Health inspection·March 7, 2024

42 CFR § 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. (d) Accidents The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (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 1/22/2024, 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 66, who had diagnosis of schizophrenia (a serious mental disorder in which people interpret reality abnormally) and had a history of multiple falls, received the care, treatment and services in accordance with professional standards of practice by failing to: -Provide the correct level of assistance for transfers and ambulation, on 7/19/2023, 8/18/2023 and 9/20/2023, per the comprehensive assessment. -Revise and implement the Fall Care Plan to include different fall interventions needed with specific levels of assistance -Complete / update a fall risk assessment after each fall As a result, on 12/8/2023, Resident 66 had an unwitnessed fall and hit the back of her head which required transfer to general acute hospital 2 (GACH 2). At GACH 2, Resident 66 had a one-inch laceration treated with staples and hematoma (a pool of blood that forms in an organ, tissue or body space, usually caused by a broken blood vessel that was damaged by an injury) on the back of her head, as well as skin tears to her abdomen and back. A review of Resident 66's admission record indicated the facility admitted the resident on 1/23/2023 with diagnoses including Huntington's Disease (a genetic disease that damages the brain and affects one movement, cognition and mental health), schizophrenia and anxiety (a mental health condition with feeling of worry, anxiety, or fear interfering with one's daily activities). A review of Resident 66's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/1/2023, indicated the resident's cognition was intact and the resident required supervision from a helper who provides verbal cues, touch and / or steadying with walking 10 to 150 feet and assistance with transfer. A review of the At Risk for Injury and Falls care plan, revised 4/10/2023, indicated Resident 66 used psychotropic medication (drug that exerts an effect on the chemical makeup of the brain and nervous system), had poor safety awareness, Huntington's disease, unsteady gait and had impulsive behavior. The care plan interventions included to assist with all transfers as needed, keep bed in lowest position and to maintain safe environment free of hazards. The care plan did not indicate interventions for Resident 66's ambulation. According to a review of the nurse's note, dated 7/11/2023, Resident 66 had a witnessed fall in the hallway and hit the back of her head. The Nurses Note indicated Resident 66 sustained a laceration to the back of her head with bleeding noted. A review of Physician's Order Summary Report dated 7/11/2023 indicated the following was provided to Resident 66: - cleansing of the resident's occipital (back of head) laceration with normal saline, patted dry and covered with a dry dressing for seven days and - provide the resident with a chest x-ray and skull x-ray after a fall A review of Resident 66's Change of Condition (COC) – Situation Background Assessment Response (SBAR) form, dated 7/19/2023, indicated the resident had a fall and two staff members assisted the resident to stand and escorted the resident back to bed. A review of Resident 66's COC - SBAR form, dated 7/28/2023, indicated the resident had another witnessed fall. The form indicated Resident 66 was seen on the floor in a sitting position in the hallway. The COC – SBAR form also indicated the resident was non-compliant with fall precautions provided. The resident was offered a helmet and wheelchair both of which she refused. According to a review of Resident 66's COC - SBAR form, dated 8/18/2023, the resident had a fall with head and hand injury, as the resident attempted to walk without assistance or supervision. A review of the nurse's note, dated 8/18/2023, indicated Resident 66 returned to the facility from GACH 1, as the resident's imaging results were negative and did not show hemorrhage (an escape of blood from a ruptured blood vessel), or fracture (broken bone) related to fall. A review of the resident's medical chart indicated there was no updated fall risk assessment completed after the 8/18/2023 fall and there was no care plan for Resident 66's non-compliance. A review of Resident 66's COC - SBAR form, dated 9/20/2023, indicated the resident fell while walking in the hallway. It indicated the resident had a rapid jerking movement and fell backwards hitting her head. It indicated the resident had on her helmet during the fall. A review of the resident's medical chart indicated a fall risk assessment was not completed after the 9/20/2023 fall. According to a review of Resident 66's COC - SBAR form, dated 12/8/2023, the resident had an unwitnessed fall in her room and the resident was not using an assistive device for ambulation or transferring. A review of the Emergency Services Patient Care Report, dated 12/8/2023, indicated the resident was transferred from the facility to a GACH for the chief complaint of a blunt head injury. The Patient Care Report indicated Resident 66 fell prior to emergency services arrival and hit the back of her head. The Emergency Services Patient Care Report indicated Resident 66 had a one-inch laceration and hematoma on the back of her head as well as skin tears to her abdomen and back. A review of the Emergency Department (ED) Physician's Note, dated 12/8/2023, indicated Resident 66 came to the ED with a posterior head laceration after a trip and fall. It indicated while at the facility, the resident lost her balance and hit the back of her head with resultant bleeding. The ED Physician Note indicated Resident 66 received five staples for an occiput laceration was repaired at bedside without complication. A review of Resident 66's Order Summary Report, indicated on 12/15/2023, the physician ordered the facility to monitor the stapled scalp site for any bleeding, pain or any sign of infection. During an interview on 1/25/2024 at 10:56 AM, Licensed Vocational Nurse 5 (LVN 5) stated that on 12/8/2023 Resident 66 fell in her room. Resident 66 split the back of her head open and there was profuse bleeding. During a concurrent review of Resident 66's care plans related to falls and the medical chart, LVN 5 stated and confirmed Resident 66's care plans were last updated on 7/31/2023. LVN 5 stated that Resident 66's Risk for Fall Care Plan should have been updated (on 8/18/2023 and 9/20/2023) after each fall to reflect new interventions, in order to prevent the resident from repeated falls. Upon further review of the resident's medical chart, LVN 5 stated and confirmed Resident 66's last fall risk assessment was completed on 7/19/2023. LVN 5 stated after Resident 66 fell, a fall risk assessment should have been completed to assess the causes of the fall and generate new interventions to prevent further falls. During an interview on 1/25/2024 at 1:55 PM, the MDS Coordinator (MDSC) stated that on 12/8/2023, Resident 66 had an unwitnessed fall and was transferred via 911 after the fall. The MDSC stated and confirmed Resident 66's fall care plan was last updated on 7/31/2023 and should have been updated after the resident fell on 8/18/2023 and 9/20/2023. The MDSC stated the care plan was to be updated to implement new interventions to prevent further falls. During an interview on 1/25/2024 at 4:37 PM, the Director of Nursing (DON) stated after Resident 66 fell on 12/8/2023, the fall care plan should have been updated on 8/18/2023 and 9/20/2023. A review of the facility's policy and procedure titled, "Fall Risk Assessment," dated 3/2018, indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. A review of the facility's policy and procedure titled, "Falls and Fall Risk, Managing," dated 3/2018, indicated the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. The facility failed to ensure Resident 66, who had diagnosis of schizophrenia and had a history of multiple falls, received the care, treatment and services in accordance with professional standards of practice by failing to: -Provide the correct level of assistance for transfers and ambulation, on 7/19/2023, 8/18/2023 and 9/20/2023, per the comprehensive assessment. -Revise and implement the Fall Care Plan to include different fall interventions needed with specific levels of assistance -Complete / update a fall risk assessment after each fall As a result, on 12/8/2023, Resident 66 had an unwitnessed fall, hit the back of her head which required transfer to GACH 2. At GACH 2, Resident 66 had a one-inch laceration treated with staples and hematoma on the back of her head, as well as skin tears to her abdomen and back. 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.