Other·December 8, 2021

F-684 § 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. F 689 §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 (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 8/17/2021 an unannounced visit was made to the facility to conduct a facility reported incident investigation and Resident 1’s care was reviewed. The facility failed to provide a floor mat by the bed and failed to have staff frequently observe Resident 1, who was diagnosed with history of falls, and history of healed fracture (broken bone), per Resident 1's care plans on falls/injury and fracture. As a result, on 8/9/2021, at 1:02 PM, Resident 1 had a fall to the floor, requiring transfer to General Acute Care Hospital (GACH) where Resident 1 was diagnosed with a displaced and angulated oblique fracture (a break that is curved or at an angle to the bone) near the distal aspect of a medullary rod within the right femur (broken thigh bone). Resident 1 underwent an open reduction and internal fixation (ORIF, a surgical procedure to fix severely broken bones) of the right distal femur (bottom part of the thigh bone). A review of the Admission Record (Face Sheet) indicated Resident 1 was 85-year-old female, admitted to the facility on 11/25/2019 with diagnoses including, history of falling, osteoarthritis (degeneration of joint cartilage), and glaucoma (a condition of increased pressure within the eye, causing gradual loss of sight). A review of the Physical Therapy evaluation and plan of treatment form dated, 2/24/2020 indicated Resident 1 was a fall risk and required supervision during transfers and reached maximized functional potential that included supervision during bed mobility and transfers. There were no other updates from physical therapy. A review of Resident 1's Fall Risk Assessment, dated 5/31/2021, indicated Resident 1 had intermittent confusion, poor safety awareness, and unable to stand without assistance due to unsteady gait making her at risk for falls. According to a review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 6/2/2021, Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making was moderately impaired. The MDS indicated Resident 1 required limited assistance with one person assist with transfers, and was not stable, only able to stabilize with staff assistance when walking. A review of Resident 1’s care plan revised 6/4/2021, indicated Resident 1 was at risk for falls/injury related to difficulty walking, history of falls, right femur fracture due to fall, and impaired cognition. The goal indicated Resident 1 was to have a reduced risk of falls and injury. The care plan interventions indicated to observe resident frequently, keep frequently used personal items within easy reach, provide safety instructions to resident regarding ambulation (walking), transfer, and activities of daily living when appropriate, low bed, and a floor mat. A review of Resident 1’s care plan revised 6/4/2021, indicated Resident 1 was at risk for spontaneous pathological stress fracture (occur in normal weakened bone) related to a history of right femur fracture (a broken thigh bone), status post (resident has experienced previously) ORIF due to a previous fall. The goal indicated the facility will minimize the risk of fracture and reduce the risk of injury daily. The care plan interventions indicated to assist Resident 1 with all transfers and ambulation as needed. A review of the Change of Condition Assessment form dated, 8/9/2021, indicated at 1:02 PM, Registered Nurse 1 (RN 1) was called by a certified nursing assistant to go to Resident 1's room. RN 1 noted Resident 1 was sitting on the floor in front of her wheelchair beside her bed. Resident 1 complained of right leg pain. The Director of Nurses came in to assess Resident 1. The DON stated Resident 1 reported she always transfers from the wheelchair to the bed by herself and now she ended up on the floor in a sitting position. Resident 1 was assisted back to bed and noted with facial grimacing. At 1:08 PM, the Physician was notified, and new orders indicated Resident 1 received an X-ray to the right leg. A review of Resident 1's Radiology Report dated 8/9/2021 indicated a displaced and angulated (two ends of the bone have shifted out of alignment), oblique fracture (a break that is curved or at an angle to the bone) near the distal aspect (a part of the body that is farther away from the center the body than another part) of the medullary rod within the femur (a broken thighbone). According to a review of the change of condition assessment form dated 8/9/2021, Resident 1 complained of pain when moving the right leg and the right leg was noted to be swollen and warm to touch. The Medical Doctor was notified with new orders for Tylenol 1000 mg by mouth every four as needed for moderate pain, ice compression, immobilize the right leg with pillows, and transfer Resident 1 to a General Acute Care Hospital. A review of GACH 1 Discharge Summary dated 8/10/2021, indicated Resident 1 was found to have another longitudinal prosthetic fracture (associated with an orthopedic implant) which the resident was required to have an additional surgical procedure. A review of GACH 1 History and Physical (H&P) dated 8/11/2021, indicated Resident 1 had an unwitnessed fall, was found to have painful swelling in the right thigh and brought to the emergency room. Resident 1 had a fracture of the right distal femur (broken thigh bone). Resident 1 was admitted and referred for orthopedic evaluation and surgery. A review of GACH 1 Operative Report dated 8/13/2021, indicated Resident 1 who had a previous right proximal femur fixed with long intramedullary rod fixation done, was found to have a new oblique fracture of right distal femur associated with previous rod fixation. Resident 1 recently underwent an open reduction and internal fixation (ORIF) of the right distal femur. Resident 1 received intravenous antibiotic, under general anesthesia (combination of medications for sleep like state, prior to surgery), a Stryker 9-hole plate (device or instrument with circular holes with locking plates and screws) was placed which was stabilized with clamps and cable fixation. Resident 1 received two units of packed red blood transfusion. During an interview with the Director of Nurses (DON) on 8/17/2021 at 2 PM, the DON stated Resident 1 went to her room after lunch and had been going from the wheelchair to the bed by herself. The DON stated Resident 1 must have lost her balance and fell on the floor. The DON stated Resident 1 did not have a floor mat because she had never fallen before and was not a high risk for falls. However, the resident had fallen before and was a fall risk. During an interview with Certified Nurse Assistant 1 (CNA 1) on 8/17/2021 at 2:30 PM, CNA 1 stated Resident 1 went to her room after lunch. CNA1 stated Resident 1 had been going back to bed by herself and did not have any issues before. CNA1 stated she was called by another nurse stating that Resident 1 was found on the floor, and she immediately called the supervisor. CNA 1 stated no floor mat was in place at the time of the fall. On 9/7/2021 at 3 PM during an interview, the Director of Rehabilitation (DOR), stated according to the physical therapy evaluation and the plan of treatment form, Resident 1 needed supervision when transferring from wheelchair to bed and bed to wheelchair. During an interview on 10/27/2021 at 2:30 PM, Resident 1 stated the day that she fell, she went back to the room by herself and noticed a shoe under the bedside table, so she got up and tried to get the shoe, but she lost her balance and fell. During a telephone interview on 11/4/2021 at 10 AM with the DON and Assistant DON, they stated frequent monitoring was done by supervisor, charge nurses, social worker, and CNA’s and that there was no scheduled time, but it was done throughout the day. Each staff makes rounds at different times throughout the day. A review of the facility's policy and procedure titled, "Promoting Safety and Reducing falls," undated, indicated because of aging, underlying processes: and psychological, social, and economic stresses, the elderly population is at an increased risk of accident and injury. Injuries from accidents are the fifth leading cause of death in individuals over age 65. By focusing on fall preventions, caregivers can enhance the quality of life for residents and maintain their highest practical level of functioning. Caregivers can best assist in falls or accident prevention by being alert to residents who have a history of falls and make conscious effort to "eyeball" them more frequently (observe the resident). Prevention of falls is the responsibility of everyone in the facility. A review of the facility's policy and procedure titled, "The Resident Care Plan," undated, indicated it was the responsibility of the Director of Nursing to ensure that each professional involved in the care of the resident was aware of the written plan of care including its location, the current problems of the resident, and the goals or objectives of the plan. It was the responsibility of the Licensed Nurse to ensure the plan of care was initiated and evaluated. The facility failed to provide a floor mat by the bed and failed to have staff frequently observe Resident 1, who was diagnosed with history of falls, and history of healed fracture (broken bone), per Resident 1's care plans on falls/injury and fracture. As a result, on 8/9/2021, at 1:02 PM, Resident 1 had a fall to the floor, requiring transfer to General Acute Care Hospital (GACH) where Resident 1 was diagnosed with a displaced and angulated oblique fracture (a break that is curved or at an angle to the bone) near the distal aspect of a medullary rod within the right femur (broken thigh bone). Resident 1 underwent an open reduction and internal fixation (ORIF, a surgical procedure to fix severely broken bones) of the right distal femur (bottom part of the thigh bone). The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.