Health inspection·June 20, 2024

California Code of Regulations, Title 22, Section 72311 (a)(1) (A)(B)(C) Nursing Service - General 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. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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. California Code of Regulations, Title 22, Section 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. Code of Federal Regulations, Title 42 483.25(d) Accidents. The facility must ensure that – §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents The facility failed to ensure safety and prevent fall (unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) for Patients 2 and 3 who were assessed at high risk for fall by failing to: 1. Updated Patient 2’s care plan interventions titled “Potential for Injury R/T Fall Risk,” and reassess Patient 2's fall risk assessment after Patient 2 fell on 4/25/2024. 2. Update Patient 3's care plan titled “Falls/Injuries R/T History of Falls” after Patient 3 had a fall on 4/9/2024. These deficient practices resulted in Patient 2 had another fall on 5/4/2024 and was sent to General Acute Care Hospital (GACH 1) and placed Patient 3 at risk for another fall incident. 1. A review of Patient 2's admission record indicated the facility admitted Patient 2, a 87 years old male on 4/22/24 with diagnoses which included muscle weakness, difficulty in walking, traumatic subarachnoid hemorrhage (traumatic head injury, resulting in bleeding). A review of Patient 2's History and Physical (H&P) dated 4/30 /24 indicated Patient 2 did not have the capacity to make decisions. A review of Patient 2's Minimum Data Set (MDS, standardized care and screening tool), dated 4/26/24, indicated Patient 2’s cognitive (processes of thinking and reasoning) was moderate impaired. The MDS indicated Patient 2 needed supervision or touching assistance for eating, oral hygiene, upper body dressing, personal hygiene, and partial moderate assist for toileting hygiene and personal hygiene. The MDS indicated, the following activities was not attempted due to medical condition or safety concerns, walking 10 feet on uneven surfaces (ability to walk 10 feet) and picking up object. During concurrent interview on 5/8/2024 at 5:47 PM and a review of Patient 2's fall risk assessment dated 4/22/24 indicated Patient 2 was assessed as high risk for fall. The Minimum Data Set Coordinator Nurse (MDSC) stated there was no documented evidence of fall risk assessment was done after Patient 2 fell on 4/25/2024. A review of Patient 2's Progress Notes dated 4/25/24 at 9:46 AM indicated the charge nurse was alerted by the house keeping staff that Patient 2 was on the floor. The progress notes indicated, the charge nurse rushed to Patient 2's bedside and Patient 2 was noted to have blood running down Patient 2’s face. Patient 2 was transferred to GACH 1 via ambulance on 4/25/24, at 12 PM. A review of Patient 2's Progress Notes dated 4/25/24 at 10:19 PM, indicated Patient 2 returned from GACH 1 at 8:30 PM with 2” laceration on the scalp with staples (also called sutures, are special types of thread that hold the edges of a wound together while it heals in place). A review of Patient 2's "Progress Notes" dated 5/4/24 at 11:47 PM (late entry) indicated "around 11:05 PM” Patient 2 was found on the floor in right lateral recumbent position (lying on the right side) and making snoring sound. Patient 2 was unresponsive. The progress notes indicated that the Patient 2 was transferred to GACH 1 via emergency transportation. A review of Patient 2's GACH 1 ED notes dated 5/4/24 at 11:44 PM indicated Patient 2 was brought in by ambulance (BIBA) from the facility for an unwitnessed fall. The GACH 1 ED notes indicated Patient 2 was noted to have a golf ball- sized hematoma on right forehead. During concurrent interview and record review on 5/8/24 at 5:47 PM with the MDSC, Patient 2's Care Plan, titled “Potential for Injury R/T Fall Risk,” initiated on 4/22/24, and revised on 5/3/2024 indicated Patient 2 was at risk for fall related to gait balance problem, psychoactive drugs (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) use, unaware of safety needs, and wandering (a patient who goes beyond the view or control of staff without the intention of leaving the health care facility). The care plan goal indicated for Patient 2 to be free from fall and will not sustain serious injury. The MDSC stated after Patient 2's fall on 4/25/24, the patient's care plan was not reviewed and updated to ensure new interventions are in place to prevent another fall. The MDSC stated the licensed nurses should have updated the care plan as soon as there's a change of condition or fall. The MDSC stated the licensed nurses should revise the CP interventions to keep patient safe and prevent another fall. During the same interview on 5/8/24 at 5:47 PM with the MDSC, the MDSC stated on 4/26/24 Patient 2 was originally in Room A near the nursing station, then on 4/26/24 the patient was transferred to Room B, and Room B is far from the nursing station. The MDSC also stated, based on the Patient 2's MDS dated 4/26/24, for Functional Abilities, Patient 2 needed supervision with assistance for toileting and transfer the patient should have a facility staff to assist the patient to the bathroom. 2. A review of Patient 3's admission record indicated the facility initially admitted Patient 3, a 78 years old female on 2/6/24 and readmitted the patient on 4/10/24 with diagnoses included difficulty walking, muscle weakness, thrombocytopenia (a condition in which there is a lower-than-normal number of platelets in the blood. It may result in easy bruising and excessive bleeding from wounds or bleeding in mucous membranes and other tissues). A review of Patient 3's MDS, dated 2/13/24, indicated Patient 3's cognition was intact. The MDS indicated Patient 3 needed supervision or touching assistance for eating, oral hygiene, and substantial maximal assistance (helper does more than half of the effort) for toileting hygiene, shower bathe self-upper and lower body dressing. The MDS indicated toilet transfer chair to bed transfer was not attempted due to medical condition or safety concerns. A review of Patient 3's "Progress Notes" dated 4/9/24 at 9:54 AM indicated Patient 3 was found on the floor on her back with a large laceration to her left elbow. The Notes indicated Patient 3 was transferred to GACH 1 via emergency transportation. During a concurrent interview with MDSC and record review on 5/8/24 at 6:39 PM, Patient 3's fall risk assessment dated 2/7/24 indicated Patient 3 was assessed as moderate risk for fall. The MDSC stated, Patient 3's fall risk assessment dated 4/10/24 indicated the patient had moderate risk for fall and did not have history of fall. The MDSC stated the fall risk assessment for Patient 3 dated on 4/10/24 was not accurate because the assessment indicated Patient 3 had no history of fall, but Patient 3 fell on 4/9/24. The MDSC stated, the fall risk assessment needs to be accurate to ensure the facility is providing interventions according to Patient 3's needs. During a concurrent interview and record review on 5/8/24 at 6:39 PM, Patient 3's care plan titled, “Falls/Injuries R/T History of Falls” dated from 4/9/24 to 5/2/24, indicated the care plan was not updated after Patient 3 fell on 4/9/2024.The MDSC stated no care plan was initiated after Patient 3 fell on 4/9/24. During an interview on 5/8/24 at 9:45 PM with the Director of Nursing (DON), the DON stated, no investigation nor report were done for Patient 2 when Patient 3 fell on 4/25/24 and on 5/4/24. The DON stated, no investigation was conducted for Patient 3's fall on 4/9/24. The DON stated, both patients (Patients 2 and 3) did not have any injuries after the fall that was why she did not conduct any investigation as to how or why the patients fell. A review of the facility's policies and procedure (P&P) titled, "Safety and Supervision of Patient," revised in 7/2017 indicated "Our facility strives to make the environment as free from accident hazards as possible. Patient safety and supervision and assistance to prevent accidents are facility-wide priorities." A review of the facility's (P&P) titled, "Safety and Supervision of Patient," revised in 3/2018 indicated "for an individual who has fallen, the staff and practitioner will try to identify possible cause within the 24 hours of fall." A review of the facility's (P&P) titled, "Assessing fall and their cause," revised in 3/2018 indicated "the purpose of this procedure is to provide guidance for assessing a patient after a fall and to assist staff in identifying cause of fall. Review the care plans to assess for any special needs of the patient.” The P&P indicated that “falls are leading cause of morbidity and mortality among the elderly in nursing homes." The facility failed to ensure safety and prevent fall for Patients 2 and 3 who were assessed at high risk for fall by failing to: 1. Update Patient 2’s care plan interventions titled, “Potential for Injury R/T Fall Risk,” and reassess Patient 2's fall risk assessment after the patient's fall on 4/25/2024. 2.Update Patient 3's care plan titled, “Falls/Injuries R/T History of Falls” after Patient 3 had a fall on 4/9/2024. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 2 and Patient 3.