Other·June 12, 2024

F689 Code of Federal Regulations, Title 42, Section 483.25 Free of Accidents / Supervision 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. California Code of Regulations, Title 22, Section 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: (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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. On 4/26/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the Recertification survey. The facility failed to ensure Resident 13, who had history of fracture, muscle weakness, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and lack of coordination (not able to move different parts of the body together well or easily), received care and services necessary to prevent accidents and falls by failing to: 1.Assess Resident 13 accurately for a high fall risk on 11/3/2023. 2.Identify measures and interventions for risk for falls prior to Resident 13’s fall on 1/20/2024. 3. Implement the facility’s P&P titled, “Fall Risk Assessment,” revised 1/18/2024, to complete a fall risk assessment on admission, and update after any falls or change of condition and with quarterly and annual MDS assessment. As a result, Resident 13 had a witnessed fall near the nurse’s station on 1/20/2024 while ambulating in the hallway. The resident was transferred to the General Acute Care Hospital (GACH) 1 and was diagnosed with an acute (new) left femoral neck fracture (hip fracture). Resident 13 underwent left hip hemiarthroplasty surgery (replaced half of a hip joint) at GACH 1. A review of Resident 13’s Admission Record (face sheet) indicated the facility admitted the resident on 9/16/2014, with diagnoses including fracture of left femur (thigh bone), personal history of traumatic healed fracture (occurs when significant or extreme force is applied to a bone), pain in left hip, chronic pain syndrome (occurs when pain remains long after an illness or injury has healed), schizophrenia, and lack of coordination and muscle weakness. A review of Resident 13’s History and Physical (H&P) dated 2/26/2020, indicated the resident could make needs known but could not make medical decisions. The H&P indicated Resident 13 required Physical Therapy (PT- certain exercises, massages, and treatments that relieve pain and help you move better), and Occupational Therapy (OT-therapy that focuses on helping people do all the things that they want and need to do in their daily lives) due to potential for falls. A review of Resident 13’s PT Evaluation and Plan of Treatment dated 3/5/2023, indicated the resident exhibited knee instability which was associated with the underlying causes of muscle weakness and reduced functional activity tolerance. The PT evaluation indicated Resident 13 had reduced quad (a group of muscles in our front thigh that support activities such as standing, walking, climbing, and running) strength and felt unsteady when walking. A review of Resident 13’s Pain Assessment dated 11/3/2023, indicated the resident had pain to his bilateral (both) knees and he thought the chronic pain syndrome and osteoarthritis (a joint disease, in which the tissues in the joint break down over time) were the causes of his pain. The pain assessment further indicated Resident 13 felt sharp pain to his knees. A review of Resident 13's Minimum Data Set (MDS- standardized assessment and care planning tool) dated 11/3/2023, indicated the resident had moderately impaired cognition (problems with a person's ability to think, learn, remember, use judgement), required facility staff set up or clean up assistance with putting on taking off footwear and toilet transfer. The MDS indicated Resident 13 required partial assistance for mobility and ambulation (walking from room to room). According to a review of the Fall Risk Assessment dated 11/3/2023, Resident 13 had never fallen, had more than one diagnoses, was not using ambulatory aids (wheelchairs, walkers, canes, and crutches), and exhibited normal gait (the pattern that you walk). The fall risk assessment indicated Resident 13 had a score of 15 and a score from 1 – 24 indicated a low risk for falls. A review of Resident 13’s Situation Background Assessment and Recommendation Form (SBAR - a form that was a documentation of a complete assessment in response to a change in condition) dated 1/20/2024, indicated Resident 13 had pain to his left leg due to a witnessed fall while ambulating in the hallway, near the nurse’s station. The SBAR form indicated Resident 13 fell on his left side. A review of Resident 13’s left hip X-Ray result dated 1/20/2024, indicated there was no acute fracture or dislocation of Resident 13’s left hip. According to review of the Post Fall Assessment dated 1/22/2024, Resident 13 went to smoke in the patio and while returning back to his room, he attempted to ambulate independently, tripped while wearing slippers, and fell on the floor on 1/20/2024. Resident 13 was found on the floor in the hallway next to the nurse’s station. A review of Resident 13’s Post Event / Fall Assessment Form dated 1/22/2024, indicated the following factors contributed to Resident 13’s current fall: improper use or failure to use assistive device, mobility issues, taking psychoactive (medications that affect the brain) anti-hypertensive medications (used to treat high blood pressure), and diagnoses of schizophrenia and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 13’s Fall Event / Interdisciplinary Team (IDT, health care professionals who work together to establish plans of care for residents) Progress Note dated 1/22/2024, indicated the root/cause analysis (technique that helps people answer the question of why the problem occurred in the first place) of the resident’s fall on 1/20/2024, was improper use of footwear, impulsiveness, and unsteady gait. The IDT progress note indicated that on 1/24/2024, during rounds, Resident 13 reported to Social Service Director (SSD) and Activity Director (AD) that he had pain to his left leg rating 6-7 out of 10 (using pain rating scale of zero being no pain and 10 being the worst pain possible) when trying to get up. The IDT progress note indicated a registered nurse on duty notified Resident 13’s physician and received an order for left pelvis (lower part of the trunk, between the abdomen and the thighs) X-Ray. A review of Resident 13’s left hip X-Ray result dated 1/24/2024, indicated an acute left femoral neck fracture. A review of Resident 13’s SBAR Communication Form dated 1/24/2024, indicated the resident complained of left hip pain, rating 8/10, and the staff noted a swelling (an abnormal enlargement of a part of the body) to Resident 13’s left hip. The SBAR communication form indicated Resident 13’s physician ordered to transfer the resident to GACH 1 for further evaluation and treatment of acute left femoral neck fracture. According to a review of GACH 1 Physician Progress Notes dated 2/1/2024, Resident 13 underwent left hip hemiarthroplasty surgery. A review of Resident 13’s active care plans on 4/27/2024, indicated the licensed staff did not develop a care plan with person-centered interventions for Resident 13’s risk for fall. During a concurrent interview and record review, on 4/27/2024 at 4:40 PM, with the MDS Coordinator (MDSN), Resident 13’s care plans were reviewed. The MDSN stated licensed nurses did not develop a care plan for Resident 13’s risk for fall. The MDSN stated on 1/20/2024, Resident 13 was wearing slippers while he was walking towards the nurse’s station and fell on the floor. During a concurrent interview and record review, on 4/27/2024 at 4:48 PM, with Registered Nurse Supervisor 1 (RN 1), Resident 13’s medical record was reviewed. RN 1 stated Resident 13 was taking anti-depressant, anti-psychotic medications and anti-hypertensive medications. RN 1 stated, “There is a risk for fall if a resident is taking these types of medications” and that it “Seems like there is no care plan with specific goals and person-centered interventions for Resident 13’s risk for fall in his medical chart.” During a concurrent interview and record review, on 4/27/2024 at 5:05 PM, with the Director of Staff Development (DSD), Resident 13’s Fall Risk Assessments were reviewed. The DSD stated Resident 13’s fall risk assessments dated 11/3/2023, indicated he was considered a low risk for potential falls and the licensed nurses documented Resident 13 had normal gait. The DSD stated Resident 13’s gait was not normal. The DSD stated, “Resident 13 had a history of surgery and pain to his left leg and both knees. Resident 13 was limping.” The DSD further stated licensed staff should have documented weak gait instead of normal gait when completing Resident 13’s fall risk assessments dated 11/3/2023. The DSD stated Resident 13 was not considered a high risk for fall based on the incorrect fall risk assessments. Therefore, appropriate interventions were not implemented to prevent his fall. The DSD stated, “Resident 13 was wearing an open toe slipper and that is why he tripped and fell.” During an interview on 4/30/2024 at 11:35 AM, Licensed Vocational Nurse (LVN) 3 stated “Resident 13 was a risk for falls because of his abnormal gait because of his knee pain. The resident was bowlegged (having legs that curve outward at the knee) and was walking fast.” LVN 3 stated “Resident 13 was wearing a pair of open-toe slippers and he fell because he tripped on his open toe slippers. Those slippers were not safe for the resident and Resident 13 was insisting to wear them.” LVN 3 further stated, “We could have prevented Resident 13’s fall on 1/20/2024, by not letting him wear those slippers.” LVN 3 stated licensed staff did not develop a care plan for Resident 13’s non-compliance (not obeying a rule) of wearing inappropriate footwear. A review of the facility’s policy and procedures (P&P) titled, “Fall Prevention Program,” revised 1/18/2024, indicated all residents will be assessed for risk for fall in order to facilitate fall prevention and reduction program. If a resident is at risk for falls, it will be identified on the care plan. A review of the facility’s P&P titled, “Fall Risk Assessment,” revised 1/18/2024, indicated the facility will complete a fall risk assessment on admission, and update after any falls or change of condition and with quarterly and annual MDS assessment. All residents will be assessed for risk for fall in order to facilitate fall prevention and reduction program. A review of the facility’s policy and procedure titled, “Post Fall Management Program,” dated 12/2016, indicated all residents will be assessed for risk of fall in order to facilitate fall prevention and reduction program. To ensure that all residents are assessed following an incident of fall. The facility failed to ensure Resident 13, who had history of fracture, muscle weakness, schizophrenia and lack of coordination, received care and services necessary to prevent accidents and falls by failing to: 1.Assess Resident 13 accurately for a high fall risk on 11/3/2023. 2.Identify measures and interventions for risk for falls prior to Resident 13’s fall on 1/20/2024. 3. Implement the facility’s P&P titled, “Fall Risk Assessment,” revised 1/18/2024, to complete a fall risk assessment on admission, and update after any falls or change of condition and with quarterly and annual MDS assessment. As a result, Resident 13 had a witnessed fall near the nurse’s station on 1/20/2024 while ambulating in the hallway. The resident was transferred to the GACH 1 and was diagnosed with an acute left femoral neck fracture. Resident 13 underwent left hip hemiarthroplasty surgery at GACH 1. The above violations presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 13.