Other·February 29, 2024

42 CFR § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. (d) Accidents The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (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: (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 1/18/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a facility reported incident investigation regarding a fall with fracture. The facility failed to ensure Resident 1, who had a history of falls and diagnoses of fractured thigh bone and dementia (impaired ability to remember, think, or make decisions), received supervision, care, treatment and services to prevent falls. The facility failed to: 1. Provide the correct level of assistance (two or more while eating) required by the comprehensive assessment and the fluid imbalance care plan. 2. Implement a comprehensive person-centered fall care plan to include supervision of Resident 1 to prevent falls. As a result, on 1/7/2024, at 7 PM, Resident 1, an 86 year old female, fell from her bed and was noted with swelling and slight purplish discoloration on the right forearm. Resident 1 complained of pain on the affected area, and an X-ray was ordered resulting in a second acute fracture of the right radius (the thicker and shorter of the two long bones in the forearm) and a fracture of the ulna (the other of the two bones which make up the lower forearm). A review of the Admission Record indicated Resident 1 was admitted to the facility on 11/2/2020 with diagnoses including displaced fracture of the base of neck of right femur (a break in the uppermost part of thighbone, next to hip joint), dementia, difficulty in walking, age-related osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases), and history of falling. A review of Resident 1's Risk for Injury Care Plan initiated on 11/2/2023, indicated this risk was related to poor body control secondary to right displaced femoral neck fracture, poor safety awareness secondary to impaired cognition, unsteady gait, advanced dementia, unclear speech and trying to get out of bed without assist. The care plan indicated the goals for Resident 1 were to provide preventive intervention to minimize injury potential. The care plan interventions indicated to assist with transfer and ambulation, to be sure the resident's call light was within reach, to keep area clutter free and well-lit and to encourage the resident to use call light for assistance as needed. The care plan interventions indicated to supply a floor bed, to provide blue pad on both sides of the bed and provide meal tray table during mealtime. The care plan did not indicate supervision was required for Resident 1. A review of Resident 1's Risk for Fall Care Plan initiated on 11/3/2023, indicated this risk was related to trying to get out of bed without assistance. The goal for Resident 1 was to provide preventive intervention to minimize potential injury. The care plan interventions indicated to supply a floor bed, blue pads on both sides of the bed, and to provide a meal tray table during mealtime. The care plan did not indicate supervision was required for Resident 1. A review of the Fall Risk Assessment dated 11/3/2023, indicated Resident 1 was at risk for fall. The Fall Risk Assessment indicated Resident 1 was disoriented x3 at all the times, had no falls in the past three months, was chair bound, required assistance with elimination, had a decreased muscular coordination, unsteady gait, required the use of an assistive device, took three or more medications currently and/or within the last seven days, and had three or more predisposing diseases present (advanced dementia, osteoporosis, fractures). The Fall Risk Assessment did not indicate whether Resident 1 was low or moderate risk for falls. According to a review of the History and Physical (H&P) dated 11/4/2023, Resident 1 did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/6/2023, indicated Resident 1 had severely impaired cognition (decisions poor; cues/supervision required). The MDS indicated Resident 1 was dependent on assistance of two or more for eating, oral hygiene, toileting hygiene, shower, upper and lower body dressing, personal hygiene and chair to bed transfer. A review of the Fluid Imbalance Care Plan (potential for dehydration), initiated on 11/3/2023, indicated Resident 1 was at risk related to displaced femoral neck fracture (bone moved out from its original position), dementia and osteoporosis. The care plan indicated Resident 1 was total dependent for all meals due to mental status and the care plan interventions indicated to provide assistance with meals. A review of Situation Background Assessment Resolution Communication Form (SBAR) dated 1/7/2024 indicated Resident 1 was found on the floor in supine position (on her back, face upward) near her bed at 7 PM. The SBAR form indicated there was no change in level of consciousness (LOC), no complaints of pain, no swelling on affected site. The SBAR indicated there was slight purplish color on right forearm, no skin tear or active bleeding observed. According to a review of the Progress Note dated 1/7/2024 at 7 PM, the Certified Nursing Assistant (CNA) 1 reported to the Licensed Nurse (LN) 1 that Resident 1 was found on the floor in her room. The Progress Note indicated LN 1 went to Resident 1's room, found the resident in the middle of the floor in supine position, and performed head-to-toe body assessment. The Progress Note indicated there was slight purplish discoloration noted on right forearm. An ice pack was applied. The Progress Note indicated Resident 2 witnessed when Resident 1 was eating dinner on the bed and suddenly Resident 1 tried get out of the bed, lost her balance, and started crawling toward Resident 2. The Progress Note did not indicate Resident 1 had assistance while eating dinner. A review of Progress Note dated 1/8/2024, indicated Resident 1 was on monitoring after being "observed on floor." The nursing note indicated at 4:30 AM the resident had swelling with slight skin discoloration on right forearm, Resident 1 complained of pain on the affected area, and a "stat "X-ray was ordered at 4:50 AM. A review of Radiology Report dated 1/8/2024, Resident 1's finding indicated: "There is a fracture of the distal radius with minimal impaction. There is minimally separated of the styloid ulna fracture. Fractures appears to be acute or subacute." A review of the Physician's Order dated 1/8/2024 at 9:24 AM, indicated to transfer Resident 1 to the General Acute Care Hospital (GACH) for fracture of the distal radius and fracture of the distal ulna. A review of the Physician's Progress notes, dated 1/11/2024, indicated Resident 1 had a fracture of the right distal radius and to continue using the current splint. On 1/18/2024 at 3:15 AM, during a phone interview, CNA 1 stated she was walking past Resident 1's room when the call light went on and she saw Resident 1 on the floor in supine position. CNA 1 stated Resident 1 was confused and was not able to say what happened. CNA 1 stated she called the charge nurse to report what she saw. CNA 1 stated during dinner time Resident 1's bed was raised to serve the dinner on the bedside table. During an observation on 1/18/2024 at 12:50 PM, Resident 1 was observed in her room with the bed in the lowest position with floor mats to the left and right side of the bed. Resident 1 was observed with a splint on her right forearm. During an observation on 1/18/2024 at 12:55 PM, Resident 2 was observed sitting in wheelchair next to her bed. During a concurrent interview Resident 2 stated that a few days ago she saw Resident 1 was eating dinner on the bed and suddenly Resident 1 tried get out of the bed, lost her balance, and started crawling toward Resident 2. Resident 2 stated that she pushed the call light for assistance when she noticed Resident 1 on the floor. On 1/18/2024 at 3:20 PM, during a phone interview, CNA 1 stated she was taking care of Resident 1 on 1/7/2024 and that during mealtime CNA 1 would raise Resident 1's bed to set up the dinner tray on the bedside table. CNA 1 stated she was providing frequent visual checks on Resident 1, but she was not aware that Resident 1 needed constant supervision during her mealtime. On 1/18/2024 at 3:59 PM, during concurrent interview and record review with Minimum Data Set Coordinator (MDSC), the MDSC reviewed Resident 1's MDS dated 11/6/2023. The MDSC stated that section GG of the MDS indicated Resident 1 was dependent on assistance of two or more helpers for eating. During an observation on 1/18/2024 at 4:30 PM, with the DON, Resident 1 was observed in her room on the floor bed with floor mats to the left and right side of the bed. Resident 1 was observed eating dinner served on a new bedside table without raising the floor bed and eating dinner without any assistance. During a concurrent interview, the DON stated the facility staff were not raising the floor bed for Resident 1 during mealtime anymore and that the resident can eat dinner without assistance, even with a splint on. A review of the facility's policy and procedure titled, "Fall Risk Assessment," reviewed 12/19/2023, indicated to provide an environment that was free from accident hazards, provide supervision and assistive devices to each resident to prevent avoidable accidents. A review of the facility's policy and procedure titled, "Fall Prevention Program," reviewed 12/19/2023, indicated to provide intervention that addresses unique risk factors measured by the risk assessment tool: medications, psychosocial, cognitive status, or recent changes in functional status. The Fall Prevention Program required the facility to provide additional intervention as directed by the resident's assessment, including but not limited to assistive devices, increased frequency of rounds, sitter if indicated. A review of the facility's policy and procedure titled, "Comprehensive Care Plans," dated 12/19/2022 indicated to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing and psychosocial needs that are identified in the resident's comprehensive assessment. The policy indicated the comprehensive care plan would describe at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The policy indicated qualified staff responsible for carrying out interventions specified in the care plan would be notified of their roles and responsibilities for carrying out the interventions initially and when changes are made. The facility failed to ensure Resident 1, who had history of falls, diagnoses of fractured thigh bone and dementia, received supervision, care, treatment and services to prevent falls. The facility failed to: -Provide the correct level of assistance per the comprehensive assessment and the fluid imbalance care plan. - Implement a comprehensive person-centered fall care plan to include supervision of Resident 1 to prevent falls. As a result, on 1/7/2024, at 7 PM, Resident 1 fell from her bed and was noted with swelling and slight purplish discoloration on the right forearm. Resident 1 complained of pain on the affected area, and an X-ray was ordered resulting in a second acute fracture of the right radius and a fracture of the ulna. 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 Resident 1.