Health inspection·September 26, 2024

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. 22 CCR §72311 Nursing Services - 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: (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. 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 8/6/2024, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding resident death and safety due to fall. The facility failed to ensure Resident 3 was free from accidents and develop and implement a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for Resident 3, who was dependent on staff with personal hygiene and diagnosed with generalized muscle weakness, morbid (severe) obesity (abnormal or excessive fat accumulation that presents a risk to health) and paraplegia (the inability to voluntarily move the lower parts of the body), by failing to: 1. Provide Resident 3 with the needed two-person assistance when Certified Nursing Assistant 1 (CNA 1) was giving nursing care to Resident 3 on 8/4/2024 without assistance from another staff. 2. Change Resident 3’s Alternating Pressure and Low Air Loss (LAL) Bariatric (relating to or specializing in the treatment of obesity) Mattress (a type of medical mattress designed to reduce pressure on the skin, which helps prevent pressure injuries or bed sores [injuries to skin and underlying tissue resulting from prolonged pressure on the skin]) from the physician’s ordered setting of 300 pounds to static mode (the mattress provides a firm surface that makes it easier for the resident to transfer or reposition) while providing Resident 3 with Activities of Daily Living (ADL – are those skills required to manage one’s basic physical needs, including personal hygiene, dressing, toileting, transferring or ambulating, and eating) care. 3. Develop and implement a care plan consistent with Resident 3’s Minimum Data Set (MDS – a standardized assessment and care-screening tool), which indicated Resident 3 was dependent on staff with personal hygiene (includes combing hair, shaving, applying make-up, washing/drying face and hands [excludes baths, showers, and oral hygiene]), toileting hygiene (ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement), and rolling left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed). As a result, Resident 3 fell while CNA 1 was providing nursing care to Resident 3, without assistance from another staff. Resident 3 sustained a laceration (wound in the skin that occurs when skin and underlying tissues are torn or cut) to the left eyebrow, had approximately one (1) liter (L – unit of measurement) of blood next to Resident 3’s head and was pronounced dead by the paramedics (healthcare professionals trained to provide a wide range of emergency services) on 8/4/2024 at 10:21 p.m., in the facility. A review of Resident 3’s Admission Record indicated the facility admitted Resident 3, a 63-year-old female resident on 9/15/2020 and readmitted on 6/3/2023 with diagnoses that included generalized muscle weakness, morbid obesity, paraplegia, and cognitive communication deficit (an impairment in thought organization, attention, memory, planning, problem-solving and safety awareness). A review of Resident 3’s Care Plan, developed on 9/16/2020, indicated that Resident 3 was at risk for skin breakdown. The interventions included were to provide LAL for wound skin maintenance due to history of pressure injury (breakdown of skin integrity due to pressure) and for staff to monitor and ensure proper setting and functioning of the LAL, every shift. A review of Resident 3’s Care Plan, developed on 9/27/2020, last revised on 7/1/2024, to address resident’s generalized weakness with decline in overall activities of daily living (ADL- tasks of everyday life) performance skill and physical status with impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and communication skills included interventions for Resident 3 to provide the resident with one person total assistance for bed mobility (how resident moves to and from lying position, turns side or side, and positions body while in bed or alternate sleep furniture). A review of Resident 3’s Order Summary Report, dated 2/18/2023, indicated to administer aspirin (medication to prevent blood clots) oral tablet chewable 81 milligrams (mg - a unit of measurement) one tablet via gastrostomy tube (Gtube- a tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used for feeding and nutrition administration) one time a day for cerebrovascular accident (CVA- medical condition that occurs when blood flow to the brain is suddenly cut off) prophylaxis (an attempt to prevent disease). A review of Resident 3’s Order Summary Report, dated 6/26/2023, indicated bilateral (both) one-half side rails as an enabler (facilitates movement while on bed). A review of Resident 3’s History and Physical, dated 3/29/2024, indicated Resident 3 did not have the capacity to understand and make decisions. A review of Resident 3’s Order Summary Report, dated 6/2/2024, indicated LAL mattress to bed every shift for skin maintenance and history of pressure injury with setting at 300 lbs., and to check settings and functions every shift. A review of Resident 3’s MDS, dated 6/3/2024, indicated Resident 3 was able to understand and be understood. The MDS indicated Resident 3 was dependent on staff for eating, oral hygiene, toileting, showering, upper and lower body dressing, rolling left and right, and personal hygiene. The MDS indicated Resident 3 weighed 250 pounds. The MDS indicated Resident 3 had impairment on the upper extremity (shoulder, elbow, wrist, and hand) and lower extremity (hip, knee, ankle, and foot) on both sides of the body. A review of Resident 3’s weight, dated 7/5/2024, indicated Resident 3 weighed 252 lbs. A Review of Resident 3’s vital signs (measurements of the body's most basic functions), dated 8/4/2024 at 8:40 p.m., indicated a blood pressure (BP - the force of blood pushing against the walls of the arteries, the normal BP for adults is a systolic pressure [upper number] of less than 120 and a diastolic pressure [lower number] of less than 80 ) of 148/67 millimeters of mercury (mmHg - unit of measurement), and heart rate (the number of times the heart beats within a minute, normal resting heart rate for adults ranges from 60 to 100 beats per minute or bpm) of 75 bpm. A review of Resident 3’s Situational Background Assessment and Recommendation (SBAR - a written communication tool that helps provide essential, concise information, usually during crucial situations) Communication Form, dated 8/4/2024, indicated that on 8/4/2024 at around 9:50 p.m., Licensed Vocational Nurse (LVN 1) called Registered Nurse (RN 1) to assess Resident 3 who had experienced a fall. Resident 3 was noted on the floor with her head turned to the side. The SBAR indicated Resident 3 was conscious and minimally responsive. The SBAR indicated Code blue (emergency code that indicates a patient is experiencing a life-threatening medical emergency) was called, and the code status was verified as Do not attempt Resuscitation (DNR- a legal document that means a person has decided not to have cardiopulmonary resuscitation [CPR] attempted on them if their heart or breathing stop). Resident 3 was immobilized and 911 was called due to possible head injury. The SBAR indicated that when the paramedics arrived, Resident 3 lost consciousness completely. A review of Resident 3’s Los Angeles Fire Department ([LAFD], an organization that provides fire prevention and fire suppression services as well as other rescue services) Patient Care Report dated 8/4/2024 at 10:04 p.m. indicated the paramedics were notified at 10:04 p.m. and were on scene at 10:10 p.m. The report indicated that on 8/4/2024 at 10:13 p.m. Resident 3 was laying supine (a person lying on their back with their face and torso pointing up) on the ground, in the room of the nursing home. The report indicated that facility’s staff stated they heard a thud (a loud, dull sound) and Resident 3 was found on the floor with blood next to her head and 911 was called, approximately 20 minutes after Resident 3 was observed on the floor. The report indicated Resident 3 was laying supine on the ground naked with approximately three (3) inch laceration to left eyebrow and approximately one liter of blood next to her head. The report indicated Resident 3’s head was approximately 18 inches from the wall, and she was laying in the middle of the room. The report indicated Resident 3’s bed was pushed out of way and was elevated approximately 24 to 36 inches (2 to 3 feet) off the ground with all side rails down. The report indicated Resident 3 was pulseless and apneic (a temporary and involuntary stop in breathing) and CPR was started. The report indicated a staff stated Resident 3 was DNR, but the paramedics continued while Resident 3’s code status was verified. The report indicated staff took approximately five (5) minutes to provide documentation of DNR, CPR was discontinued, and Resident 3 was declared dead at 10:21 p.m. A Review of Resident 3’s Skin check, dated 8/4/2024 at 10:37p.m., indicated 1.5-inch skin tear to left upper eyebrow. A review of Resident 3’s County of Los Angeles Department of Medical Examiner’s Death Investigation Summary, completed on 8/5/2024 at 1:18 p.m., indicated, Resident 3’s death was pronounced on 8/4/2024 at 10:21 p.m. The Investigation Summary indicated a “Summary and Opinion Narrative,” indicating, “The cause of death is attributed to acute cardiac dysfunction (a sudden, life-threatening condition in which your heart is unable to do its job) as a result of hypertensive (refers to heart problems that occur because of high blood pressure that is present over a long time) and atherosclerotic (a condition that develops when a sticky substance called plaque builds up inside your arteries) cardiovascular disease. A recent acute (sudden onset) contributory condition is blunt facial trauma consisting of a laceration on the face which caused significant hemorrhage (bleeding) clinically…. Due to the facial injury being the result of rolling off a bed in a nursing facility, the manner of death is considered accident.” During an interview on 8/6/2024 at 11:15 a.m., with Resident 5, who was Resident 3’s roommate and who was present when Resident 3 fell. Resident 5 stated that on 8/4/2024 at around 10:00 p.m., one staff (CNA 1) attempted to change Resident 3’s incontinence brief (undergarment designed to absorb urine and it can be fastened at the hip). Resident 5 stated the curtain between both beds was closed but she heard Resident 3 fall off the bed. Resident 5 stated that the staff (CNA 1) rolled Resident 3 to change her incontinent brief. Resident 5 further stated there was only one staff assisting Resident 3. Resident 5 stated Resident 3’s bed only had one upper small siderail and Resident 3’s bed was positioned at the highest level. Resident 5 stated there were no landing mats (to provide cushioned landing surface and reduce the likelihood of injury) next to Resident 3’s bed. Resident 5 stated Resident 3 fell on her face, near Resident 5’s bed. During an interview on 8/6/2024 at 12:14 p.m., CNA 1 stated that on 8/4/2024 at around 9:30 p.m., she (CNA 1) was about to provide care to Resident 3, and while standing on Resident 3’s right side, she (CNA 1) elevated the resident’s bed to the level of her waist. CNA 1 stated she (CNA 1) was six feet tall, and the bed may have been about three feet off the ground. CNA 1 stated Resident 3 was lying on her back, and she rolled Resident 3 onto her left side, placed Resident 3’s hand on the handrail with CNA 1’s hands on Resident 3’s hip. CNA 1 stated she rolled the draw sheet under Resident 3, opened the incontinence brief tab took the left hand off Resident 3 and Resident 3 let go of the handrail and fell face down. CNA 1 stated she did not request assistance from another staff before performing care and did not change the pressure on Resident 3’s LAL to static mode. During an interview on 8/6/2024 at 12:32 p.m., LVN 1 stated that Resident 3 was bed-bound (confined to bed), alert and oriented to self (able to correctly identify self). LVN 1 stated that on 8/4/2024 at around 9:30 p.m. to 9:45 p.m. she (LVN 1) was passing medications when CNA 1 came out (from Resident 3’s room) running stating Resident 3 fell on the floor. LVN 1 stated she stopped what she was doing and ran into Resident 3’s room. Resident 3’s bed was pushed back but the bed was locked. Resident 3 was on the floor with the face down near Resident 5’s bed. LVN 1 stated there was no landing mat and Resident 3 was making a noise like she (Resident 3) was trying to breathe. LVN 1 stated she turned Resident 3 and noted Resident 3 with a cut on the left eyebrow with blood. LVN 1 stated Resident 3’s bed was too high, possibly three feet from the ground. LVN 1 stated Resident 3 required assistance from two staff or three staff depending on the physical capabilities of the staff on shift, for care. During a concurrent interview and record review on 8/6/2024 at 2:47 p.m., with Registered Nurse (RN 2), Resident 3’s MDS dated 6/3/2024 and care plan for generalized weakness dated 7/1/2024, were reviewed. RN 2 stated based on the MDS, Resident 3 needed a two-person assistance when providing care. RN 2 stated that the care plan indicated Reside