10/26/20 at 2:01 p.m., during an interview, CNA 1 stated Resident 1 was able to stand, transfer with one person assist, was steady on his feet, was able to turn from side to side in bed, pull, and grab prior to the fall. A review of the facility's Transfer of Resident from/to Bed revised date 5/19 indicated to assess a resident's capabilities and provide the form of transfer best suited to his needs and to maintain resident safety during the procedure. The policy indicated that it was the facility's policy to assess and provide appropriate and safe transfer techniques for each resident based on individual need. When assisting a resident to a chair, apply a gait belt around the resident's waist securely enough to prevent sliding up over ribs. The facility failed to ensure that written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved, including but not limited to: The facility’s Certified Nursing Assistant 1 (CNA 1) failed to use a gait belt (an assistive device which can be used to help safely transfer a person from a bed to a wheelchair, assist with sitting and standing, and help with walking around) to assist Resident 1, who was at risk for fall, had unsteady balance, and required extensive assistance from staff during transfers and toilet use, from the wheelchair onto the shower chair in the resident’s bathroom. As a result, Resident 1 sustained a fall and required a transfer to General Acute Care Hospital (GACH). Upon admission to the GACH, Resident 1 was moaning, groaning, not answering questions, had pain on the knee and the urinary catheter site. Resident 1 had nondisplaced (type of fracture in which the bone cracks in only one place and doesn't move to change alignment) C5 (fifth neck bone) fracture (broken). Resident 1 was readmitted to the facility, on 9/29/20, and had to wear a hard-cervical collar (a device to prevent neck movement). Three days after readmission to the facility (10/2/20), Resident 1 developed left sided weakness and left lower extremity numbness (inability to feel), had difficulty with fine motor control of both hands and difficulty with gait. On 10/8/20, Resident 1 developed new onset left sided hemiparesis (muscle weakness or partial paralysis on one side of the body). This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.