Other·February 6, 2024

42 CFR §483.25 Accidents. The facility must ensure that: (d)(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. 42 CFR §483.21(b) Comprehensive Care Plans (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. 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 12/28/2023, the California Department of Public Health (CDPH) received a facility-reported incident indicating Resident 1 had a fall incident with injury. On 1/4/2024, at 11:30 a.m., the CDPH conducted an unannounced visit at the facility to investigate Resident 1’s fall incident with injury. Resident 1 was admitted to the facility with a history of falls and required assistance and observation while walking and toileting. The facility failed to: 1. Implement Resident 1’s care plan for assistance and interventions during walking and toileting, when a Licensed Vocational Nurse 1 (LVN) identified during his bedside rounds on 12/27/2023 at 11:25 p.m., that Resident 1 was in the restroom alone. 2. Provide assistance and supervision and prevent accident hazards when Resident 1 fell unsupervised and unassisted in the restroom. 3. Follow its policies and procedure (P&P) titled “Safety and Supervision of Residents,” which required the facility to implement interventions to reduce accident risk when hazards were identified. As a result, Resident 1 fell on 12/27/2023 at 11:35 p.m., and sustained a fracture (broken bone) to the right arm which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment. A review of Resident 1’s admission record indicated Resident 1, was a 100-year-old female, initially admitted to the facility on 4/8/2021 and readmitted on 6/6/2023, with diagnoses including syncope and collapse (fainting), nontraumatic intracranial hemorrhage (bleeding in the brain), and a history of falling. A review of Resident 1’s history and physical (H&P), dated 1/3/2024 indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s fall risk care plan titled “At risk for fall and fall related injuries related to Resident with impaired balance when moving from a seated to standing position, walking, moving on and off the toilet, surface to surface transfers,” dated 6/30/2023, the care plan’s interventions indicated staff will assist the resident with safe transfers, provide enough support and anticipate the resident’s needs. A review of Resident 1’s care plan titled, “Activities of Daily Living (ADL), dated 9/12/2023, the care plan interventions indicated staff will anticipate needs daily, assist with bed mobility, transfers, ambulation (walking), locomotion (movement around the unit), dressing, toileting, personal hygiene, and bathing as indicated, and provide enough support. The care plan interventions also indicated staff will observe Resident 1’s ability to stand, transfer, and perform hygiene after toileting. A review of Resident 1’s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 12/8/2023, indicated Resident 1 was usually able to understand and was usually understood by others. The MDS indicated Resident 1 required supervision or touching assistance (staff provides verbal cues and/or touching/steadying and/or places one or two hands on the patient’s body to help with balance] as resident completes activity) during mobility activities such as sitting to standing, chair/bed to chair transfer, toilet transfer, walking 10 feet and walking 50 feet. The MDS indicated Resident 1 required partial/moderate assistance (staff lifts, holds or supports resident) for walking 150 feet. A review of Resident 1’s progress notes, dated 12/27/2023 at 11:25 p.m., indicated, LVN 1 completed initial bedside rounds (checking on the resident’s status) and noted Resident 1 was in the restroom. LVN 1 told Resident 1 to use the call light for assistance when done using the restroom. The progress notes indicated on 12/27/2023 at 11:35 p.m., 10 minutes after LVN 1’s bedside rounds, LVN 1 heard Resident 1 called for help from the restroom and upon opening the door, LVN 1 observed Resident 1 face down on the floor. A review of Resident 1’s radiology (process of taking pictures to diagnose and treat diseases) report dated 12/28/2023, indicated acute right supracondylar (a round part at the end of a bone) fracture of the distal humerus (lower end of the upper arm). A review of the Interact situation, background, assessment, and recommendation (SBAR) note, dated 12/28/2023, indicated Resident 1 fell on 12/27/2023 and complained of pain and limited range of motion (movement) to the right elbow. The SBAR indicated Resident 1’s elbow x-ray (a test used to generate images of tissues and structures inside the body) indicated acute distal humerus (upper arm bone) fracture on 12/28/2023. A review of Resident 1’s progress notes dated 12/28/2023, indicated Resident 1’s x-ray report indicated acute fracture of the right distal humerus. The progress notes indicated, Resident 1 was transferred to a GACH, on 12/28/2023 at 11:39 p.m. for further evaluation and treatment. The progress notes indicated Resident 1’s left forehead birth mark was purple in color, the right elbow and bilateral knees were swollen, and the left knee had a slight purplish skin discoloration. During an interview with Resident 1 on 1/4/2024 at 12:45 p.m., Resident 1 stated she went to the restroom by herself with her walker. Resident 1 stated when she stood up, she felt weak and fell forward. Resident stated she did not call for help and thought she could use the bathroom without using the call light. During a concurrent interview and record review with LVN 2 on 1/5/2024 at 9:57 a.m., Resident 1’s care plan titled, “Activities of daily living (ADL) Functional,” was reviewed, LVN 2 stated Resident 1 required a one person assist with toilet use. During a concurrent interview and record review with the interim Director of Nursing (DON) on 1/5/2024 at 11:18 a.m., Resident 1’s Investigative Summary, was reviewed. The DON stated the report indicated; that Resident 1 was in the restroom with a walker, and a Certified Nurse Assistant (CNA) 1 told Resident 1 to use the call light when she was done using the restroom. The DON stated Resident 1 did not use the call light and fell. The DON stated CNA 1 should have stayed with Resident 1 and not left the resident alone in the restroom. During a phone interview with LVN 1 on 1/5/2024 at 12:22 p.m., LVN 1 stated during his rounds, he observed Resident 1 in the restroom and instructed Resident 1 to use the call light when done, while he continued with his rounds. LVN 1 stated about 10 minutes later, he heard Resident 1 calling for help from the restroom. LVN 1 stated he rushed to the restroom and found Resident 1 on the floor. LVN 1 stated no one was with Resident 1 when she fell because the resident usually used a walker and was mostly independent at night, including going to the restroom. LVN 1 stated he read Resident 1’s MDS after Resident 1 fell and noted that Resident 1 was supposed to have supervision going to the restroom. During a review of Resident 1’s GACH Emergency Department (ED) Provider Note dated 12/28/2023, the ED note indicated Resident 1 presented to the ED with a right elbow injury and a severe pain level of 8 out of 10 (a pain level of 10 is the worse pain), following a fall on 12/27/2024, in the facility. The note indicated Resident 1’s pain was worse with movement. The note indicated Resident 1’s right elbow fracture was treated with immobilization, closed reduction (a procedure to repair a broken bone without cutting the skin), pain control, and anti-inflammatories (medications to relieve pain, and reduce inflammation). The note indicated Resident 1 was discharged back to the facility on 1/1/2024. A review of the facility’s P&P titled “Care Plans, Comprehensive Person-Centered,” dated 4/2017, the P&P indicated the care plan will reflect treatment goals, timetables, and objectives in measurable outcomes and aid in preventing or reducing decline in the resident’s functional status and/or functional levels. A review of the facility’s P&P titled “Safety and Supervision of Residents,” revised 12/2017, indicated when accident hazards were identified, the Quality Assurance (QA&A)/safety committee shall evaluate and analyze the cause of hazards and develop strategies to mitigate or remove the hazards to the extent possible. The P&P indicated, implementing interventions to reduce accident risks and hazards shall include assigning the responsibility for carrying interventions, ensuring that interventions were implemented correctly and consistently. The P&P indicated resident supervision was a core component of the system’s approach to safety. A review of the facility’s P&P titled “Managing Fall and Fall Risk,” dated 12/2018, indicated staff will identify interventions related to the resident’s specific risks and causes to prevent the resident from falling and to minimize complications from falling. The facility failed to: 1. Implement Resident 1’s care plan for assistance and other interventions during walking and toileting, when a LVN identified during his bedside rounds on 12/27/2023 at 11:25 p.m., that Resident 1 was in the restroom alone. 2. Provide assistance and supervision and prevent accident hazards when Resident 1 fell unsupervised and unassisted in the restroom. 3. Follow its P&P titled “Safety and Supervision of Residents,” which required the facility to implement interventions to reduce accident risk when hazards were identified. As a result, Resident 1 fell on 12/27/2023 at 11:35 p.m., and sustained a fracture to the right arm which required hospitalization in a GACH for evaluation and treatment. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.