Other·June 23, 2022

F684 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(a)(2) 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. On 12/15/2021, the California Department of Public Health made an unannounced visit to the facility to investigate a facility reported incident about Resident 1’s quality of care. The facility failed to ensure Resident 1, who had dementia (loss of memory, thinking and reasoning), was a high risk for falls and was diagnosed with schizophrenia (serious mental disorder in which people interpret reality abnormally, may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior), received care, treatment, and services in accordance with the facility’s policies and procedures. The facility failed to: -Ensure Resident 1 was provided a low bed and floor mats, per facility’s Fall Prevention Program policy; and -Notify the Physician of Resident 1’s altered behavior and / change in condition. As a result, on 11/27/2021, at 8:20 a.m., Resident 1 sustained an injury, complained of left leg pain, moaned with facial grimacing when trying to stand, and had bilateral (both) hip bruises with pain on movement. Resident 1 was transferred to the general acute care hospital (GACH 1) where Resident 1 was found to have a left hip fracture (complete or partial break in the bone) and required surgery. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on 11/15/2021, with diagnoses including schizophrenia, major depressive disorder and dementia. A review of Resident 1's Fall Risk Assessment dated 11/15/2021, indicated Resident 1 had intermittent confusion, was chair bound, and had a balance problems while standing. The fall risk assessment indicated Resident 1 had a total score of 10 (10 or greater indicated the resident should be considered a high risk for potential falls). The fall risk assessment indicated the prevention protocol should be initiated and immediately documented on the care plan. A review of the Care Plan for Falls dated 11/15/2021, indicated Resident 1 was at risk for falls due to wandering, constant pacing, poor safety awareness, restlessness / frequent position changes, and use of medication with potential adverse side effects. The care plan goal indicated Resident 1 would have no falls or injuries daily for the next three months. The interventions indicated to provide adequate lighting, monitor resident's whereabouts and / location with visual checks at least every two hours, keep call light within reach and answer promptly, monitor for sedation, dizziness, unsteady standing / or sitting balance, and inform the physician if any were noted. The interventions did not include placing Resident 1's bed in the lowest position and applying bilateral floor mats. A review of Resident 1's Behavior Care Plan dated 11/15/2021, and updated on 11/26/2021, indicated Resident 1 had altered behavior patterns related to schizophrenia manifested by persistent wandering from room to room, episodes of cleaning the floor, and lying and sleeping on the floor. The care plan goal was to reduce the episodes of behavior daily and minimize the risk of decline daily for 90 days. The interventions included to provide reality awareness, assess what may cause and trigger behavior, attempt to reduce and / eliminate those triggers if possible, notify the physician of any refusals, and psychiatrist follow up as indicated. According to a review of Resident 1's Behavioral Pattern Care Plan dated 11/15/2021 and updated on 11/26/2021, Resident 1 had the behavior of wandering, moving without rational purpose, was oblivious to needs or safety, was constant pacing and had episodes of cleaning the floor for no apparent reason. The interventions included to redirect behavior to something positive, psychology and psychiatrist consult, monitor side effects of medications, and notify the physician. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/23/2021, indicated Resident 1's cognitive skills of daily decision making were moderately impaired (unable to make decisions), and the resident was disoriented to year, month and day. The MDS indicated Resident 1 needed one-person physical assistance with activities of daily living (ADLs, includes bed mobility, transfer, dressing, eating). A review of Resident 1's Nursing Daily Notes dated 11/26/2021, indicated Resident 1's skin was assessed, and no bruises or discoloration were observed. Resident 1 denied pain or discomfort. The daily notes indicated Resident 1 was assisted back to bed, and staff explained to resident to use the call light, provided reality orientation, and redirection. The daily notes did not indicate that Resident 1 was restless, pacing back and forth in the hall, lying down on the floor inside her room or cleaning the floor using her hands. A review of Resident 1's Nurses Progress Notes dated 11/27/2021, at 8:20 a.m., indicated Resident 1 was sitting on her bed and complained of pain on the left leg. Resident 1 was unable to get up. Resident 1 was moaning and with facial grimacing when assisted to stand up. Resident 1 was placed back to her bed. The nurse’s notes indicated during assessment there were bruises on bilateral hips. Resident 1 was given acetaminophen (pain medication) 650 milligrams (mg.). A review of Resident 1's Physician and Telephone Orders dated 11/27/2021, at 9:15 a.m., indicated Resident 1's primary physician gave an order to transfer Resident 1 to GACH 1 due to pain on bilateral hips. A review of Resident 1's the GACH 1 Urgent Care Physician's Note dated 11/27/2021, at 7:02 p.m. indicated Resident 1 had bruises on bilateral hips. Resident 1 had increased pain and decreased range of motion (ROM, full movement potential of a joint,) in the left hip. A review of Resident 1's History and Physical dated 11/28/2021 at 4:35 p.m., indicated x-rays of the hip indicated a displaced left sub capital hip fracture (broken bones have moved out of their normal position). The history and physical form indicated Resident 1 was unable to explain the circumstances of how this happened due to confusion. A large hematoma (collection of blood outside of blood vessels caused by an injury) was noted on bilateral hips. The history and physical form indicated Resident 1 was unable to move the left leg without visible pain and discomfort. According to a review of Resident 1's GACH 1 Operative Report dated 12/3/2021, Resident 1 presented to GACH 1 after a fall and suffered a left hip injury. This GACH 1 report indicated Resident 1 had left hip hemiarthroplasty (surgical procedure that involved replacing half of the hip joint). A review of Resident 1's Nurses Progress Notes dated 12/8/2021 at 10:55 p.m., indicated Resident 1 was re-admitted to the facility with 24 staples (used to close incisions after surgery) on the surgical site in the left hip measuring 16 centimeters (cm.) by 0.5 cm. The surgical site had no evidence of infection with wound dressing. Leg abduction pillow (device used to prevent the hip from moving out of the joint) was in place to prevent hip adduction (movement of the leg away from the midline of the body) or internal rotation (twisting motion that creates inward rotation of the thigh at the hip joint). On 12/15/2021, at 10:03 a.m., during an interview the Director of Nursing (DON) stated Resident 1 may have had an unwitnessed fall on 11/26/2021 between the hours of 9 p.m. to 7 a.m. The DON stated on 11/26/2021, at 9 p.m., Resident 1 was found on the floor in her room and was cleaning the floor with her hands. Resident 1 was assessed and had no injury. At 10 p.m., Resident 1 was found on the floor again, assessed and had no injury. Resident 1 was assisted back to bed. At 12:30 a.m., Resident 1 was found lying on the floor with pillow and blanket. Resident 1 was assisted back to bed. At 2 a.m. Resident 1 was found lying on the floor with pillow and insisted that her sister wanted her to sleep on the floor. Resident 1 was assisted back to bed. At 4 a.m., Resident 1 wanted to sleep on the floor and tried to slide down from her bed. Resident 1 was assisted back to bed. At 5:20 a.m. Resident 1 was trying to slide down from her bed and assisted back to bed. At 7 a.m. Resident 1 was sliding down from the bed and crawled towards the closet. On 12/15/2021, at 10:57 a.m., during an interview Registered Nurse Supervisor (RNS) 1 stated on 11/27/2021, at about 8 a.m., he received report that Resident 1 had bruises on bilateral hips. RNS 1 stated Resident 1 complained of pain in the left hip and RNS 1 gave her pain medication. Resident 1's primary physician was notified and gave an order to transfer Resident 1 to GACH 1 for further evaluation. On 12/17/2021, at 4:20 p.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1 stated on 11/26/2021, at about 9 p.m., Resident 1 was found on the floor on her knees cleaning the floor with her hands. LVN 1 stated he assisted Resident 1 in getting up from the floor and Resident 1 was able to stand up easily. Resident 1 had no complaints of pain. LVN 1 stated he did not document his assessment in resident’s medical records. LVN 1 stated at 10 p.m. Resident 1 was found on the floor again, cleaning the floor. On 12/17/2021, at 4:35 p.m. during a telephone interview, RNS 2 stated Resident 1 was found sitting on the floor two different times on 11/26/2021, both times cleaning the floor with her hands. RNS 2 agreed that when Resident 1 was found on the floor, Resident 1 may have had an unwitnessed fall. RNS 2 stated he did not notify the physician. During an interview on 12/22/2021, at 10:36 a.m., the Certified Occupational Therapist Assistant (COTA) stated prior to the fall, Resident 1 was ambulatory and independent when walking. After the fall, Resident 1 had to use a wheelchair and can only walk for a distance of three feet. On 12/22/2021, at 9:26 a.m., during an interview and a review of Resident 1's Care Plan for fall and the facility’s Policy for Fall Management with the DON, the DON was unable to find documentation indicating Resident 1 was placed on low bed and floor mats as stipulated in the facility's policy and procedures. The DON stated the low bed would lessen the impact of injury in case of falls. The DON further stated when Resident 1 was exhibiting behavior of restlessness, inability to sleep, sliding and crawling out of bed, and cleaning and wiping the floor, the DON would have called the physician. The DON was unable to find documentation that the physician was notified. During a telephone interview on 12/22/2021, at 4:29 p.m., LVN 2 stated during the night shift on 11/27/2021, Resident 1 was restless and crawling out of bed. LVN 2 stated she found Resident 1 on the floor four different times, cleaning the floor. LVN 2 stated Resident 1 would crawl out of bed or slide herself off the bed., LVN 2 assessed Resident 1 for injury and there was no injury observed. LVN 2 stated she did not document her assessments or interventions each time Resident 1 was found on the floor and stated she did not notify the physician. During a telephone interview on 12/30/2021 at 4:22 p.m., the Psychiatrist Nurse Practitioner (NP) stated when Resident 1 was exhibiting behavior of restlessness, inability to sleep, sliding out of bed and found on the floor, the facility staff should have notified her. The NP stated she could have given an order for laboratory tests to rule out infection, delirium or dehydration. The NP stated she may prescribe new medication. A review of the facility's policy and procedures titled, "Fall Prevention Program," date 12/2016, indicated the facility will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. All residents will be assessed following incident of fall. The policy indicated a fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. The policy indicated if upon admission, a risk for fall is identified, initiate use of fall prevention and reduction program according to fall risk score. If a resident is at risk for falls, it will be identified on the care plan. All precautions will be implemented to protect the resident according to the fall prevention and reduction program. Direct staff will re-assess resident with every episode of fall. The Policy indicated consider the use of the following equipment: -bed and/or chair alarms -alarms at exit -nonskid floor mat -raised edge mattress -nurses call systems and communication systems -beds for residents at risk for fall - low bed, bed in lowest position. The policy indicated to keep the beds in lowest position when feasible. Use height adjustable "hi-low" beds or fixed low-deck height beds where applicable. Consider providing a bed footboard to assist patients and residents use in transferring in and out of bed or in ambulating about the bedroom. Mattresses should be firm enough to support safe bed transfer. Landing mattress may be used for fall prevention next to bed to decrease injuries. A review of the facility's policy and procedures titled, "Change of Condition," dated 8/2017, indicated to promptly notify the resident, his or her attending physician and representative of changes in the residents' medical/mental condition and/or status. Acute medical changes or serious change in condition manifested by a marked change in physical, mental or psychosocial status licensed nurse will notify the physician. Nurses will record in the resident's medical record information relative to changes in the resident's medical or mental condition or status. The facility failed to ensure Resident 1, who had dementia (loss of memory, thinking and reasoning), was a high risk for falls and was diagnosed with schizophrenia (serious mental disorder in which people interpret reality abnormally, may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior), received care, treatment, and services in accordance with the facility’s policies