Other·February 22, 2024

§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: (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. The California Department of Public Health (Department) determined during the concurrent investigation of a complaint and facility reported incident that the facility failed to provide adequate supervision and assistance to Resident 1 when, on 12/4/2023, Certified Nursing Assistant (CNA) 1 provided one-person assistance while giving care and turning Resident 1 in his bed. Resident 1 was assessed as a high fall risk needing two-person assistance with bed mobility (moving, turning, or positioning of body in bed). As a result, Resident 1 suffered an avoidable fall, resulting in an acute fracture to Resident 1’s left femur that required an operation including a hip screw fixation to his left hip. On 12/19/2023, the California Department of Public Health made an unannounced visit to the facility to investigate a complaint and a facility-reported incident about quality-of-care/treatment allegations. The facility failed to prevent a fall and injury for Resident 1, who was identified as a high fall risk. On 12/4/2023, the facility failed to provide Resident 1, who was assessed as needing extensive assistance with bed mobility with two-person physical assistance when CNA 1 did a one-person assistance while giving care and turning Resident 1 in his bed. As a result, on 12/4/2023 at 2:50 p.m., Resident 1 had an avoidable fall resulting to Resident 1 experiencing pain, acute fracture to the left femur, and an operation procedure called “Intramedullary hip screw fixation left hip” at the GACH 1. A record review of Resident 1’s Admission Record indicated the facility originally admitted the 58-year-old male resident on 6/7/2023 with diagnoses of encephalopathy (dysfunction in the brain causing confusion or memory loss), polyneuropathy (damaged nerves that cause problems in sensation, coordination or have effect on body functions), and personal history of transient ischemic attack (temporary blockage of blood flow to the brain), and cerebral infarction (damage to the brain due to lack of oxygen). A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 9/13/2023, indicated that Resident 1’s cognitive skills for daily decision-making tasks were severely impaired. The MDS further indicated that Resident 1 required extensive assistance with bed mobility, transfers (moving from bed to wheelchair), and total dependence from staff for toileting needs (use of toilet including cleansing after toilet use). Resident 1 required the assistance of two staff members to complete these tasks. A review of Resident 1’s Fall Risk Evaluation, dated 6/7/2023, indicated that Resident 1 scored a fall risk total score on the facility’s fall risk assessment of 18, where a score of 10 or higher indicates the resident is at high risk of falls. The assessment also indicated, “If Resident is a fall risk, initiate fall risk precautions.” On 12/19/2023 at 9:52 a.m., during a phone interview, CNA 1 stated Resident 1’s fall took place on 12/4/2023 around 2:50 p.m. CNA 1 admitted being aware Resident 1 required a two-person assist. CNA 1 further stated that while providing care to Resident 1, CNA 1 did not realize Resident 1 was already at the edge of the bed, causing Resident 1 to fall off the bed. CNA 1 stated that since it was at the end of the shift, there were no other staff members available to assist in providing care to Resident 1. CNA 1 stated Resident 1’s fall could have been prevented if assistance from another staff member was provided. On 12/19/2023 at 10:10 a.m., during a phone interview, Licensed Vocational Nurse (LVN) 1, identified Resident 1 as alert and having weakness to one side of the body. LVN 1 stated, “We do a daily huddle at the start of each shift, and we tell the CNAs which residents require two-staff assistance.” LVN 1 stated that Resident 1 had a red-colored star sticker on the nameplate at the doorway to the room which meant that Resident 1 required two-person assist. LVN 1 stated that the facility is trying to prevent falls with injury, and Resident 1 received surgery after the fall. LVN 1 stated that the risks of surgery include infection to the surgical site, excessive bleeding, pain including severe pain, emotional harm, and risk for death. On 12/19/2023 at 10:38 a.m., during an interview, Resident 1 recounted his fall in the facility a couple of weeks prior. Resident 1 stated the staff member (CNA 1) was working alone with Resident 1 during the time of the fall. When asked how Resident 1 felt about the incident, Resident 1 stated, “I felt bad because I told the CNA that I don’t like being turned from my left side. I am weak on my left side. I had a stroke, and my right side is my stronger side. I ended up having a fall and I had surgery on my left hip.” On 12/21/2023 at 1:35 p.m., during a concurrent interview and record review of a document titled, “Shift Huddle,” with the Director of Staff Development (DSD), the DSD stated CNA 1 received training for fall prevention management including training on the meaning of a red star sticker, which always meant the resident identified with the sticker on a nameplate is a two-person assist. A concurrent review of the document titled, “Shift Huddle,” dated 12/2/2023, 12/3/2023, and 12/4/2023, indicated that CNA 1 signed-in as a participant in the shift updates. The DSD stated that CNA 1 participated in three separate dates and signed the participation of residents’ safety concerns with Resident 1 included in the list as high risk for falls. The DSD stated that on 12/4/2023 around 2:50 p.m., CNA 1 did not follow the instructions of having two staff members to assist Resident 1, which was necessary because Resident 1 has left sided weakness to the body. The DSD stated Resident 1 always had a red star sticker on the nameplate. DSD stated that the failure was that CNA 1 did not follow the two-staff assist for Resident 1, that Resident 1 encountered a fall which resulted in left hip fracture and need for surgery. The DSD stated the risks for surgery include risk for infection on surgical site, further decline in Resident 1’s mobility, Resident 1 could be depressed from not being able to participate in activities of daily living because of the weakness and being tired, bleeding, and develop a blood clot from decreased mobility. The DSD stated, “All this could lead to death.” On 12/21/2023 at 2:35 p.m., during an interview with Registered Nurse 1 (RN 1), RN 1 stated Resident 1 required two persons assist meaning when Resident 1 turns, there should be another staff to assist on each side as Resident 1 was not able turn independently. RN 1 stated that Resident 1’s fall could have been prevented by following the required assistance needed by Resident 1 and providing two staff members. RN 1 stated the risks involved with going through surgery include pulmonary embolism which is a blood clot going into the lungs that could impair breathing and cause death. RN 1 stated Resident 1 had history of embolism. RN 1 stated that the open surgical sites can lead to infection, and it can lead to depression for the resident, and pain caused by limitation in movement. RN 1 stated symptoms of depression are decreased activity, poor appetite or decreased participation with activities including rehabilitation therapy (care that can help you get back, keep, or improve abilities that you need for daily life), insomnia, and difficulty sleeping. A review of Resident 1’s record titled, “Change in Condition Evaluation,” dated 12/4/2023 at 2:50 p.m., indicated that Resident 1 was found on the floor lying on his right side. The evaluation indicated Resident 1 complained of pain on his left shoulder and left leg with pain level of four out of 10 (which means moderate pain using the pain rating scale). The evaluation indicated CNA 1 was changing Resident 1 and while turning Resident 1 on his side, Resident 1 rolled off the bed hitting his left shoulder on the bedside table and falling to the floor. A review of Resident 1’s Physician’s Order, dated 12/4/2023 at 3:31 p.m., indicated a stat (immediate) order to conduct an x-ray of Resident 1’s left humerus (upper arm bone) and left femur due to Resident 1’s pain. A review of Resident 1’s record titled, “Radiology Report,” with date of service on 12/4/2023, indicated, “Conclusion: Limited exam with only 1 view of the hip which is suspicious for a nondisplaced (when the bone cracks or breaks but remains in correct position) fracture.” A review of Resident 1’s Physician’s Order, dated 12/4/2023 at 10:55 p.m., indicated to transfer Resident 1 to GACH 1 for Computed Tomography (CT) scan for a possible fracture. A review of Resident 1’s GACH 1 record titled, “Radiology Report,” dated 12/5/2023 at 9:55 a.m., indicated a CT scan was done on Resident 1’s left hip without use of contrast. Resident 1’s CT scan result indicated he suffered an acute fracture to the left femur. A review of Resident 1’s GACH 1 record titled, “Operative and Procedure Reports,” dated 12/7/2023 at 11:31 a.m., indicated Resident 1 had an operation procedure “Intramedullary hip screw fixation left hip.” The indication for surgery also stated that the risks of this procedure include, but are not limited to bleeding, infection, neurovascular damage (damage to major blood vessels supplying brain), malunion (healing of bone in abnormal position), nonunion (failure of fractured bone to heal), implant failure, anesthesia risk (risks with use of medications that block pain), loss of limb, and loss of life. A review of Resident 1’s “Care Plan,” initiated on 6/8/2023, with the focus indicating, “Potential changes in mental status, lethargy related to compromised brain function associated with encephalopathy” included the intervention to “Provide necessary assistance as needed.” A review of the current facility-provided policy and procedure titled, “Resident Safety,” with last revised date of 4/15/2021, indicated the purpose, “To provide a safe and hazard free environment.” A review of the current facility-provided policy and procedure titled, “Falling Star Program,” with last revised date of 2/1/2023 included the purpose to ensure residents will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. A review of the current facility-provided policy and procedure titled, “Fall Management Program,” with last revised date of 3/13/2021, indicated, “The facility will implement a Fall Management Program that supports providing an environment free from fall hazards.” The facility failed to prevent a fall and injury for Resident 1, who was identified as a high fall risk. On 12/4/2023, the facility failed to provide Resident 1, who was assessed as needing extensive assistance with bed mobility with two-person physical assistance when CNA 1 did a one-person assistance while giving care and turning Resident 1 in his bed. As a result, on 12/4/2023 at 2:50 p.m., Resident 1 had an avoidable fall resulting to Resident 1 experiencing pain, acute fracture to the left femur, and an operation procedure called “Intramedullary hip screw fixation left hip” at the GACH 1. The above 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.