Health inspection·December 2, 2021

F-684 § 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. 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 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 10/21/2021 an unannounced visit was made to the facility to conduct an annual recertification survey and Resident 3’s care was reviewed. The facility failed to provide an environment free of accident hazards and supervision for Resident 3, who was a high fall risk and had history of falls with fracture (broken bones). On 10/16/2021, at 9 AM, the Certified Nursing Assistant 1 (CNA 1) assisted the resident to the activity room, where Resident 3 remained alone, unsupervised. As a result, at 9:20 a.m., Resident 3 was found lying on her left side near her wheelchair, complaining of moderate pain (6/10, six out of 10 in a pain rating scale from zero to 10, zero indicting no pain and 10 the wort possible pain) to the left hip and thigh. On 10/17/2021, Resident 3 was diagnosed with a left hip fracture requiring transfer to General Acute Care Hospital 1 (GACH 1) on 10/18/2021. A review of the Admission Record indicated Resident 3, a 67-year-old female, was admitted to the facility on 6/23/2021 with diagnoses including history of falling, wedge compression fracture T9-T10 vertebrae (fracture in the thoracic spine [the middle portion of the spine], osteopenia (a medical condition in which the protein and mineral content of bone tissue is reduced), and osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D). A review of Resident 3’s Fall Risk Assessment dated 6/23/2021, indicated the resident had a balance problem while standing, walking, and required the use of assistive devices. Resident 3 was a high risk for falls. A review of Resident 3's Plan of Care developed on 6/23/2021 for the resident history of falls, poor balance and decrease in functional status, indicated interventions to assist Resident 3 with all transfers and ambulation, have the call light within reach and answer promptly, and encouraging assistance as needed with transfers and ambulation. A review of Resident 3's Plan of Care developed on 6/23/2021 for the resident’s diagnoses of osteoporosis and osteoarthritis, and risk of pathological fracture (a broken bone that is caused by a disease, rather than an injury) indicated the interventions to assist the resident safely during transfers, maintaining safe and hazard free environment, handling gently when positioning, and placing call light within reach, A review of Resident 3's care plan for history of falls, poor balance and decrease in functional status developed 6/23/2021, included the interventions to assist with all transfers or ambulation, call light within reach and answered promptly, encourage the resident to use it for assistance as needed. The care plan intervention indicated Resident 3 needed prompt response to all request for assistance and encourage the resident to call for assistance before attempting to transfer or ambulate if able. A review of Resident 3’s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 6/30/2021, indicated the resident required extensive assistance (staff provide weight-bearing support) with one-person assist for bed mobility, dressing, eating, toilet use, and personal hygiene. Resident 3 was not steady for surface-to-surface transfer, between bed and chair, wheelchair, and standing position. A review of Resident 3’s Change of Condition (COC) Notes, dated 10/16/2021, indicated at 9:20 a.m., the Activities Assistant (AA) reported to Registered Nurse 1 (RN 1) finding Resident 3 in the Activity Room, lying on her left side near her wheelchair, complaining of moderate pain to the left hip and thigh. The Charge Nurse medicated Resident 3 with acetaminophen for moderate pain, with frequent staff visual checks for safety. The physician, when informed, ordered x-rays (a photographic or digital image of the internal composition of a part of the body) of both hips, pelvis, and left thigh. A review of Resident 3’s Radiology (x-ray) Report, dated 10/17/2021, indicated the resident suffered a comminuted (a break with multiple pieces) left intertrochanteric fracture (a type of hip fracture) and superolateral displacement (abnormal position) of the distal fragment. A review of Residents 3's Progress Notes dated 10/18/2021, indicated the Medical Doctor was notified of Resident 3's x-ray results and gave new orders to transfer Resident 3 to GACH 1 for evaluation (two days after the fall). A review of Resident 3’s GACH 1’s History and Physical (H&P) exam dated 10/19/2021, indicated the resident was admitted on 10/18/2021 from a nursing home where she fell, developed left sided pain, and was brought to the hospital due to a left hip fracture, awaiting orthopedic consult. On 10/18/2021 at 9:20 a.m., during an observation and interview, Resident 3 was observed awake, alert, speaking a foreign language. Resident 3 stated no one paid any attention to her. Resident 3 grabbed her left leg and stated she fell in the activities room (on 10/16/2021) and she was having pain. On 10/19/2021 at 10 a.m. during an interview, RN 1 stated she was working on day shift on 10/16/2021 and around 9:20 a.m. she was paged to go to the Activity Room because a resident fell on the floor. The Receptionist went on his break and the AA went to cover for the Receptionist. RN 1 stated, “At the time, no one was inside the Activity Room supervising the resident (Resident 3).” RN 1 stated she assessed Resident 3, assisted the resident back to the wheelchair and to bed. Resident 3 complained of pain rated six of 10 (6/10, pain rating scale from zero to 10, zero indicating no pain and 10 the worst possible pain; 6/10 is equivalent to moderate pain). RN 1 stated the Charge Nurse gave Resident 3 Tylenol (pain medication) and notified the physician of the fall, who ordered x-rays. On 10/19/2021 at 11 a.m., during an interview, Director of Nursing (DON) stated she did not know why Resident 3 was left alone in the Activity Room. On 10/20/2021 at 1 p.m. during an interview, Activities Director (AD) stated if there were residents in the Activity Room, staff should always be there to monitor the residents. On 10/20/2021 at 1:15 p.m. during a telephone interview, AA stated the morning of Saturday 10/16/2021, he was asked to cover the Receptionist during the receptionist break. AA stated that at the time, he was checking people into the facility, answering the phones, and he saw Resident 3 in the Activity Room by herself. AA stated he was unsure why CNA 1 left Resident 3 in the Activity Room by herself. The AA stated, he could see the resident attempting to stand up, so he went to get RN 1 and when they went to the Activity Room, Resident 3 was already on the floor. On 10/21/2021 at 11:20 a.m., during a telephone interview, CNA 1 stated she assisted Resident 3 out bed into the wheelchair as requested by the resident. Resident 3 told her she wanted to go to the Activity Room to sit her by a table. CNA 1 stated the Activity Room door was open and she could see there was someone at the Reception Desk. CNA 1 acknowledged not informing anyone she was leaving Resident 3 alone. A review of Resident 3’s GACH 1’s Orthopedic Surgery Consultation Note dated 10/21/2021, indicated Resident 3 benefitted from surgical fixation of the left hip fracture but she had a change in condition. Resident 3 had significantly worsening difficulty breathing and required continuous face mask with high flow oxygen. On 10/22/2021 at 11 a.m., during an interview, the Administrator (ADM) stated someone should have been with the resident in the Activity Room. A review of Resident 3’s GACH 1’s Neurology Consult dated 10/25/2021, indicated the resident was transferred to the Intensive Care Unit (ICU -a designated area of a hospital that is dedicated to the care of patients who are seriously ill) due to cardiac arrest (unexpected loss of heart function). Resident 3 was intubated (a flexible plastic tube into the windpipe to maintain an open airway) and sedated. Neurology was consulted for seizure-like activity (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements [stiffness, twitching or limpness], behaviors, sensations, or states of awareness) with irregular movement of upper body, lasting a couple of seconds. No history of seizures. A review of the facility’s policy and procedures titled, “Falls and Fall Risk Managing,” revised March 2018, indicated the staff will identify interventions related to the resident’s specific risks and try to prevent the resident from falling and try to minimize complications from falling. The staff with the input of attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. The facility failed to provide an environment free of accident hazards and supervision for Resident 3, who was a high fall risk and had history of falls with fracture (broken bones). On 10/16/2021, at 9 AM, CNA 1 assisted the resident to the activity room, where Resident 3 remained alone, unsupervised. As a result, at 9:20 a.m., Resident 3 was found lying on her left side near her wheelchair, complaining of moderate pain (6/10, six out of 10 in a pain rating scale from zero to 10, zero indicting no pain and 10 the wort possible pain) to the left hip and thigh. On 10/17/2021, Resident 3 was diagnosed on with a left hip fracture requiring transfer to GACH 1 on 10/18/2021. 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 3.