Other·January 3, 2024

42 CFR §483.25 (d)(2) Accidents. The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. 42 CFR §483.21(b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident. 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: (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. (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 § 72517-Staff Development Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: (1) Problems and needs of the aged, chronically ill, acutely ill, and disabled patients. 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 11/15/2023, the California Department of Public Health (CDPH) received two (2) facility reported incidents (FRIs) indicating: a. Resident 1 fell on 11/14/2023 and sustained a right hip fracture (broken bone). b. Resident 2 fell on 11/13/2023 and sustained a left hip fracture. On 11/17/2023, at 9:48 a.m., the CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Follow its policy and procedures titled “Care Plans, Comprehensive Person-Centered” which indicated the Interdisciplinary Team ([IDT] a team of health professionals working together to provide needed care to residents) must review and update a resident’s care plan when there was a significant change in the resident’s condition. Resident 2 fell on 7/24/2022 and an IDT Fall Review was done on 7/25/2022 with recommendations to prevent further falls. Resident 2’s fall risk care plan was not revised to reflect the IDT’s recommendations. 2. Ensure Resident 2, who fell on 7/24/2022, had an accurate post fall risk assessment (an assessment conducted after a fall) to correctly identify and reflect Resident 2’s clinical condition, as a high risk for fall. 3. Ensure Resident 3 had an updated care plan including the facility’s corrective actions and plan of care dated 11/8/2023 to prevent Resident 3 from falling on 11/20/2023. As a result, Resident 2 fell on 11/13/2023 and sustained a left hip fracture, which required hospitalization at a general acute care hospital (GACH) for evaluation and treatment. It also resulted in Resident 3 falling on 11/20/2023, 12 days after she fell on 11/8/2023 and sustaining a fracture. 1. A review of Resident 2’s Admission Record, the Admission Record indicated Resident 2 was admitted on 3/5/2021 with diagnoses including vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) age-related osteoporosis (a condition where bones become weak and breaks easily), and high blood pressure. A review of Resident 2’s History and Physical exam (H&P) dated 3/30/2023, indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2’s medical record titled eINTERACT (electronic communication) Change in Condition Evaluation (COC), dated 7/24/2022 at 2:49 p.m., indicated on 7/24/2022, Resident 2 was found sitting next to his bed with his back resting on side the of bed. The COC indicated Resident 2 did not sustain any injuries and did not complain of pain. A review of Resident 2’s medical record titled Fall Risk Evaluation, (post fall assessment), dated 7/24/2022 indicated Resident 2’s fall score was 4 (low fall risk). The fall risk evaluation indicated scoring based on the eight clinical condition parameters, however, the scores did not correspond to what best described Resident 2 after the fall. The fall risk evaluation document indicated a total score of 10 or greater, indicated high risk for potential falls. The evaluation form indicated if a resident had a high fall risk, fall prevention measures should be initiated immediately and documented on the care plan. A review of Resident 2’s IDT Fall Review, dated 7/25/2022 at 3:53 p.m., indicated on 7/24/2022, the IDT discussed Resident 2’s fall dated 7/24/2022 at 3:18 p.m. The report indicated Resident 2 had cognitive (mental/ thinking) and physical impairments prior to the fall, was receiving antipsychotic medication (medication to treat mental disorders) and had predisposing diseases. The report indicated IDT recommendations included to place Resident 2’s call light within reach and encourage Resident 2 to use call light for assistance, to assist the resident with toileting, frequent visual check, bed in lowest position, wheelchair alarm (a fall prevention product that alerts caregivers monitor the movement of the patients who are frequently in a chair, like a wheelchair) to alert staff when resident is getting up on wheelchair without assistance, medication review, rehabilitation evaluation and treatment as indicated. A review of Resident 2’s care plan (CP), specifically an entry titled, “At risk for fall and fall-related injuries indicated the actual fall dated 7/24/2022. The care plan did not indicate Resident 2 had a wheelchair alarm to alert staff when Resident 2 got up on wheelchair without assistance as indicated in the IDT meeting after the 7/23/2022 fall. The care plan did not indicate the IDT had a follow up meeting to discuss if Resident 2 no longer needed a wheelchair alarm. A review of Resident 2’s Minimum Data Set ([MDS] a comprehensive assessment and care planning tool) dated 8/31/2022, indicated Resident 2 was cognitively impaired. The MDS indicated Resident 2 required extensive assistance (resident is involved in activity and staff provide the weight-bearing support) with bed mobility, transfer, locomotion (movement) on and off the unit, toilet use and personal hygiene. The MDS indicated Resident 2 used a wheelchair for movement and had history of falling. The MDS also indicated Resident 2 was receiving antipsychotic medicine on a routine basis. A review of Resident 2’s Situation, Background, Assessment, Recommendation (SBAR) Communication Form” dated 11/13/2023, indicated on 11/13/2023, Resident 2 had a fall which resulted in a left leg pain rated at 3 out of 10, (a numeric pain scale to measure pain intensity: with 0-no pain, 1-3 mild pain, 4-6 moderate pain, 7-9 severe pain, 10- worst pain possible) and a left ear skin tear. A review of Resident 2’s Incident Report dated 11/13/2023, indicated Resident 2 had an unwitnessed fall and was observed with a left ear skin tear measuring 1 centimeter ([cm] unit of measurement) by 0.1cm. The report indicated there was moderate bleeding from the skin tear. The report indicated Resident 2 complained of left leg pain rated at 3 out of 10 with movement and was given an undisclosed dose of Tylenol. The report also indicated Resident 2 was unaware of what caused the fall and stated, “I don’t know, I think I was going home.” A review of a fax report from the facility dated 11/14/2023 at 12:11p.m., indicated Resident 2 had an unwitnessed fall, was transferred to the GACH for further evaluation and management. The fax report indicated the facility received information from the GACH on 11/14/2023, indicating Resident 2 had a left hip fracture and was to be transferred to another GACH for surgical intervention. A review of Resident 2’s progress notes dated at 11/13/2023 at 3 p.m., indicated Resident 2 was found by a Restorative Nurse Assistant (RNA 1), sitting on the floor in the resident’s room with his back leaning against the wall, facing the bathroom door and both legs were extended. A review of Resident 2’s clinical progress notes dated 11/13/2023 at 4:50 p.m., indicated Resident 2 was transferred to a GACH for further evaluation after he fell on 11/13/2023. A review of Resident 2’s imaging report from the GACH titled Computed Tomography ([CT] computerized procedure used to show images inside the body including bones and fat) Left Hip Without Contrast (without using dye (colored substance]), dated 11/14/2023, indicated Resident 2 had a “nondisplaced (still aligned) subcapital [the fracture that extends through the junction of the head and neck of femur(hip)] fracture of the left femoral (hip) neck. During a concurrent interview and record review, on 11/20/2023 at 12:44 p.m., with Registered Nurse (RN) 1, Resident 2’s care plan titled “The resident has had an actual fall with no injury, minor injury, serious injury, poor balance and unsteady gate” revised 05/01/2023, was reviewed. RN 1 stated Resident 2 did not have an updated care plan with interventions to prevent falls. RN 1 stated she was unsure if Resident 2 had history of falls. RN 1 stated Resident 2 had a second unwitnessed fall on 11/13/2023. RN 1 also stated Resident 2 was at high risk for falls based on his diagnoses and impaired cognition. RN 1 stated there should have been an updated care plan with interventions to prevent falls and injury. During an interview on 11/20/2023 at 2:40 p.m., Licensed Vocational Nurse (LVN) 2, stated Resident 2 fell on 11/13/2023 and was transferred to the hospital. LVN 2 stated Resident 2 was at risk for falls due to unsteady gait, confusion, and diagnosis of vascular dementia. LVN 2 stated at the time of the fall on 11/13/2023, staff were not implementing any resident-specific interventions for Resident 2. LVN 2 also stated he could not recall if Resident 2’s wheelchair had an alarm to alert staff if the resident attempted to get out of his wheelchair unattended. During an interview on 11/20/2023 at 3:15 p.m., the Director of Staff Development (DSD), stated all residents at risk for falls should have a care plan with resident-specific interventions to prevent falls. The DSD stated not having the fall risk care plan could negatively impact a resident’s safety and could contribute to falls and injuries. During a concurrent record review with the Director of Nursing (DON), on 11/20/2023 at 3:57 p.m., Resident 2’s Fall Risk Evaluation Assessment dated 7/24/2022, the IDT Fall Review dated 7/25/2022, and Resident 2’s fall risk care plan dated 7/24/2022 were reviewed. The DON stated Resident 2’s assessment indicated the resident had a low fall risk. The DON stated the assessment was incorrect because Resident 2 had a high fall risk. The DON stated a high fall risk would have prompted the staff to create a fall prevention care plan. The DON stated Resident 2 did not have an updated fall prevention care plan which included IDT recommendations such as frequent visual check, and wheelchair alarm at the time the resident fell, on 11/13/2023. 2. A review of Resident 3’s Admission Record, indicated Resident 3 was admitted to the facility on 10/6/2023 with diagnoses including hemiplegia (loss of the ability to move and feel on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body that affects performing daily activities like eating or dressing), lack of coordination, difficulty walking, and history of falling. A review of Resident 3’s H&P, dated 10/8/2023, indicated Resident 3 did not have the capacity to understand and make decisions. A review of Resident 3’s MDS dated 10/12/2023, indicated Resident 3 had severe cognitive impairment and was dependent on staff transferring from a sitting to standing position, to and from a bed or chair. The MDS indicated bed and chair alarms were used less than daily. A review of Resident 3’s care plans indicated “The resident is at risk for falls related to difficulty walking, lack of coordination, multi med use, incontinent (inability to control bowel and bowel functions) and impaired decision making” dated 10/19/2023 and indicated interventions such as a bed and wheelchair alarm, check for placement and functioning per facility protocol, and to ensure the resident wore a well-fitted non-skid footwear. A review of Resident 3’s SBAR, dated 11/8/2023, indicated Resident 3 fell on 11/8/2023, complained of pain and showed non-verbal signs of pain. The SBAR did not identify Resident 3’s pain location, pain intensity or any interventions provided. A review of Resident 3’s Fall Risk Evaluation report dated 11/8/2023, indicated Resident 3 had a high risk for falls. The evaluation indicated Resident 3 had balance problems while standing and walking, change in gait pattern when walking through the doorway, and required the use of assistive devices such as a cane, wheelchair, or walker. A review of the facility’s Investigation Report dated 11/8/2023, indicated Resident 3 had an unwitnessed fall on 11/8/2023. The report indicated Resident 3 had climbed out of bed. The report indicated the facility’s corrective actions and plan of care to prevent re-occurrence of the incident was to perform frequent visual checks, resident monitoring and assist the resident to the bathroom every 2 hours if possible. A review of Resident 3’s Fall risk care plan did not indicate Resident 3’s fall on 11/8/2023 or any actions taken in response to the fall. The care plan did not have updated interventions to prevent further falls. A review of Resident 3’s IDT Fall Review, dated 11/10/2023, indicated Resident 3 had a history of falls. The Fall Review indicated the root cause analysis for Resident 3’s falls included episodes of forgetfulness, poor safety awareness, impulsiveness, poor standing balance, and complex medical condition. The review indicated recommendations such as to anticipate the resident’s needs, provide assistance when getting up, periodic visual checks, provide a safe and hazard-free environment and provide safety reminders. A review of Resident 3’s SBAR dated 11/20/2023, indicated Resident 3 fell on 11/20/2023. The SBAR did not indicate if Resident 3 sustained an injury or if the resident was in pan. During an interview on 12/1/2023 at 1:59 p.m. the DON stated the IDT fall review on 11/10/2023, for Resident 3’s fall on 11/8/2023 had incorrect documentation. The DON stated the interventions (frequent visual checks) discussed during IDT were not added into Resident 3’s actual fall and at-risk care plans. The DON stated when care plans are not revised, it increases the possibility of a fall, which have contributed to Resident 3’s fall on 11/20/2023. During a concurrent observation and interview, on 11/17/2023 at 1:51 p.m., with Certified Nursing Assistant (CNA) 1, Resident 3 was sitting on the wheelchair in the hallway wearing one white furry house slipper and white socks on the right foot. One slipper was observed on the floor. CNA 1 stated Resident 3 was not wearing non-skid nor a well-fitted slipper. CNA 1 stated the purpose of the non-skid and a well-fitted footwear was to prevent falls. CNA 1 stated she was unaware Resident 3 had fallen in the facility. During a concurrent interview, and record review on 11/17/2023 at 2:32 p.m., with a Licensed Vocational Nurse (LVN) 1, Resident 3’s fall prevention care plan, dated 10/19/2023 was reviewed. LVN 1 stated the car