Other·October 5, 2023

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. F 689 §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 8/17/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident about the quality of care for Resident 1. As a result of the investigation, CDPH determined that the facility failed to: 1.Re-evaluate the interventions related to Resident 1’s specific risks and causes to try and prevent the resident from falling and try to minimize complications from falling in accordance with the facility’s policy and procedure titled, “Falls and Fall Risk, Managing,” last revised 3/2018. 2.Implement additional or different interventions when Resident 1 continued to fall despite initial interventions, in accordance with the facility’s policy and procedure titled “Falls and Fall Risk, Managing,” last revised 3/2018. 3.Conduct an interdisciplinary team (IDT) meeting for Resident 1 after she suffered from two unwitnessed falls on 7/6/2023 and 8/3/2023 in accordance with the facility’s policy and procedure titled, “Care Plan, Comprehensive Person-Centered," last revised 12/2016. 4.Review and update Resident 1’s care plan when there were significant changes in the Resident 1's condition on 6/27/2023, 7/6/2023, 8/3/2023. As a result, Resident 1 who was cognitively impaired (trouble remembering, learning new things, concentrating), identified as a high fall risk, and had a history of falls, had an unwitnessed fall on 7/6/2023 and 8/3/2023 and developed an acute to subacute right intertrochanteric femoral fracture with mild posterior displacement (broken right hip) and required surgery to repair the right hip fracture. A review of Resident 1's Admission Record indicated the resident was a 78 year old female, re-admitted to the facility on 6/26/2023 with diagnoses including congestive heart failure (a condition where the body cannot pump blood well enough to give the body a normal body supply), end stage renal disease (occurs when the kidneys are no longer able to work at a level needed for day-to-day life), dependence on renal dialysis (a treatment to clean the body's blood when the kidneys are not able to), dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and long term use of anticoagulants (medication that helps prevent blood clots). A review of Resident 1's Risk for Fall Care Plan initiated 5/23/2023 indicated, the resident had episodes of forgetfulness, trying to get up by herself, and not using the call light. The Care Plan interventions indicated to be sure the resident's call light was within reach and to encourage the resident to use it for assistance as needed. The care plan interventions indicated Resident 1 needed prompt response to all requests for assistance and to ensure Resident 1 was wearing appropriate footwear (non-skid) / socks when ambulating or mobilizing in the wheelchair, follow fall protocol, and a safe environment with even floors free from spills and or clutter, adequate glare-free night light, a working and reachable call light, the bed in low position at night, and having personal items within reach. A review of the Morse Fall Scale form (an assessment tool used to predict the resident's potential for experiencing a fall) dated 6/1/2023, indicated Resident 1 scored a 65, as a score of 45 or greater indicated a high risk for falls. The Morse Fall Scale form indicated Resident 1 had a history of falling and exhibited a weak gait (resident may shuffle and steps were short). A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 6/7/2023, indicated the resident had moderately impaired cognition (decisions poor; cues/supervision required), required extensive assistance and one-person physical assistance for bed mobility, transferring, locomotion (movement) on/off unit, dressing, and toilet use. The MDS indicated Resident 1 required limited assistance and one-person physical assistance for personal hygiene; and supervision and set up help for eating. The MDS further indicated Resident 1 was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, and surface-to-surface transferring. The MDS further indicated Resident 1 normally used a walker and wheelchair; and was frequently incontinent (having no voluntary control) of urine and always incontinent of bowel. According to a review of Resident 1's Morse Fall Scale dated 6/27/2023, the resident scored 85, as a score of 45 or greater indicated a high risk for falls. The Morse Fall Scale form indicated Resident 1 had history of falling, exhibited a weak gait, and the resident overestimated or would forget her limits. A review of Resident 1's Change of Condition (COC) documentation dated 7/6/2023 at 4:30 PM, indicated Resident 1 claimed she had a fall but could not specify the day and location. The COC indicated Resident 1 complained of pain to the right side of her face with noted maroon/purplish discoloration of the periorbital (skin surrounding the eye) area of the right eye and mid-forehead. The COC indicated Resident 1's clinician was notified with recommendations for an x-ray of the skull, monitor discoloration, and continue neuro checks per facility protocol. A review of Resident 1's care plan initiated 7/6/2023, indicated Resident 1 claimed she had a fall and the interventions were for Resident 1 to have a tab alarm in bed/wheelchair to alert staff of the resident getting out of bed unassisted, neurological assessment per facility protocol for 72 hours, and a stat x-ray to skull. A review of the Physician's Order dated 7/6/2023, indicated Resident 1 was to have a low bed with floor mats to prevent injury secondary to the resident trying to get out of bed unassisted. According to a review of Resident 1's x-ray of the skull results signed 7/7/2023 at 1:41 PM, it was an unremarkable examination. A review of Resident 1's care plan initiated 7/25/2023, indicated the resident was trying to get out of bed or chair without assistance and had episodes of forgetfulness. The care plan interventions indicated to frequently cue Resident 1, monitor the resident for episodes of getting out/up and redirect behavior, move the resident to a room closer to the station to provide easy visibility/cueing, ensure the tab alarm was applied and functioning well, to keep the bed in lowest position at all times and ensure the floor mats were in place. A review of Resident 1's COC documentation dated 8/3/2023 at 2:45 PM, indicated the resident had an unwitnessed fall and denied pain. A review of Resident 1's Pain Assessment dated 8/3/2023 at 3:06 PM, indicated Resident 1 denied pain and upon assessment could move all extremities with no complaints of pain. A review of Resident 1's COC documentation dated 8/3/2023 at 5:48 PM, indicated Resident 1 had an episode of screaming and yelling with complaints of severe throbbing pain to the right hip, right thigh, and right heel. The COC indicated Acetaminophen (pain medication) was administered to Resident 1 but was not effective in relieving the resident's pain. A review of the Physician's Order dated 8/3/2023, indicated to transfer Resident 1 to GACH 1 to rule out limb threatening ischemia (inadequate blood supply) to the right lower extremity. According to a review of GACH 1 Computed Tomography Angiogram (CT scan, detailed images of the body that uses a dye to create pictures of blood vessels) of the lower extremity dated 8/3/2023 at 11:16 PM, Resident 1 had an acute to subacute right intertrochanteric femoral fracture with mild posterior displacement (broken right hip). A review of GACH 1 Physician Progress Note indicated on 8/7/2023 Resident 1 received right hip fracture repair with intramedullary nail (a surgical rod forced into a long bone of the extremities that acts as an immobilization device to hold the two ends of the fractured long bone in position) surgery. During an observation on 8/17/2023 at 2:57 PM, Resident 1 was lying on her back in bed with the bed position low and floor mats to the left and right side of the bed. During a concurrent interview, Resident 1 stated she was in the hospital last week because she had an operation on both hips. During an interview on 8/17/2023 at 3:58 PM, Certified Nursing Assistant (CNA) 1 stated Resident 1 frequently tried to get out of bed and had a bed alarm, but sometimes when staff check the resident, she was already sitting at the side of the bed. CNA 1 stated Resident 1 needed assistance with walking and was confused most of the time. A review of the facility's Policy and Procedure titled, "Care Plan, Comprehensive Person-Centered," revised 12/2016, indicated the interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. During an interview on 8/17/2023 at 4:30 PM, the Director of Nursing (DON) stated there was no IDT meeting held for Resident's 1 COC on 8/3/2023. During an interview on 8/22/2023 at 2:14 PM, Registered Nurse Supervisor (RNS) 3 stated she was working on 8/3/2023 when Resident 1 fell. RNS 3 stated Resident 1 was found on the floor by Licensed Vocational Nurse (LVN) 2. RNS 3 stated Resident 1 did not like to use the call light and had very impulsive behavior. RNS 3 stated Resident 1 did not have a sitter but needed one to prevent falls. RNS 3 stated the current solution was to place Resident 1 near the nurse's station. During an interview on 8/22/2023 at 2:22 PM, LVN 2 stated he was working on 8/3/2023 when he heard Resident 1's bed alarm again and went and helped her back to bed. LVN 2 stated Resident 1 was usually alert with episodes of confusion, tried to get out of bed all the time, was impulsive, and did not use the call light. On 8/22/2023 at 2:45 PM, during an interview, CNA 2 stated she remembered Resident 1 coming back from dialysis on 8/3/2023 and Resident 1 tried to get out of bed. CNA 2 stated she helped Resident 1 back to bed a couple of times that day. CNA 2 stated Resident 1 never used the call light, and she would help Resident 1 to the chair. CNA 2 stated Resident 1 did not have a sitter but should have one because she always tried to get out of bed. During a telephone interview on 8/22/2023 at 4:20 PM, Resident 1's Family Member (FM) stated the resident had a history of falls and was always trying to get out of bed. The FM stated she was informed of Resident 1's fall on 8/3/2023 but stated she had not had an IDT meeting with the facility regarding Resident 1's plan of care after the resident fell on 8/3/2023 or when she was re-admitted to the facility. A review of Resident 1's Resident Care Conference documentation indicated there were no resident care conferences / IDT meetings documented for Resident 1's COC regarding falls on 7/6/2023 and 8/3/2023. During an interview on 8/23/2023 at 9 AM, the Medical Records (MR) staff stated the only IDT meeting for Resident 1 was dated for 6/9/2023. During an interview on 8/23/2023 at 9:04 AM, Registered Nurse Supervisor (RNS) 3 stated IDT meetings were usually done after an incident like a fall, or a complaint. During a concurrent interview and record review on 8/23/2023 at 9:08 AM, Resident 1's Resident Care Conference documentation was reviewed with Social Services (SS). SS stated IDT meetings were done quarterly, if the resident or family members had issues, on admission if there were concerns, and with a COC. The SS stated that he was part of the IDT meetings and an IDT meeting for Resident 1 was not held after her COC on 7/6/2023 or 8/3/2023. SS stated according to the facility's policy an IDT meeting should have been held with Resident 1's family after the resident had a COC . SS stated the purpose of an IDT meeting was to discuss the resident's plan of care, the family's concerns, and to give updates to family members on the plan of care. SS stated if an IDT was not held there was a potential for the resident concerns and plan of care to not be addressed. During a concurrent interview and record review on 8/23/2023 at 9:20 AM, Resident 1's Resident Care Conference documentation was reviewed with Registered Nurse Supervisor (RNS) 2. RNS 2 stated not conducting an IDT meeting can lead to the resident not receiving updated care after a change in condition. RNS 2 stated Resident 1 needs to be monitored closely due to the resident's impulsive behavior and attempts to get out of bed to keep the resident safe from falls. A review of the facility's Policy and Procedure titled, "Falls and Fall Risk, Managing," revised 3/2018, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and to try to minimize complications from falling ...Resident conditions that may contribute to the risk of falls include fever, infection, delirium and other cognitive impairment, pain, lower extremity weakness, poor grip strength, medication side effects, orthostatic hypotension, functional impairments, visual deficits, and incontinence ...If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant ...Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarm will be monitored for efficacy and staff will respond to alarms in a timely manner. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue to change the current interventions. As a result of the investigation, CDPH determined that the facility failed to: 1.Re-evaluate the interventions related to Resident 1’s specific risks and causes to try and prevent the resident from falling and try to minimize complications from falling in accordance with the facility’s policy and procedure titled, “Falls and Fall Risk, Managing,” last revised 3/20