Health inspection·July 25, 2024

§483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident’s clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. 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. 22 CCR § 72311 Nursing Services - 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: (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. On 6/11/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a recertification survey. The facility failed to: 1. Provide services to maintain mobility (ability to move) for Resident 7 with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility, by failing to: a. Provide Resident 7 with Rehab Rounding and Screening: Rehabilitation Services in the form of passive range of motion ([PROM] movement of joint through the ROM with no effort from the person) in both arms and both legs from 8/3/2022 to 9/30/2022 in accordance with the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities) and Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) discharge recommendations dated 8/3/2022, and physician's orders dated 8/3/2022, for the Restorative Nursing Aide ([RNA] a certified nursing aide program that helps residents to maintain their function and joint mobility). b. Apply the resting hand splint [material secured to the arm with straps which extends from the fingertips to the forearm to position the wrist and the fingers to maintain ROM and prevent the development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness)] to Resident 7's right arm from 8/3/2022 to 2/10/2023 (for six months) in accordance with the OT's discharge recommendations dated 8/3/2022, and physician's orders dated 8/3/2022, for the RNA to apply a right resting hand splint for up to six hours, five times per week. c. Obtain both knee splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to Resident 7's knees as indicated in the PT Discharge Summary dated 8/3/2022, for positioning and contracture prevention from 8/3/2022 to 3/26/2024 (for 19 months). d. Monitor Resident 7's ROM in each joint of both arms and legs quarterly in accordance with Resident 7's care plan for limitation in ROM dated 9/7/2022, which indicated to assess Resident 7's joint mobility quarterly. e. Apply both hand rolls (rolled towel placed in the palm) to Resident 7's hands on 6/11/2023 in accordance with the physician's orders dated 5/12/2024, for the RNA to apply both hand rolls for four to six hours, five times per week as tolerated. f. Apply the elbow extension splint (splint which prevents bending at the elbow) on Resident 7's right arm on 6/11/2024 in accordance with the physician order dated 6/3/2024, for the RNA to apply the right elbow extension splint for 4-6 hours, five times per week as tolerated. g. Ensure the facility's policy and procedures (P&P) titled, "Rehab Rounding and Screening: Rehabilitation Services," included screening that covers objective data and assessments to identify functional decline. As a result, Resident 7 developed further ROM limitations in both arms and legs, including the development of contractures of the right hand, right elbow, both shoulders, and legs, which caused Resident 7 to feel pain with movement and ROM, and prevented Resident 7 from getting out of the bed, including receiving a shower. Resident is a 73-year-old female admitted to the facility on 7/15/2022 with diagnoses including hemiplegia (severe or complete loss of strength or paralysis of one side of the body) or hemiparesis (partial weakness or inability to move one side of the body) following a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant (used more often) side, dysphagia (difficulty swallowing), gastrostomy tube status ([G-tube] a tube surgically placed directly into the stomach for administration of medications and nutrition), aphasia (loss of ability to understand or express speech as a result of brain damage), and functional quadriplegia (complete immobility due to frailty or severe physical disability). A review of Resident 7's Rehabilitation Screening Form, dated 7/15/2022, indicated the resident had contractures present in both arms (unspecified joints and severity) and both legs (unspecified joints and severity). The Rehabilitation Screening Form indicated PT and OT evaluations were requested for Resident 7. A review of Resident 7's OT Evaluation and Plan of Care, dated 7/15/2022, indicated the resident had ROM in both shoulders and both elbows within functional limits (WFL, sufficient movement without significant limitation). The OT Evaluation indicated Resident 7 had impairment in both wrists and minimal (unspecified) limitation in both hands. The OT Evaluation indicated Resident 7 was dependent (helper does all the effort or the assistance of two or more helpers is required for the resident to complete the activity) on staff for oral hygiene (ability to clean teeth and mouth), toileting, showering/bathing, upper body dressing, and lower body dressing. A review of Resident 7's PT Evaluation and Plan of Care, dated 7/15/2022, indicated the resident had severe (unspecified) contractures in both hips, both knees, and both ankles. The PT Evaluation indicated Resident 7 was dependent for rolling to both sides, chair/bed-to-chair transfers, and toilet transfers. A review of Resident 7's OT Discharge Summary, dated 8/3/2022, indicated the resident had a resting hand splint applied to the right hand for six hours and a hand roll applied to the left hand for six hours. The OT Discharge Summary indicated recommendations for an RNA program to provide PROM to both of Resident 7's arms followed by the application of a hand roll on Resident 7's left hand and a resting hand splint on Resident 7's right hand for up to six hours, five days per week. A review of Resident 7's PT Discharge Summary, dated 8/3/2022, indicated the RNA (unknown) demonstrated 100 percent (%) competence with PROM exercises in both legs in a comfortable range to decrease Resident 7's risk for further contractures. The PT Discharge Summary also indicated Resident 7 would benefit from both knee splints for positioning and to prevent further contracture, pending health insurance approval. A review of Resident 7's physician orders, dated 8/3/2022, indicated an RNA program to provide PROM to both arms and both legs, to apply a left-hand roll for up to 6 hours, and to apply a right resting hand splint for up to six hours, five times per week as tolerated. A review of Resident 7's Restorative Nursing Flow Sheets ([RNA Flow Sheets] record of RNA session) did not include RNA sessions for the month of 8/2022. A review of Resident 7's physician's orders, dated 8/30/2022, indicated an order to discontinue RNA for PROM to both legs. A review of Resident 7's census (record of hospitalizations, room changes, and payer source changes) indicated Resident 7 was transferred to the general acute hospital (GACH) on 8/31/2022. A review of Resident 7's physician orders, dated 9/2/2022, indicated to discontinue RNA for PROM to both arms, the application of the left hand roll up to 6 hours, and application of the right resting hand splint for up to six hours due to Resident 7's hospitalization. A review of Resident 7's census indicated the resident was readmitted to the facility on 9/6/2022. A review of Resident 7's care plan for limitation in ROM related to history of cerebral vascular accident ([CVA] a condition when blood flow stops to a part of the brain, brain damage due to blocked blood flow) with right-sided weakness, initiated on 9/7/2022, indicated an intervention to assess Resident 7's joint mobility (ROM at each joint) upon admission and quarterly or as needed. A review of Resident 7's Rehabilitation Screening Form, dated 9/7/2022, indicated the resident did not have any changes in ROM and positioning. The Rehabilitation Screening Form did not include Resident 7's joint mobility assessment in both arms and both legs. The Rehabilitation Screening Form indicated therapy services were not indicated and Resident 7 was referred to RNA. A review of Resident 7's physician orders, dated 9/7/2022, indicated for RNA to provide PROM to both arms and both legs, five times per week as tolerated. Resident 7's physician's orders did not include RNA for the application of the left-hand roll and right resting hand splint. A review of Resident 7's RNA Flow Sheets did not include RNA sessions for the month of 9/2022. A review of Resident 7's RNA Flow Sheet for 10/2022 indicated RNA provided the resident with PROM to both arms and both legs, five times per week as tolerated, and did not include for the RNA to apply Resident 7's left hand roll or right resting hand splint. A review of Resident 7's Rehabilitation Screening Form, dated 10/21/2022, indicated the resident did not have any changes in ROM and positioning. The Rehabilitation Screening Form did not include Resident 7's joint mobility assessment in both arms and both legs. The Rehabilitation Screening Form indicated to continue with the RNA plan of care. A review of Resident 7's RNA Flow Sheets from 11/2022 to 1/2023 indicated RNA provided the resident with PROM to both arms and legs, five times per week as tolerated, and did not include for the RNA to apply Resident 7's left hand roll or right resting hand splint. A review of Resident 7's Rehabilitation Screening Form, dated 1/5/2023, indicated the resident did not have any changes in ROM and positioning. The Rehabilitation Screening Form did not include Resident 7's joint mobility assessment in both arms and legs. The Rehabilitation Screening Form indicated to continue with the RNA plan of care. A review of Resident 7's physician's orders, dated 2/10/2023, indicated for RNA program to apply both hand rolls for four to six hours, five times per week as tolerated. A review of Resident 7's RNA Flow Sheet for 2/2023 indicated the RNA applied both hand rolls for four to six hours, five times per week as tolerated, starting on 2/10/2023. A review of Resident 7's RNA Flow Sheets from 3/2023 to 11/2023, indicated the RNA provided the resident with PROM to both arms and legs and applied both hand rolls for four to six hours, five times per week. A review of Resident 7's Rehabilitation Screening Form, dated 12/5/2023 (11 months since the last Rehabilitation Screening on 1/5/2023), indicated the RNA (unknown) reported a change of condition, including Resident 7 screaming when attempting to place left hand roll. The Rehabilitation Screening Form indicated a new RNA program included applying a right-hand roll. A review of Resident 7's physician's orders, dated 12/5/2023, indicated for RNA to apply the right-hand roll for four to six hours, five times per week. A review of Resident 7's Rehabilitation Screening Form, dated 12/28/2023, indicated the resident did not have any noted changes in ROM. Resident 7's Rehabilitation Screening Form did not include Resident 7's joint mobility assessment in both arms and legs. The Rehabilitation Screening Form indicated to refer Resident 7 to RNA to maintain ROM in both arms and both legs. A review of Resident 7's RNA Flow Sheets for 1/2024 and 2/2024 indicated the RNA provided the resident with PROM to both arms and legs and applied both hand rolls for four to six hours, five times per week, from 1/1/2024 to 2/8/2024. A review of Resident 7's census indicated the resident was transferred to the GACH on 2/8/2024 and was readmitted back to the facility on 2/14/2024. A review of Resident 7's Rehabilitation Screening Form, dated 2/15/2024, indicated to refer the resident to the OT and PT evaluations for details. A review of Resident 7's OT Evaluation and Plan of Care, dated 2/15/2024, indicated the resident had impaired ROM in both arms, including right shoulder flexion (lifting the arm upward) 0 to 45 degrees (0 to 45 degrees, normal 0 to 180 degrees), right elbow flexion (bending the elbow) 90 to 150 degrees (normal 0 to 150 degrees), left shoulder flexion 0 to 10 degrees, left elbow flexion 20 to 150 degrees, and left wrist flexion (bending the wrist downward) 0 to 45 degrees (normal 0 to 90 degrees). A review of Resident 7's PT Evaluation and Plan of Care, dated 2/15/2024, indicated the resident had impaired ROM in both legs, including both hips fixed (unable to move) to 130 degrees of hip flexion (bending the leg at the hip joint toward the body, normal 0 to 130 degrees) and both knees fixed to 150 degrees of knee flexion (bending the knee, normal 0 to 135 degrees). A review of Resident 7's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 4/22/2024, indicated the resident was dependent on staff with oral hygiene, toileting, showering/bathing oneself, upper and lower body dressing, rolling to both sides and tub/shower transfers. The MDS indicated Resident 7 did not attempt chair/bed-to-chair transfers due to medical condition or safety concerns. A review of Resident 7's OT Discharge Summary, dated 4/24/2024, indicated the RNA program for ROM exercises was established and Resident 7 tolerated wearing both hand rolls and a right elbow extension splint for five hours. The OT discharge recommendations included RNA to provide Resident 7 with PROM to both arms, apply both hand rolls, and apply the right elbow extension splint. A review of Resident 7's PT Discharge Summary, dated 4/26/2024, indicated knee splints were applied to both knees starting on 3/26/2024. The PT Discharge Summary indicated Resident 7 had both knee splints applied for up to four hours and had improved ROM to 95 to 110 degrees. The PT Discharge Summary also indicated the RNA (unknown) provided a 100% return demonstration for PROM to both legs through the available ROM. The PT Discharge recommendations included for RNA to provide Resident 7 with PROM to both legs, five times per week as tolerated, and to apply both knee extension splints. A review of Resident 7's physician's orders, dated 4/26/2024, indicated for RNA to provide PROM to both legs and apply the right elbow extension splint for 4 to 6 hours, five times per week as tolerated. Another physician order, dated 4/26/2024, indicated for the RNA to apply both of Resident 7's knee extension splints (duration unspecified), seven times per week as tolerated. A review of Resident 7's physician's orders, dated 5/13/2024, indicated for RNA to apply both hand rolls for four to six hours, five times per week as tolerated. A review of Resident 7's RNA Flow Sheet for 5/2024 indicated the RNA provided PROM to both arms and legs, applied both hand rolls for four hours, and applied both knee splints for four hours, five times per week. During a telephone interview, on 6/11/2024 at 11:4