Other·February 5, 2024

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. §483.25(d) Accidents. The facility must ensure that - (d)(1) The resident environment remains as free of accident hazards as is possible; and (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 12/11/2023, 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. As a result of the investigation, CDPH determined that the facility failed to: 1. Provide a 1:1 sitter as ordered, and care planned, in accordance with the Physician’s Order dated 12/4/2023, Resident 1’s Care Plan initiated and revised on 12/4/2023, and the facility’s policy and procedure titled, “Supervision/Sitter,” released 11/2023. 2. Develop a care plan for Resident 1’s non-compliance with the abduction pillow (a pillow placed between the legs that helps prevent the hip from turning in or away from the body. It keeps the hip straight while in bed and while asleep. The abduction pillow holds the hip in one position to help it heal), in accordance with the facility’s policy and procedure titled, “Care Planning (IDT) Policy,” effective 11/16/2023. 3. Ensure Resident 1 was seen by a physician within 72 hours of admission to the facility, in accordance with the facility’s policy and procedure titled, “Physician Visits,” revised 11/2023. As a result, on 12/5/2023 (eight days after original surgery) it was observed Resident 1's left foot was pointing inward. On 12/6/2023, the resident was transferred to the General Acute Care Hospital (GACH), for further evaluation and management of the left lower extremity abnormal position. Resident 1, an 87-year-old female, developed a second dislocation of the left hip and required a closed reduction left hip surgery under anesthesia. A review of Resident 1’s Admission Record indicated the facility admitted the resident on 11/30/2023 with diagnoses including fracture of the left femur (broken hip joint, 11/27/2023), repeated falls, lack of coordination, unsteadiness on the feet, Alzheimer’s Disease (the most common type of dementia, a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and psychosis (a mental disorder characterized by a disconnection from reality). A review of Resident 1’s Physician’s Order dated 11/30/2023, indicated to apply abductor pillow while in bed every shift. The Physician’s Order indicated Resident 1 was to have no flexing post 90 degrees and no internal rotation (for the left leg). A review of Resident 1’s Nurses Notes dated 12/1/2023, indicated the resident was non-compliant with safety measures, tried to get out of bed unassisted, and refused to be assisted during ambulation. The note indicated redirection was ineffective, and that Resident 1 was reminded to use the call light but was unable to put it to use due to her condition. The nurses note indicated Resident 1 removed the abductor pillow three times while in bed during the 7 AM to 3 PM shift. The nurses note indicated Resident 1 was explained the risk and benefits multiple times but continued to refuse. A review of Resident’s 1’s Orders-Administration Note dated 12/2/2023 indicated the resident was non-compliant with the abductor pillow and the risk and benefits were explained. A review of Resident 1’s Nurses Notes dated 12/2/2023 at 8:25 PM, indicated the resident got up from bed unassisted three times at the start of the PM shift, was non-compliant with safety measures and indicated the redirection was ineffective. The nurses note indicated Resident 1 was being monitored, was reminded to use the call light, but the resident was unable to put it to use due to her condition. The note further indicated Resident 1 was non-compliant to keep the abductor pillow on. A review of Resident 1’s Nurses Notes dated 12/3/2023 at 7:15 AM, indicated there was a 1:1 sitter at the resident’s bedside, resident was non-compliant with the use of the abductor pillow and the risk and benefits were explained. According to a review of Resident 1’s Skilled Services Documentation dated 12/3/2023 at 5:28 PM, the resident was trying to get up from bed unassisted, and safety reminders and visual checks were provided. A review of Resident 1’s Case Manager Note dated 12/4/2023 at 11:20 PM, indicated an urgent request was sent to the resident’s insurance for a 1:1 sitter. The note indicated the sitter was to be provided by Resident 1’s insurance for diagnoses including Alzheimer’s disease, dementia, psychotic disturbance, anxiety disorder, psychosis not due to a substance or known physiological condition. A review of Resident 1’s Physician’s Order dated 12/4/2023, indicated for a 1:1 sitter to be provided by the resident’s insurance for diagnoses including Alzheimer’s disease, dementia, psychotic disturbance, anxiety disorder, psychosis not due to a substance or known physiological condition. A review of the facility’s Nursing Staff Assignment and Sign-In Sheet for the C-Wing Floor dated 12/4/2023 for the 7 AM– 3 PM shift, indicated Certified Nursing Assistant (CNA) 8 was assigned to be 1:1 sitter for Resident 1. A review of Resident 1’s Care Plan initiated and revised on 12/4/2023, indicated the resident had altered thought process related to Alzheimer’s disease and dementia as evidenced by a short term and long-term memory problem, the resident could not recall after five minutes or of long past; unable to make decisions, a problem understanding others, and a problem making needs known. The care plan indicated interventions included to provide a 1:1 sitter as ordered, to anticipate and meet needs, observe/report change in cognitive status, increasing confusion, increased forgetfulness, and a change in communication skills. The care plan interventions further indicated to provide reality orientation, provide calm, therapeutic environment and structured routine, establish and maintain a consistent, routine, environment, use simple language, and to allow resident ample time to absorb and respond to information. According to a review of Resident 1’s Care Plans there was no care plan initiated for the resident’s non-compliance to use the abductor pillow or for the resident’s attempts to get out of bed without assistance. A review of the facility’s Nursing Staff Assignment and Sign-In Sheet for the C-Wing Floor dated 12/4/2023 for the 3 PM– 11 PM shift, indicated CNA 8 was again assigned to be the 1:1 sitter for Resident 1, and the 11PM– 7 AM shift, indicated Resident 1 was assigned a sitter. A review of the facility’s Nursing Staff Assignment and Sign-In Sheet for the C-Wing Floor dated 12/5/2023, for the 7 AM – 3 PM shift, did not indicate there was a 1:1 sitter for Resident 1. The Sign-In Sheet indicated Resident 1 was one of six residents assigned to CNA 6 that shift. A review of the facility’s Nursing Staff Assignment and Sign-In Sheet for the C-Wing Floor dated 12/5/2023 for the 3 PM – 11 PM shift, did not indicate there was a 1:1 sitter for Resident 1. The Sign-In Sheet indicated Resident 1 was one of the six residents assigned to CNA 9 that shift. A review of Resident 1’s Change of Condition (COC) Evaluation form dated 12/5/2023 at 9:13 PM, indicated the resident had an abnormal appearance of the left leg that started on 12/5/2023 at night. The COC form indicated Resident 1’s family visited and informed the charge nurse that the resident’s leg looked different. The COC form indicated the charge nurse and Registered Nurse (RN) assessed the resident and noted the resident’s the left foot was pointing inward. The COC form indicated Resident 1 had previous behavior of non-compliance and trying to get out of bed. The COC form indicated the wedge was in place, the primary care clinician was notified. According to a review of Resident 1’s Physician’s Oder dated 12/5/2023, a STAT (immediate) x-ray (an imaging study that creates pictures of the inside of the body using radiation) of the left hip, knee, and ankle was ordered. A review of Resident 1’s Nurses Notes dated 12/6/2023 at 1:58 PM, indicated radiology was checked to follow-up with the resident’s x-ray, and indicated a tech was not yet assigned. A review of Resident 1’s Nurses Notes dated 12/6/2023 at 4:30 PM, indicated a phone call was received from Medical Doctor (MD) 1 of the GACH. The note indicated MD 1 ordered to transfer Resident 1 to the GACH for further evaluation and management of the left lower extremity abnormal position / appearance, related to status post left hip arthroplasty (hip replacement, a surgical procedure in which the hip joint is replaced by a prosthetic implant, that is, a hip prosthesis) per Family Member (FM) 1’s request. A review of Resident 1’s Emergency Department Physician’s Notes from the GACH dated 12/6/2023 at 8:43 PM, indicated the resident was brought in by ambulance complaining of the left foot turned inwards. The History and Physical indicated Resident 1 denied pain on arrival. A review of Resident 1’s Imaging Report of the left hip dated 12/6/2023 at 10:39 PM, indicated the resident had posterior superior acetabular component dislocation (dislocated left hip). A review of the History and Physical (H&P) Update from the GACH dated 12/7/2023, indicated MD 1 was informed by FM 1 that Resident 1 was noted to be without abduction pillow and the leg was noted to be shortened when she visited the resident on 12/5/2023. The H&P update further indicated the x-ray imaging showed dislocation of a left hemiarthroplasty and no evidence of a fracture. The Update indicated Resident 1 would need closed reduction under anesthesia that same day. According to a review of the Surgery and Procedure Reports from the GACH dated 12/7/2023 at 5:06 PM, Resident 1 had an operation under anesthesia (the second operation in approximately one week). The Surgery and Procedure Report indicated Resident 1 had a left hip closed reduction of dislocated hip prosthesis. During a telephone interview on 12/13/2023 at 10:40 AM, FM 1 stated she did not like the care the facility provided to Resident 1. FM 1 stated she went to visit Resident 1 on 12/5/2023 in the evening and found the resident’s left leg twisted. FM 1 stated she then informed the nurse what she had seen. FM 1 stated Resident 1 had a 1:1 sitter at the GACH and she spoke to MD 1 from the GACH who stated the resident’s leg did not look good. FM 1 stated MD 1 informed her that Resident 1 must have fell or got the injury when the resident was changed. FM 1 stated MD 1 told her Resident 1’s leg was dislocated so he was going to try and snap the leg back in. FM 1 stated MD 1 informed her Resident 1 lost a lot of tissue from the injury. FM 1 stated facility staff informed her they could not be watching Resident 1 and the resident could not have a 1:1 sitter during the day to watch the resident. FM 1 stated the facility staff told her sorry and that they were going to try to do their best. During a concurrent interview and record review on 12/13/2023 at 1:47 PM, the Nursing Staff Assignment and Sign-In Sheet for the C-Wing Floor dated 12/5/2023 for the 7 AM – 3 PM shift was reviewed with Registered Nurse (RN) 4. RN 4 stated she was working on the C-wing on 12/5/2023 on the 7 AM to 3 PM shift. RN 4 stated Resident 1 was non-compliant with the abductor pillow and indicated the resident removed it and tried to get up out of bed. RN 4 stated Resident 1 required a 1:1 sitter and there were no reports from staff regarding abnormalities of the left leg that shift. RN 4 stated there were no reports that Resident 1 fell on that shift. RN 4 stated on the sign in sheet there was no indication there was a sitter for Resident 1 on 12/5/2023 during the 7 AM to 3 PM shift. During an interview on 12/13/2023 at 2:34 PM, CNA 6 stated she was taking care of Resident 1 on 12/5/2023 during the 7 AM to 3 PM shift. CNA 6 stated that on that shift Resident 1 would try to stand up and would throw away her abductor pillow. CNA 6 stated Resident 1 did not have a sitter on 12/5/2023 during her shift. CNA 6 stated she fed the resident breakfast and lunch, and indicated she had to stay with the resident a while because the resident would try to get out of bed. CNA 6 stated she went in and out of the room to see and help Resident 1. CNA 6 stated Resident 1 was confused and on occasions would see Resident 1 with her legs hanging off the side of the bed. On 12/13/2023 at 4:10 PM, during an interview, CNA 9 stated she was working 12/5/2023 on the 3 PM to 11 PM shift and was assigned to take care of Resident 1. CNA 9 stated Resident 1 would try to stand up and try to remove the pillow between her legs. CNA 9 stated Resident 1 did not have a sitter at the change of the shift and indicated she told the charge nurse the resident needed a 1:1 sitter. CNA 9 stated FM 1 came to sit with the resident that night sometime after 4 PM. CNA 9 stated FM 1 saw how Resident 1’s leg looked different and told the charge nurse. During a telephone interview on 12/14/2023 at 10:34 AM, MD 2 stated she saw Resident 1 on 12/4/2023. MD 2 stated she was not informed Resident 1 was declining the abductor pillow. MD 2 stated Resident 1 needed to use the abductor pillow at all times after her left hip surgery on 11/27/2023. MD 2 stated if Resident 1 was not compliant with the abductor pillow the left hip could get dislocated. During a concurrent interview and record review on 12/14/2023 at 1:42 PM, Resident 1’s care plan was reviewed with RN 4. RN 4 stated Resident 1 was confused and was non-compliant with the abductor pillow. RN 4 stated Resident 1 started refusing and removing the abductor pillow on 12/1/2023 and would regularly try to get out of bed. RN 4 stated Resident 1 did not have a care plan initiated for the resident’s non-compliance of the abductor pillow prior to the residents change of condition on 12/5/2023. RN 4 stated the care plan was part of communication and identify concerns that needed attention. RN 4 stated not care planning for Resident 1’s non-compliance could cause staff to not be aware of the resident’s needs and affect the resident quality of care. During a concurrent interview and record review on 12/5/2023 at 11:50 AM, the Nursing Staffing Assignment and Sign-In Sheet for the C-Wing Floor dated 12/5/2023 for the 7 AM – 3 PM shift and Resident 1’s care plan was reviewed with the Director of Nursing (DON). The DON