Health inspection·December 28, 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. 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 11/13/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the recertification survey and investigation of a facility reported incident. The facility failed to ensure Resident 31, who had a history of repeated falls and was a high fall risk, received monitoring for episodes of restlessness, per the comprehensive assessment and Falls care plan to prevent accidents. As a result, on 11/11/2023, Resident 31, a 94-year-old male, fell from his wheelchair and was found on the floor by the Certified Nursing Assistant (CNA). Resident 31 had discomfort to the left arm, had a head injury and was transferred to the General Acute Care Hospital (GACH) the same day, where he was diagnosed with a hematoma (an abnormal pooling of blood in the body under the skin that results from a broken or ruptured blood vessel) on the forehead, face abrasion (type of open wound that was caused by the skin rubbing against a rough surface), and a face contusion (bruise, when small blood vessels break open and leak blood into the nearby area). A review of Resident 31's Admission Record indicated the facility re-admitted the resident on 7/25/2021 with diagnoses including age-related osteoporosis (a disease that weakens bones), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), aphasia (loss of the ability to understand or express speech) following a cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), benign prostatic hyperplasia (enlarged prostate), and a history of falling. The Admission Record indicated Resident 31's emergency contact was Family Member (FM) 3. A review of Resident 31's Care Plan initiated on 7/25/2021 indicated the resident was high risk for falls due to a diagnosis of dementia, poor safety judgement, history of multiple falls, use of antidepressant medication, and use of blood pressure medication. The care plan goals indicated Resident 31 would be free of falls and the resident's risk for fall would be minimized. The care plan interventions indicated to monitor Resident 31 for episodes of restlessness due to the need for incontinence (lack of voluntary control over urination or defecation) care; to monitor the resident's behavior of trying to get out of bed unassisted, and to consider further interventions when the resident started exhibiting behavior again. The care plan did not indicate a revision or update by 10/25/2023 on a quarterly basis. A review of Resident 31's Morse Fall Scale (an assessment tool that predicts the likelihood a resident will fall) dated 9/14/2023, indicated the resident was a high risk for falling with a history of falling, used a wheelchair and nurse assistance, and had impaired gait (difficulty rising from chair, watches the ground, grasps furniture, person or aid when ambulating, cannot walk unassisted). The Morse Fall Scale further indicated Resident 31 overestimated or forgot the limits of his ability to ambulate safely. A review of the MDS dated 9/20/2023, indicated Resident 31 had severely impaired cognition (never/rarely made decisions), was totally dependent and required one-person physical assistance for transferring, and locomotion (movement) on and off the unit. The MDS indicated Resident 31 required extensive assistance and two-person physical assistance for bed mobility and toilet use. The MDS indicated Resident 31 was not steady and only able to stabilize with staff assistance when moving from a seated to standing position and with surface-to-surface transferring. According to a review of the Physician’s Order Summary Report from 9/2023 to 11/2023, there were no orders to monitor Resident 31 for episodes of restlessness or behavior of trying to get out of bed unassisted. A review of Resident 31' Medication Administration Record (MAR) for 11/1/2023 to 11/11/2023, indicated there was no documentation for the monitoring of episodes of restlessness due to the need for incontinence care, or for the monitoring of the resident's behavior of trying to get out of bed unassisted. A review of the Situation Background Assessment and Request (SBAR) Communication Form dated 11/11/2023, indicated at 6:19 PM certified nursing assistant (CNA) heard a tab alarm, rushed to check, found Resident 31 lying on the floor by the hallway, and called for help. The SBAR indicated the Registered Nurse (RN) went to check Resident 31 and found the resident leaning on his left side with his face towards the floor. The SBAR indicated a neuro assessment was done, Resident 31 was alert and responsive, a skin assessment was done, and the resident was noted with a skin tear to the nasal bridge, lump on the forehead, and skin tear to the right hand. The SBAR indicated Resident 31 was able to move all extremities but was noted with discomfort at the left upper extremity upon movement. The SBAR further indicated Resident 31's primary physician was notified with recommendations to transfer Resident 31 to the General Acute Care Hospital (GACH) for evaluation. The SBAR further indicated Resident 31's Family Member (FM) 3 was notified. A review of the Physician's Order dated 11/11/2023 indicated may transfer Resident 31 to GACH 1 Emergency Department (ED) for evaluation related to status post fall. A review of GACH 1 records indicated Resident 31 arrived to GACH 1's Emergency Department (ED) via ambulance on 11/11/2023 at 8:05 PM with a chief complaint of a head injury. According to a review of GACH 1's ED Care Timeline, on 11/11/2023 at 8:27 PM, Resident 31 was brought in complaining of a fall with a hematoma (an abnormal pooling of blood in the body under the skin that results from a broken or ruptured blood vessel) on the forehead, laceration (a deep cut or tear on the skin) on the nose, and left hand and shoulder pain. A review of GACH 1 ED Provider Notes dated 11/11/2023 at 8:53 PM, indicated Resident 31 was sent to GACH 1 from the facility to rule out head bleed and left shoulder fracture (break in the bone). The ED Provider Note indicated findings that Resident 31 had a midline frontal scalp edema (swelling caused by too much fluid trapped in the body's tissues) and hematoma. A review of GACH 1's After Visit Summary dated 11/11/2023, indicated Resident 31 had diagnoses of a head injury, face abrasion (type of open wound that's caused by the skin rubbing against a rough surface), and face contusion (bruise, when small blood vessels break open and leak blood into the nearby area). A Review of GACH 1's ED Care Timeline, indicated on 11/12/2023 at 1:09 AM Resident 31 was transferred back to the facility. During an observation on 11/13/2023 at 8:50 AM, Resident 31 was observed lying in bed, with a bruise, maroon in color, an elevated bump to the middle of his forehead and a laceration on his nose. During a concurrent interview, when asked about the injuries, Resident 31 did not answer. During an interview on 11/14/2023 at 2:38 PM, Physical Therapist Assistant (PTA) stated Resident 31 was often restless, was confused and was not able to stand on his own. The PTA stated Resident 31's cognition was on and off. The PTA further stated Resident 31 could not remember to use the call light for assistance after being instructed to do so. During an interview on 11/14/2023 at 9:04 AM, the covering Director of Rehabilitation (DOR) stated Resident 31 had dementia and required nursing to monitor him at all times. The DOR stated Resident 31 needed continuous monitoring to prevent falls. The DOR stated Resident 31 was forgetful and tried to get out of bed. The DOR stated Resident 31 did not know to call for assistance. On 11/15/2023 at 10:20 AM, during a telephone interview, FM 3 stated they did not feel the facility's interventions to prevent falls for Resident 31 were working. FM 3 stated Resident 31 had fallen in the facility at least two times and was previously found lying on the floor and later complained of pain on the hip. FM 3 stated, "I understand falls happen, but they have dementia and needs to be watched more carefully." During an interview on 11/15/2023 at 10:25 AM, CNA 4 stated she was Resident 31's CNA and was familiar with the care the resident needs. CNA 4 stated Resident 31 needed entire assistance and indicated the resident could not do anything on his own. CNA 4 stated sometimes Resident 31 tried to get out of bed, the resident was very anxious and was trying to sit on the edge of the bed. CNA 4 stated Resident 31 was confused, could not stand up by himself, and did not walk. CNA 4 stated Resident 31 required monitoring because he was not alert enough to use the call light. During an interview on 11/15/2023 at 10:38 AM, Licensed Vocational Nurse (LVN) 1 stated he was taking care of Resident 31 and the resident used the wheelchair to get around. Resident 31 could not walk but tried to get out of the wheelchair and bed. During a concurrent review of Resident 31's Risk for Falls Care Plan, LVN 1 verified there were interventions to monitor Resident 31 for episodes of restlessness due to the need for incontinence care; to monitor the resident's behavior of trying to get out of bed unassisted, and to consider further interventions when the resident started exhibiting behavior again. LVN 1 stated monitoring would normally be documented on the MAR and there was no documentation for monitoring on Resident 31's MAR for 11/2023. LVN 1 stated if there was an order for monitoring, then there would be documentation for the monitoring. LVN 1 stated these things should be in place to alert the staff that the interventions need to be done. During an interview on 11/15/2023 at 10:58 AM, Resident 31's Order Summary Report, Risk for Falls Care Plan, and Medication Administrator Record (MAR) for 11/2023 were reviewed with Registered Nurse (RN) 1. RN 1 stated monitoring behaviors would be documented on the MAR and would be documented as tally marks on the MAR to see how often the resident would have the behaviors. RN 1 stated behaviors were monitored to see the trend of the behaviors and to prevent falls. On 11/15/2023 at 3:57 PM, during an interview, CNA 7 stated Resident 31 often tried to get out of bed and the wheelchair by himself. During an observation and interview on 11/15/2023 at 4:07 PM, Resident 31 was observed lying in bed with a bruise to his forehead and laceration to his nose. Resident 31 was observed with the bed low, floor mats to both sides of the bed, and a bed alarm in place. Resident 31 stated that he had pain that comes and goes to his nose and forehead. Resident 31 stated he did not remember how he got the pain, but stated the pain gets really painful, then gets better, then gets painful again. During a concurrent interview and record review, on 11/16/2023 at 11:46 AM, The DON stated there was no physician's order for the interventions to monitor behavior or episodes of restlessness for Resident 31, but indicated a physician's order to monitor the resident was obtained on 11/15/2023. The DON stated there was no documentation for the monitoring of episodes of restlessness or behavior of trying to get out of bed unassisted prior to 11/15/2023. The DON stated monitoring would be useful to identify trends and characteristics of restlessness and useful to prevent falls. A review of the facility's policy and procedure titled, "Routine Resident Checks," revised 7/2013, indicated staff shall make routine resident checks to help maintain resident safety and well-being. To ensure routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. The Nursing Supervisor / Charge Nurse shall keep documentation related to these routine checks, including the time, identity of the person making checks, and any outcomes of each check. A review of the facility's policy and procedure, revised 7/2017, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions; providing training as necessary; ensuring interventions are implemented; and documenting interventions. Monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently; evaluating the effectiveness of interventions; modifying or replacing interventions as needed; and evaluating the effectiveness of new or revised interventions. Resident supervision was a core component of the systems approach to safety. The type and frequency of resident supervision was determined by the individual's assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition. A review of the facility's policy and procedure titled, "Falls - Clinical Protocol," revised 3/2018, indicated the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. The facility failed to ensure Resident 31, who had a history of repeated falls and was a high fall risk, received monitoring for episodes of restlessness, per the comprehensive assessment and Falls care plan to prevent accidents. As a result, on 11/11/2023, Resident 31, a 94-year-old male, fell from his wheelchair and was found on the floor by the CNA. Resident 31 had discomfort to the left arm, had a head injury and was tr