Health inspection·April 15, 2022

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 11/2/2021 the California Department of Public Health (CDPH or State Agency [SSA]) made an unannounced visit to the facility for a Facility Reported Incident regarding Resident 1’s quality of care. The facility failed to ensure Resident 1, who had dementia (loss of memory, thinking and reasoning), glaucoma (a group of eye conditions that cause blindness), received antipsychotic medications (medicines used to treat psychosis [a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality] and other mental and emotional conditions), and was a high risk for fall, was assessed regularly for fall risk and was provided a safe environment and supervision to prevent falls, as indicated in the resident's care plans. As a result, on 11/1/2021, at 8:30 a.m., Resident 1 had a fall, the right knee and right hip was slightly swollen, and when staff attempted to move Resident 1 in the bed she started crying and holding her right hip. X-rays indicated a right hip fracture (broken femur [thighbone]). On 11/1/2021 Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where she underwent surgery to repair the fracture on 11/5/2022. A review of Resident 1's Admission Record (Face Sheet), indicated the facility admitted the resident, a 79-year-old female, on 7/1/2021 with diagnoses including dementia, muscle weakness, and glaucoma. A review of Resident 1's Fall Risk Assessment, dated on 7/1/2021, indicated the resident had intermittent confusion, a problem with gait (walking) / balance and received three to four medications that may increase the resident's risk for falls within the last seven days. The fall risk assessment indicated Resident 1 had a score of 12, and a total score of 10 or above represented high risk for fall. A review of Resident 1's Care Plan developed on 7/1/2021 for the resident’s risk for falls indicated the resident had a propensity to falls and injurious falls related to the use of psychotropic medication (drug that affects behavior, mood, thoughts, or perception) that cause dizziness, drowsiness, confusion, and memory problems. The care plan interventions included updating the fall risk assessment every three months, monitoring, and anticipating factors causing falls, providing hazard free environment, and reviewing medication for side effects. The care plan did not indicate how the hazard free environment should be demonstrated. A review of the Physician's Order for Resident 1, dated 7/1/2021, indicated to give the antipsychotic Seroquel 50 milligrams (mg) by mouth [an antipsychotic medication used for psychosis] at bedtime manifested by persistent yelling/screaming/crying for no reason. According to a review of Resident 1's Care Plan developed on 7/1/2021 for the resident use of Seroquel, the resident was a high risk to experience complications related to its use and its common side effects including sedation (state of being relaxed or sleepy because of a drug) confusion and restlessness. The care plan interventions included to evaluate the side effects of the medication and to monitor resident's behavior in public and private. A review of Resident 1's Care Plan developed on 7/17/2021 and updated on 8/26/2021, indicated the resident was at risk of elopement (a resident who leaves the facility when doing so may present an imminent threat to health or safety because of legal status or because the resident has been deemed too ill or impaired to make a reasoned decision to leave) due to disorientation and episodes of wandering (occurs when a person with dementia roams around and becomes lost or confused about their location). The care plan interventions included monitoring Resident 1's whereabouts, applying a wander guard alarm (consist of a bracelet or anklet that triggers an alarm when the resident attempts to go through the door equipped with the alarm), and maintaining a safe and hazard free environment. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 8/9/2021, indicated Resident 1's cognitive skills of daily decision making were severely impaired (never/rarely made decisions) and required supervision with one-person physical assist with transferring, walking in room / unit, and toilet use. A review of Resident 1’s Psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) progress note dated 10/28/2021 indicated Resident 1's wandering behavior and her agitation was becoming worse. The psychiatrist progress note indicated the plan was to start the resident on Ativan (an anti-anxiety medication) 0.5 mg by mouth. A review of Resident 1's Care Plan developed on 10/28/2021 for Resident 1’s anxiety (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities), indicated the resident had episodes of anxiety manifested by going room to room. The care plan interventions included referring the resident to a psychological consult and treatment, administering Ativan 0.5 mg as needed for 14 days and monitoring and recording episodes of behavior, per psychotropic policy. According to a review Resident 1’s Situation - Background - Assessment - Response (SBAR - a technique that can be used to facilitate prompt and appropriate communication between the healthcare provider) communication form and progress note, dated 10/30/2021 indicated Resident 1 had severe agitation with wandering behavior, was crying, screaming, yelling, and removing name plates from residents’ rooms. Resident 1 expressed not trusting anyone, wanted to leave, and became angry when staff attempted to take the name plates from her. A review of the Physician's Order for Resident 1, dated 10/30/2021, timed at 12:30 p.m., indicated to administer Ativan 2 mg intramuscular (a technique used to deliver a medication deep into the muscles. This allows the medication to be absorbed into the bloodstream) injection now, for severe agitation. A review of Resident 1's Medication Administration Record (MAR) indicated the resident received a dose of Ativan 0.5 mg by mouth on 10/31/2021, one at 9 a.m., and another at 5 p.m. The MAR also indicated Resident 1 received a dose of Seroquel 50 mg in the evening, but there was no black box warning (the most stringent warning for drugs and medical devices on the market, potentially increasing the mortality of elderly patients with dementia-related psychosis. It may increase the risk of falls due to drowsiness, orthostatic hypotension (a form of low blood pressure that happens when you stand up from sitting or lying down. Orthostatic hypotension can make you feel dizzy or lightheaded, and maybe even cause you to faint) noted. A review of drugs.com (https://www.drugs.com/drug-interactions/ativan-with-seroquel-1488-899-1979-1274.html), 2021, indicated that a combination of Ativan and Seroquel may cause an interaction, combination may cause excessive sedation, confusion, dizziness, or lack of coordination. A review of the Nursing Progress Notes dated 11/1/2021 at 4:55 a.m., indicated Resident 1 was in bed asleep, wakes with verbal stimuli, no distress noted and resident denied any pain or discomfort. The progress notes did not indicate Resident 1 fell or was in pain. A review of Resident 1's x-ray report taken at the facility dated 11/1/2021 indicated the resident sustained an acute minimally displaced (the bone snaps into two or more parts and moves so that the two ends are not lined up straight), impacted (bones driven into each other) right femoral neck (about 1 or 2 inches from where the head of the thighbone meets the socket) fracture. According to a review of the Physician’s Order dated 11/1/2021 at 2:40 p.m., Resident 1 was transferred to the Emergency Room for further evaluation, diagnosis of displaced femoral fracture. A review of GACH 1 emergency room (ER) note for Resident 1 dated 11/1/2021 indicated Resident 1 was transferred to the ER after a right hip fracture due to a fall onto her right side. Resident 1 complained pain rated at 8/10 (pain rating scale from zero to 10, zero indicating no pain and 10 the worst possible pain) to her right hip that was worse with movement. A review of GACH 1 Operative Report dated 11/5/2021, indicated Resident 1 underwent a bipolar hemiarthroplasty of the right hip (a surgical procedure to replace the head of a damaged femur [thigh bone] with an implant designed to stabilize the femur and restore hip function). During an interview on 11/2/2021, at 12:44 p.m., the Assistant Director of Nursing (ADON) stated she entered Resident 1 's room on 11/1/12021 between 8:30 a.m., and 8:40 a.m., with Registered Nurse 1 (RN 1). Resident 1 told the ADON she was rushing to put on her shoes to catch her husband and she fell on the floor on her right side. During an interview on 11/2/2021, at 12:56 p.m., RN 1 stated that she went into Resident 1's room around 8:30 a.m., on 11/1/2021 after being alerted by Licensed Vocational Nurse 1 (LVN 1) that the resident was crying. RN 1 stated Resident 1's right knee was slightly swollen and when they attempted to move Resident 1 in the bed she started crying and holding her right hip. RN 1 stated upon assessment, the resident's right hip had redness and swelling. RN 1 stated the physician was notified and ordered x-rays on the right hip. During an interview with LVN 1, on 11/2/2021, at 1:25 p.m., LVN 1 stated Resident 1 was not at risk for fall because a yellow sticker would be placed outside the resident's door, a floor mat would be placed next to the bed and a bed pad alarm and wheelchair alarm would be in place. LVN 1 further stated and confirmed that none of these interventions were in place for Resident 1. During an observation, after the resident was re-admitted post fall on 12/14/2021 at 9 a.m., Resident 1 was sitting in the hallway in a wheelchair with a sitter at her side (a caregiver who provides residents in need of supervision with companionship and care, a compassionate substitute for restraints, seclusion rooms, and other measures to deal with challenging patients). In the resident's room, a left and right floor mat were present and there was a yellow fall risk sticker on her nameplate. On 12/30/2021, at 2:24 p. m., during a phone interview and record review, the ADON stated the resident had to be re-assessed for fall risk every three months and as needed. The ADON stated Resident 1's fall risk was not re-assessed after three months on 10/1/2021 and that a reassessment should have been done when she was placed on wander-guard on 10/30/2021. The ADON stated they did not implement the care plan interventions. During an interview on 12/31/2021, at 1:45 a.m., Certified Nursing Assistant 1 (CNA 1) stated she worked 11 p.m. to 7 a.m. shift on 10/31/2021. CNA 1 stated Resident 1 was not on any fall precautions, and she was not advised by the charge nurse that Resident 1 had received any medication that might place the resident at fall risk. During an interview with DON on 3/7/2022 at 1:33 p.m., the DON stated Resident 1's fall risk was initially assessed on 7/1/2021 and 11/1/2021. The DON further stated that a fall risk score of 10 or above represented a high risk for falls and "It is important to know the fall risk for a resident so that we can attend to the person's needs, be alert and prevent fractures." During an interview on 3/8/2022 at 7:32 a.m., LVN 1 stated, “Even though Resident 1 was ambulatory (able to walk) we should have watched her closely, we should have closely monitored her.” LVN 1 stated, "We should have put a fall risk sticker on her name outside her door, we should have told the CNA to watch her closely, to know her whereabouts and to assist her to the bathroom." A review of the facility's policy and procedure titled, "Falls and Fall Risk, Managing," undated indicated conditions that may contribute residents falling include delirium and other cognitive impairment, medication side effects and visual deficits, neurological disorders and balance and gait disorders. A review of the facility's policy and procedure titled, "Assessing Fall and Their Causes," undated, indicated residents must be assessed upon admission and regularly afterward for potential risk for falls. Relevant risk factors must be addressed promptly. The facility’s Psychotropic policy was requested and provided the Antipsychotic Medication Use policy. A review of the facility’s policy titled, “Antipsychotic Medication Use,” undated, indicated antipsychotic medications will not be used if the only symptoms are one or more of the following: a. Wandering; b. Poor self-care; c. Restlessness; d. Impaired memory; e. Mild anxiety; f. Inattention or indifference to surroundings; g. Sadness or crying alone that is not related to depression or other psychiatric disorders; 1. Fidgeting (make small movements, especially of the hands and feet, through nervousness or impatience). J. Nervousness; or k. Uncooperativeness. The facility failed to ensure Resident 1, who had dementia, glaucoma, received antipsychotic medication and was a high risk for fall, was assessed regularly for fall risk, was provided a safe environment and supervision to prevent falls, as indicated in the resident's care plans. As a result, on 11/1/2021, at 8:30 a.m., Resident 1 had a fall, the right knee and right hip was slightly swollen, and when staff attempted to move Resident 1 in the bed she started crying and holding her right hip. X-rays revealed a right hip fracture. On 11/1/2021 Resident 1 was transferred to GACH 1 where she underwent surgery to repair the fracture on 11/5/2022. 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.