Other·September 27, 2023

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. 42 CFR §483.25(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 8/30/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident about the quality of care for Resident 1. The facility failed to ensure Resident 1, who was diagnosed with hemiplegia (paralysis of one side of the body), and reduced mobility, received two or more-person physical assistance with transfer, per the comprehensive assessment. Resident 1 was transferred by one person assistance from the wheelchair to the bed by Certified Nursing Assistant 1 (CNA) on 8/18/2023. As a result, Resident 1, complained of severe pain to the right leg on 8/18/2023, requiring transfer to the general acute care hospital (GACH) 1 where Resident 1 was diagnosed with a distal femoral fracture (break in thigh bone just above the knee joint) and treated with a soft cast. Resident 1 complained of unrelieved pain, was transferred to GACH 2 where the resident underwent an open reduction and internal fixation (ORIF, a type of surgery used to stabilize and repair broken bones, using screws, plates, sutures, or rods to hold the bone together for purposes of healing) on 8/27/2023. A review of the Admission Record indicated the facility admitted Resident 1, a 74-year-old female, on 6/22/2020 with diagnoses including osteoporosis (a bone disease where bones become weak and brittle) hemiplegia and hemiparesis (paralysis of one side of the body and partial paralysis of one side of the body) following cerebral infarction (blood supply to the part of the brain was interrupted or reduced), and reduced mobility. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 7/19/2023 indicated Resident 1 had unclear speech, difficulty communicating some words or finishing thoughts, but was able, if prompted or given time. Resident 1 comprehends most conversations and had adequate hearing and vision. The MDS indicated Resident 1 needed one-person physical assistance with bed mobility, dressing, toilet use, personal hygiene, or bathing and required two or more persons physical assistance with transfer. The MDS further indicated Resident 1 was not steady during transfer between bed and chair or between bed and wheelchair, but able to stabilize with staff assistance. According to a review of the Quarterly Nursing Risks Evaluation / Assessments dated 7/19/2023, Resident 1 needed two or more persons with bed mobility and needed two-person physical assistance during transfers. A review of the osteoporosis Care Plan revised on 8/3/2023 indicated Resident 1 was at risk for injuries, pathological fracture (occurs to areas of weakened bone caused by an underlying disease), and pain. The care plan goal indicated Resident 1 will remain free of injuries or complications related to osteoporosis through the review date. Further review of the care plan did not indicate any interventions to prevent injury during transfer or to prevent accidents as a facility-wide priority. According to a review of the activities of daily living (ADLs, skills required to independently care for oneself such as eating, bathing and mobility) Care Plan initiated on 9/2/2022 and revised on 8/3/2023, Resident 1 had a self-care deficit related to impaired balance and right-side weakness. The care plan goal indicated Resident 1 will maintain current level of function through the review date. The care plan interventions indicated Resident 1 required total assistance by two staff to move between surfaces (transferring from chair to bed). A review of the Situation Background Assessment or Appearance and Request (SBAR) dated 8/18/2023 at 1:30 p.m., indicated Resident 1 complained of right knee pain due to transfer from wheelchair to bed after physical therapy. The SBAR indicated Licensed Vocational Nurse (LVN) 2 heard Resident 1 yelling out in pain and upon entering the room Resident 1 pointed to her right leg. LVN 2 attempted to readjust the right leg and Resident 1 cried out in pain. The SBAR indicated Resident 1 tried to explain how she hit her knee when CNA 1 transferred the resident from wheelchair back to bed after physical therapy. During an assessment of Resident 1’s right knee there was no sign of redness, warmth, or tenderness, but a bump was observed on the knee. The primary physician was notified and gave an order for x-ray of the right knee. The SBAR indicated Resident 1 was given Tylenol Extra Strength (medication for pain) 500 milligrams (mg., unit of measurement) two tablets for pain, with relief. According to a review of the Radiology Report (provides a translation of Xray images into words) dated 8/18/2023, Resident 1 had an impacted fracture (break in the bones that occurred when one fragment of the bone is driven into a second piece of bone) of the distal femur (thigh bone just above the knee joint). A review of the Progress Notes dated 8/18/2023 indicated Resident 1’s primary physician was notified of the Xray result and gave an order to transfer Resident 1 to GACH 1 for evaluation. A review of the Progress Notes dated 8/19/2023 at 1:14 a.m., indicated Resident 1 left the facility at 12:51 a.m. by ambulance. A review of the GACH 1 Emergency (ED) Provider Notes dated 8/19/2023 at 8:15 a.m. indicated Resident 1 was admitted to the GACH with severe pain in the right leg. The ED examination indicated Resident 1’s right leg was swollen and externally rotated (when the thigh and the knee rotate outward, away from the body). A review of GACH 1’s x-ray of Resident 1’s right femur dated 8/19/2023 indicated a distal femoral fracture. A review of the Admission Notes dated 8/20/2023 at 2:54 p.m., indicated the facility re-admitted Resident 1 from GACH 1 with diagnoses including closed fracture (bones push up against the skin but do not pierce the skin) of the right femur. The Admission Notes indicated Resident 1 had a soft splint (material or device used to protect and immobilize a body part) on the right leg. Resident 1 did not have surgery. A review of the SBAR dated 8/22/2023 at 11:53 a.m., indicated the situation that Resident 1 had a right distal femur fracture and complained of unrelieved pain with current pain medication. The SBAR indicated the soft splint on Resident 1’s right leg required re-evaluation and a more appropriate device with possible placement of hard cast. Pain management evaluated Resident 1 and gave an order for Norco (opioid medication for moderate to severe pain) every four hours. The SBAR indicated the primary physician was notified and gave order to transfer Resident 1 to GACH 2. According to a review of the GACH 2 Operative Note dated 8/27/2023, Resident 1 had an open reduction and internal fixation (ORIF) of the supracondylar fracture (a break in the femur at the knee joint) of the right femur. A review of the Admission Notes dated 8/29/2023 indicated the facility re-admitted Resident 1 from GACH 2. During an observation and concurrent interview on 8/30/2023 at 8:38 a.m., Resident 1 was lying in bed, with a cast and long brace on the right leg. Resident 1 stated she hurt herself during transfer from wheelchair to bed. Resident 1 pointed to her right knee indicating she had pain. During an interview on 8/30/2023 at 9:10 a.m., the MDS was reviewed with LVN 1, who stated and confirmed Resident 1 needed two or more persons for transfer to prevent injury to the resident. LVN 1 stated Resident 1 had a fracture after CNA 1 transferred Resident 1 by herself. On 8/30/2023 at 12:52 p.m., Resident 1’s ADL self-care deficit care plan revised on 8/3/2023 was reviewed with the director of nursing (DON). During a concurrent interview the DON stated Resident 1’s care plan indicated the resident needed two persons for transfer. The DON stated Resident 1 may have hit her knee against the wheelchair when CNA 1 solely transferred Resident 1 from the wheelchair to the bed on 8/18/2023. The DON stated if two people were not assisting the resident, an accident may occur. The DON stated Resident 1, “Had osteoporosis and a single snap or hitting of an object may trigger a fracture.” During a telephone interview on 8/30/2023 at 5:30 p.m., certified nursing assistant (CNA 1) stated on 8/18/2023 at about 2 p.m., she solely transferred Resident 1 from wheelchair to bed. CNA 1 stated after transfer to bed, Resident 1 turned to her right side and complained of pain on the right leg. CNA 1 stated she could transfer Resident 1 by herself with no assistance. “She is not a heavy patient.” CNA 1 then stated LVN 2 provided Resident 1 with pain medication. A review of the facility policy titled, “Safety and Supervision of Residents,” revised on 1/2021, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. The same policy indicated the Interdisciplinary care team (IDT) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision and assistive device. Implementing interventions to reduce accident risks and hazards shall include ensuring that interventions were implemented. The facility failed to ensure Resident 1, who was diagnosed with hemiplegia and reduced mobility, received two or more-person physical assistance with transfer, per the comprehensive assessment. Resident 1 was solely transferred from wheelchair to bed by CNA 1 on 8/18/2023. As a result, Resident 1, complained of severe pain to the right leg on 8/18/2023, requiring transfer to GACH 1 where Resident 1 was diagnosed with a distal femoral fracture and treated with a soft cast. Resident 1 complained of unrelieved pain, was transferred to GACH 2 and underwent an ORIF on 8/27/2023. 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.