Health inspection·December 30, 2024

§483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 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. §483.25(e) Incontinence. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. 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 12/2/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct an investigation regarding a facility reported incident of Resident 1's fall with injury. The facility failed to: 1. Develop, review, implement, and revise care plan related to Resident 1's high fall risk, including but not limited to staff assistance and equipment when transferring Resident 1 from bed to toilet (see Bowel and Bladder Incontinence care plan) and having/developing an active/non-resolved fall care plan. 2. Ensure Resident 1's environment is as accident free as possible of risk and ensure adequate supervision and assistive devices related to Resident 1's high fall risk. This includes but is not limited to supervising and assisting Resident 1's transfer to toilet with necessary assistive equipment. 3. Ensure Resident 1, who is incontinent of bladder, receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. 4. Develop and/or implement facility policies and procedures including Fall Risk Assessment, Urinary Incontinence - Assessment and Management Care Plans, and Care Plans, Comprehensive Person-Centered as described below. As a result of these failures, on 11/28/2024 approximately at 11:30 PM, Resident 1 tried to go to the bathroom by himself and fell. Resident 1 was transferred to the General Acute Care Hospital (GACH) for further evaluation where he was diagnosed with a displaced intertrochanteric (where hip and thigh meet) fracture (a partial or complete break in a bone) of right femur (the thigh bone). A review of Resident 1's admission record indicated the resident was admitted to the facility on 12/5/2020 and re-admitted on 9/13/2023, with diagnoses including generalized muscle weakness, cognitive communication deficit (a person's inability to learn, remember, use judgement, and make decisions), and chronic kidney disease (damaged kidneys cannot filter blood as needed causes risks of high blood pressure and heart disease). A review of the Bowel and Bladder Incontinence care plan initiated 3/9/2023 indicated the interventions to assist Resident 1 to the bathroom toilet every two hours and when needed, to encourage the resident to ask for assistance during toileting program and to encourage the resident participation in bowel and bladder re-training program for seven days. There was no revision or review date indicated on the care plan. A review of Resident 1's Fall Risk Assessment dated 11/11/2024 indicated the resident had a history of 1 -2 falls in the past three months, required use of assistive devices, and for level of consciousness the resident was disoriented. The assessment indicated Resident 1 had a score of 17, as a score of 10 or greater indicated a high risk for potential falls. A review of Resident 1's Minimum Data Set (MDS, a mandated federal assessment tool) dated 11/15/2024, indicated Resident 1 was moderately confused, unable to make decisions, or follow instructions. The MDS indicated Resident 1 was dependent on a manual wheelchair for mobility and required partial assistance from another person for indoor ambulation. The MDS indicated Resident 1 had a fall in the last 2-6 months prior to admission and was dependent on staff for toilet transfer. According to a review of the At Risk for Fall care plan initiated 12/7/2020, the resident had gait / balance problems, attempts to stand unassisted, and was unaware of safety needs. The care plan goal indicated the resident would not sustain injuries for 90 days. The care plan interventions indicated to anticipate and meet the resident's needs, assist with all transfers or ambulation, and that the resident needed a safe environment. Further review of the At Risk for Fall care plan indicated a resolved date of 9/18/2023. This indicated there was no active Fall care plan for Resident 1. A review of Resident 1's Certified Nursing Assistant (CNA) tracking log titled, "Toilet transfer: The ability to get on and off a toilet or commode," dated 11/26/2024 indicated at 2:25 PM, the resident had supervision or touching assistance to get on and off the toilet. At 8:30 PM indicated 'not applicable' for the activity. On 11/27/2024 at 8:41 PM, the log indicated 'not attempted due to environmental limitations, i.e., lack of equipment.' On 11/28/2024 at 2:34 PM, Resident 1 had supervision for the activity and at 6:58 PM, there was no attempt for Resident 1 to be assisted on and off the toilet due to medical condition or safety concerns. Further review of the log indicated there was no documentation of an additional attempt after 6:58 PM. A review of the Physician's Order Summary Report dated 11/29/2024, indicated to transfer Resident 1 to the GACH for further evaluation and treatment of status post fall. According to a review of the facility document received to the Department on 12/2/2024, Resident 1 had a fall on 11/28/2024 around 11 PM. Resident 1 was found on the floor by the closet and stated he was trying to go to the bathroom. The facility document indicated the physician was notified, ordered an X-ray of the right hip and the technician reported there was a dislocation. A review of the Progress Notes dated 12/2/2024 indicated Resident 1 was screaming because of pain during the x-ray performed on 11/29/2024. A review of Resident 1's re-admission record dated 12/2/2024 indicated Resident 1 had a new diagnosis of a displaced intertrochanteric (the area between the greater and lesser bone, where hip and thigh meet) fracture (a partial or complete break in a bone) of right femur (the thigh bone, the longest and strongest bone in the body), initial encounter for closed fracture. A review of Resident 1's post fall Interdisciplinary Team (IDT) note dated 12/2/2024 indicated Resident 1 fell on 11/28/2024 approximately 11 PM during shift change. The IDT note indicated Resident 1 had periods of confusion and required supervision during activities of daily livings (ADLs). During an interview on 12/2/2024 at 2:45 PM, Resident 2 (Resident 1's roommate) stated Resident 1 fell near the bathroom door while trying to go to bathroom on Thanksgiving Day. Resident 2 stated Resident 1 was yelling for help. "I got out of my bed and tried to get help, staff came and assisted Resident 1." During an interview on 12/3/2024 at 6:24 AM, Licensed Vocational Nurse (LVN) 3 stated, "I assist Resident 1 daily. Resident 1 was confused and very dependent on staff for mobility and ADLs." During a concurrent interview and record review on 12/3/2024 at 10:45 AM with Director of Staff Development (DSD), Resident 1's At Risk for Fall and Incontinence care plans, dated 12/7/2020 and 3/9/2023 respectively, were reviewed. The DSD stated Resident 1 had mobility and cognitive deficiencies that contributed to his fall. The DSD stated, after review of Resident 1's At Risk for Fall care plan and Incontinence care plan that the quarterly care plans for June 2024 were not reviewed or revised and was missing. The DSD stated the importance of reviewing and revising the care plans was to provide accurate direction and guidance to staff and to meet the resident's needs. During an interview on 12/4/2024 at 12:27 PM with MDS coordinator, Resident 1's care planning revisions were reviewed. The MDS coordinator stated and acknowledged there was a deficiency in updating the At Risk for Fall and Incontinence quarterly care plans for Resident 1. On 12/5/2024 at 1:38 PM, during a telephone interview, CNA 3 stated he was assigned to care for Resident 1 on the night Resident 1 fell while trying to go to bathroom. CNA 3 stated he heard a loud bang near Resident 1's room and went to check the noise. CNA 3 stated he found Resident 1 lying flat on his back in front of the bathroom and assisted the charge nurse to place Resident 1 back to his bed. CNA 3 stated Resident 1 was screaming and was assessed with no visible injury noted. CNA 3 stated Resident 1 was not consistent with using call lights because he gets confused. CNA 3 stated Resident 1 did not have routine schedules to assess for toileting needs, nor staff conducted hourly or random checks. During an interview on 12/5/2024 at 2:06 PM, the Director of Nursing (DON) stated Resident 1 required frequent reminders to call for assistance and was dependent on staff for ambulating. The DON stated Resident 1 was checked and changed by staff for bathroom needs. Staff conducted frequent rounds, but they were not documented. When the DON was asked about the bowel bladder incontinence care plan intervention regarding Resident 1 required assistance every two hours for transfer to the bathroom, the DON stated the facility did not document the rounds, every two hours, for Resident 1. A review of the facility's policy and procedures (P&P) titled, "Fall Risk Assessment," revised January 2024, indicated the staff with the support of the attending physician, would evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition. The staff and attending physician would collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that were not modifiable. A review of the facility's P&P titled, "Urinary Incontinence - Assessment and Management," revised January 2024 indicated facility staff and practitioner would appropriately screen for and manage individuals with urinary incontinence and that management would follow relevant clinical guidelines. The policy indicated to provide services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. A review of the facility's Policy and Procedures (P&P) revised January 2024, titled, "Care Plans, Comprehensive Person-Centered," indicated "A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team must review and update the care plan: a. when the desired outcome is not met; d. At least quarterly, in conjunction with the required quarterly MDS assessment." The facility failed to: 1. Develop, review, implement, and revise care plan related to Resident 1's high fall risk, including but not limited to staff assistance and equipment when transferring Resident 1 from bed to toilet (see Bowel and Bladder Incontinence care plan) and having/developing an active/non-resolved fall care plan. 2. Ensure Resident 1's environment is as accident free as possible of risk and ensure adequate supervision and assistive devices related to Resident 1's high fall risk. This includes but is not limited to supervising and assisting Resident 1's transfer to toilet with necessary assistive equipment. 3. Ensure Resident 1, who is incontinent of bladder, receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. 4. Develop and/or implement facility policies and procedures including Fall Risk Assessment, Urinary Incontinence - Assessment and Management Care Plans, and Care Plans, Comprehensive Person-Centered as described below. As a result of these failures, on 11/28/2024 approximately at 11:30 PM, Resident 1 tried to go to the bathroom by himself and fell. Resident 1 was transferred to the GACH for further evaluation where he was diagnosed with a displaced intertrochanteric fracture of right femur. The above violations jointly, separately, or in combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.