Health inspection·November 21, 2024

F689 42 CFR §483.25(d) Accidents. 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. 42 CFR §483.40 Behavioral Health Services Each resident must receive and the facility must provide the necessary behavior health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.

F744 §483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. (b) Based on the comprehensive assessment of a resident, the facility must ensure that - (3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. 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: (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. 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 10/30/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility for a facility reported incident (FRI), regarding Resident 1's safety. As a result of the FRI investigation, CDPH determined the facility failed to: 1.Identify and develop an appropriate care plan for Resident 1's dementia through an Interdisciplinary Team (IDT) approach, with appropriate interventions including implementation of individualized care and maximize Resident 1's safety. 2.Implement the High Risk for Falls care plan dated 8/8/2024 to provide Resident 1 with a safe environment. 3.Provide Resident 1 with supervision for bed mobility, per the ADL Self-Care Performance Deficit care plan related to dementia dated 8/8/2024. 4.Implement the facility's revised policy titled, "Dementia - Clinical Protocol," dated January 2024, where the IDT would identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. As a result, on 10/8/2024, Resident 1, an 88-year-old female had a fall and was found on the floor in her room. On 10/9/2024, Resident 1 presented to the General Acute Care Hospital (GACH) with a swollen right leg, minimal movement, and expressed pain. At the GACH, Resident 1 was diagnosed with a displaced right femur and was placed under general anesthesia for Open Reduction and Internal Fixation (ORIF -a type of surgery used to stabilize and repair broken bones, which includes some form of hardware used to hold the bone together so it can heal) surgery and required one unit blood transfusion. A review of Residents 1's admission record (face sheet) indicated the resident was initially admitted to the facility on 1/20/2022 with diagnoses including syncope and collapse (fainting, a sudden loss of consciousness caused by a brief period of low blood pressure and inadequate blood flow to the brain. Collapse, also known as pseudo-syncope, a sudden loss of consciousness caused by other factors, such as a seizure or hypoglycemia [low blood sugar]), dementia, psychosis (a mental disorder, collection of symptoms that affect the mind, where there has been some loss of contact with reality), and abnormalities of gait and mobility. A review of Resident 1's History and Physical report completed 1/18/2022, indicated the resident wandered around and had fluctuating capacity to understand and make decisions. A review of the Impaired Cognition care plan evidenced by dementia and confused thoughts, dated 1/26/2023, indicated the interventions were to provide reality orientation, provide all necessary assistance and anticipate needs. A review of the Interdisciplinary Team (IDT - a coordinated group of experts from several different fields who work together toward a common resident goal) Post Event Note dated 6/24/2024, indicated the reason for the meeting was because Resident 1 had a fall event on 6/24/2024 at 9:30 am. The IDT Note indicated the resident had Parkinson's disease, dementia, psychosis, was alert and oriented x1 with confusion. The IDT note indicated a charge nurse observed Resident 1 on the floor lying on the left side in front of the resident's room. Resident 1 was unable to verbalize what happened. The IDT note indicated Resident 1 had discoloration on the right cheek and left side of jaw and was transferred to the GACH. The root cause analysis indicated Resident 1 had unspecified dementia that interfered with daily functioning. According to a review of the Physician's Order Summary Report dated 6/27/2024, Resident 1 received Depakote (an antipsychotic medication, anticonvulsant) 125 milligrams (mg), two times a day for bipolar disorder psychosis manifested by resistant care, constant pacing. The Physician's Order Summary also indicated Resident 1 had a bed pad alarm to alert staff if resident tried to get up unassisted, as resident was a high risk for fall related to unsteady gait secondary to dementia. A review of the Nurses Notes dated 8/6/2024, indicated Resident 1 had unsteady gait and balance problems while sitting or standing. The Nurses Note under Behavior indicated that Resident 1 wanders and that Resident 1 had no behavior problems noted. This indicated a discrepancy. The Nurses Note indicated Resident 1 had no complaint of pain at this time, that staff were to anticipate needs due to history of fall, and Resident 1 was to continue to attend rehab activities. The note indicated Resident 1's transfer to and from bed was extensive assist. A review of the Nurses Notes dated 8/7/2024 indicated Resident 1 had unsteady gait and balance problems while sitting or standing. The Note indicated under Behavior, that Resident 1 had no behavior problems noted. The Nurses Note indicated Resident 1 had no complaint of pain at this time, to anticipate needs due to history of fall, and to continue to attend rehab activities. The note indicated Resident 1's transfer to and from bed was extensive assist. A review of Resident 1's ADL Self-Care Performance Deficit care plan dated 8/8/2024, related to Dementia and Impaired Balance indicated the resident would maintain current level of function. The care plan interventions indicated the resident was able, with supervision, for bed mobility and eating. A review of Resident 1's High Risk for Falls care plan dated 8/8/2024, related to confusion, gait balance problems, and unaware of safety needs, indicated the resident would be free of falls. The care plan interventions indicated to anticipate and meet Resident 1's needs, resident needs prompt response to all requests for assistance, and that the resident needed a safe environment. A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 8/9/2024, indicated the resident was severely impaired in cognitive skills for daily decision making (trouble concentrating, completing tasks, understanding, following instructions). The MDS indicated the resident required supervision or touching assistance when walking at least 10 feet in a room. According to a review of Resident 1's Fall Risk evaluation dated 8/8/2024, the resident had a history of falling, was disoriented to person, place and time and had a gait or balance problem while standing, walking and making turns. The Fall Risk Screen indicated Resident 1 was a high risk for falls with a score of 15 (a score of 10 or above indicated a resident was a high risk for falling). A review of Resident 1's Situation Background Assessment and Response form (SBAR) dated 10/8/2024 at 4:30 PM, indicated the resident was found on the floor of her room, with no grimacing or signs of discomfort, and no swelling or bruising, and was place back in her bed. A review of the Physician's Order dated 10/9/2024 at 3:20 pm indicated to transfer Resident 1 to the GACH for further evaluation and treatment of right hip fracture and give a bed hold for 7 days. A review of Resident 1's GACH Emergency Department (ED) note dated 10/9/2024, indicated the resident presented from the skilled facility with a swollen right leg, minimal movement, and expressed pain. The ED note indicated an X-ray was conducted of Resident 1's right femur (thigh bone) with the findings of an angulated intertrochanteric fracture (where the bone changes from vertical to a 45 degree angle) of the right femur with lesser trochanter avulsion (a rare injury that occurs when the iliopsoas muscle [a deep muscle group that connects the spine to the lower limbs] contracts forcefully, pulling away the attachment point on the lesser trochanter (a bony projection on the upper thigh bone that serves as an attachment point for the hip flexor muscles). A review of Resident 1's GACH Consultation Note dated 10/11/2024 indicated the history about the fall was unclear, but Resident 1 did have bruises about the body with an assumption of a fall. The consultation note indicated that due to the resident's fracture, surgery was recommended for pain control, early ambulation, and return to functional status. The GACH Operative Note dated 10/11/2024 indicated Resident 1 had right hip long cephalomedullary nail placement (a surgical procedure that treats thigh fractures, involves inserting a nail into the thigh) under general anesthesia. A review of the GACH Discharge Summary dated 10/15/2024 indicated Resident 1 required an Open Reduction and Internal Fixation (ORIF) surgery of the right femur. Resident 1 had acute blood loss related to the surgery and required one unit blood transfusion. During an interview on 10/21/2024, at 2:21 pm, Registered Nurse (RN) 1 stated she reviewed Resident 1's care plans but could not provide the measurable goals or interventions that addressed the resident's diagnosis of dementia. RN 1 was unable to provide documented evidence the licensed nursing staff identified and/or assessed specific details that placed an emphasis on supervision and safety from falls. During an interview on 10/22/2024 at 10:15 am, when asked if supervision was provided for Resident 1's bed mobility, CNA 1 stated staff usually walked the halls and checked often on the residents. CNA 1 stated the night of Resident 1's incident on 10/8/2024, she did not recall checking the resident's room or hearing an alarm going off, but the resident was discovered on the floor. On 10/22/2024, at 11:18 am, during an interview, the Director of Nursing (DON) stated the language used in care plans should be precise and easy to understand. The DON stated, "I was not able to find any interventions on supervision for dementia care," of the resident (Resident 1). The DON stated the licensed nursing staff did not develop a care plan with measurable goals and interventions to address the care and services of Resident 1 with a diagnosis of dementia. During a concurrent interview and record review on 10/28/2024 at 10 am with the Assistant Director of Nursing (ADON), Resident 1's care plans were reviewed. The ADON stated and confirmed Resident 1 had dementia but did not have a dementia care plan with individualized interventions with emphasis on supervision. The ADON stated the resident's care plan should have had more clear language used, and individualized interventions that involve supervision for the resident. The ADON stated the resident was found on the floor in her room and could not say for certain if the fall could have been prevented. The ADON stated it was important to have a dementia care plan with goals and interventions to address Resident 1's behavior and ensure the resident was safe. The ADON stated there was a risk that the resident was not receiving care that was specific to her diagnosis of dementia. A review of the facility's revised policy titled, "Dementia - Clinical Protocol," dated January 2024, indicated for a resident with confirmed diagnosis of Dementia, the IDT would identify a resident - centered care plan to maximize remaining function and quality of life. The physician would evaluate residents with new or worsening cognitive impairment and behavior and differentiate dementia from other causes. The IDT would identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. A review of the facility's policy and procedure titled, "Falls and Fall risk, Managing," revised 1/19/2024, indicated fall is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g. resident pushed another resident). The staff with the input of the physician would implement a resident centered fall prevention plan to reduce the specific factors of fall for each resident at risk or with a history of falls. The policy indicated if falls recurred despite initial interventions staff would implement additional or different interventions or indicate why the current approach remains relevant. The staff would monitor each resident's response to interventions intended to reduce falling or the risk of falling. A review of the facility's revised policy titled, "Care Planning - Interdisciplinary Team," indicated care planning / IDT was responsible for the development of an individualized comprehensive care plan for each resident. The facility failed to: 1.Identify and develop an appropriate care plan for Resident 1's dementia through an IDT approach, with appropriate interventions including implementation of individualized care to maximize the resident's safety. 2.Implement the High Risk for Falls care plan dated 8/8/2024 to provide Resident 1 with a safe environment. 3.Provide Resident 1 with supervision for bed mobility, per the ADL Self-Care Performance Deficit care plan related to dementia dated 8/8/2024. 4.Implement the facility's revised policy titled, "Dementia - Clinical Protocol," dated January 2024, where the IDT would identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. As a result, on 10/8/2024, Resident 1 had a fall and was found on the floor in her room. On 10/9/2024, Resident 1 presented to the GACH with a swollen