Health inspection·October 4, 2024

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. 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. § 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. An unannounced visit was conducted by California Department of Public Health on 8/19/2024 at 11:20 AM to investigate a facility reported incident regarding patient’s fall (unintentional descent that results in a coming to a rest on the floor, on or against another surface, on another person, or an object). The facility failed to prevent multiple falls of Patient 1 by: 1. Failing to develop and implement a fall care plan (a document that outlines the facility's plan to provide personalized care to a patient that includes measurable objectives and timeframes to meet a patient's medical, nursing, and mental and psychosocial needs) for Patient 1’s actual falls on 7/24/2024, and 8/2/2024 per facility policy.   2. Failing to ensure that care plan for “Impaired cognition (ability to understand and make decisions)” dated 7/8/2024 and 7/30/2024 and “High risk for falls” dated 7/9/2024 and 7/30/2024 included interventions unique (patient specific) to Patient 1’s needs. 3. Failing to ensure Certified Nurse Assistant (CNA) 1 did not leave Patient 1 sitting in the wheelchair in the hallway unsupervised by facility staff on 8/2/2024 that led to the patient sliding down from the wheelchair and falling to the floor. These deficient practices resulted in Patient 1’s multiple falls. On 7/24/2024 at 4:00 PM, Patient 1 slid from the wheelchair and CNA (CNA not specified) assisted patient to the floor. The patient was sent to General Acute Care Hospital (GACH) 1 and had right hip hemiarthroplasty (surgical procedure that replaces half of a joint with an artificial component, while leaving the other half intact). The patient returned to the facility on 7/29/2024. On 8/2/2024 at 9:25 AM, Patient 1 had another fall in the facility, and the patient was sent to GACH 2 via 911 (universal emergency number throughout the United States to request emergency assistance). Patient 1 sustained right hip prosthesis (man-made joint that replaces a damaged hip joint during hip replacement surgery) dislocation (occurs when the ball of a hip implant moves out of the socket) requiring closed reduction (a procedure for treating a hip dislocation without surgery, using manipulation of thigh bone to put the hip back in place). A review of Patient 1’s Admission Record (Face Sheet), the Face sheet indicated Patient 1 is a 91-year-old- female patient who was initially admitted to the facility on 4/6/2024 and readmitted on 8/9/2024 with diagnoses that included fracture (partial or complete break in a bone) of the right femur (thigh bone), dislocation of right hip prosthesis, muscle weakness (lack of muscle strength), Alzheimer’s disease (brain disorder that slowly destroys memory and thinking skills), dementia with behavioral disturbance (loss of cognitive functioning such as thinking, remembering and reasoning that interferes with daily activities with agitation including verbal and physical aggression, and wandering), depression (constant feeling of sadness and loss of interest which stops one from doing normal activities), and repeated falls. A record review of Patient 1’s Morse Fall Scale (a method for determining a patient's likelihood of falling which are completed during a patient’s admission, quarterly and after each sustained fall) Report dated 4/6/2024 and 7/8/2024, indicated Patient 1 is at high risk for falls. A record review of Patient 1’s Care Plan for high risk for fall initiated on 7/9/2024 indicated Patient 1 was a high risk for fall. The care plan indicated the goal to minimize risk or major injury within 90 days. The care plan did not indicate specific interventions on how to monitor/ supervise to prevent patient from falling. A review of Patient 1’s History and Physical (H&P) dated 7/10/2024, indicated Patient 1 does not have the capacity to understand and make decisions. A review of Patient 1’s Minimum Date Set ([MDS] a standardized assessment and care screening tool) dated 7/15/2024, indicated Patient 1 had severe cognitive impairment (ability to think, learn, remember, use judgement and making decisions) and was dependent (Helper does all the effort. Patient does none of the effort to complete the activity or the assistance of two or more helpers is required for the patient to complete the activity) for tub/shower transfer (ability to get on and off the toilet), required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) for sit to stand position, chair/bed-to-chair transfer and toilet transfer. A review of Patient 1’s Situation-Background-Assessment-Recommendation (SBAR-a technique used to provide a framework for communication between members of the health care team) communication form dated 7/24/2024, timed at 4:33 PM, the note indicated Patient 1 had a fall witnessed by a Certified Nurse Assistant (CNA, not specified). The SBAR indicated per CNA, Patient 1 slid down from the wheelchair, and CNA was unable to hold Patient 1 and assisted the patient to sit down on the floor. The SBAR also indicated Patient 1 was transferred to GACH 1 for evaluation. A review of GACH 1 Emergency Department (ED-the department of a hospital that provides immediate treatment for acute illnesses and trauma) record dated 7/24/2024, indicated Patient 1 had a chief complaint of right hip pain and per report, Patient 1 was on a wheelchair and slid hitting the patient’s right hip. A review of Computed Tomography (CT, a medical imaging technique used to obtain detailed internal images of the body) of pelvis (area of the body below the abdomen that contains the hip bones, bladder and rectum) without contrast (test being performed without use of a contrast, which is a special dye injected into the body to enhance the visibility of certain tissues and structures on the scan, allowing for a clearer image) from GACH 1, dated 7/24/2024 timed at 10:19 PM, impression indicated fracture right femoral head/neck which is comminuted (bone that is broken in at least two places), angulated (the two ends of the broken bone are at an angle to each other), and displaced (fracture where ends of the bone have moved out of alignment, creating a gap). A review of GACH 1’s Surgery and Procedure Reports dated 7/26/2024 time at 6:17 AM, indicated a right hip hemiarthroplasty was performed for Patient 1 on 7/25/2024. A review of Patient 1’s progress notes from the facility dated 7/29/2024 timed at 10:47 PM, the progress notes indicated Patient 1 was admitted back to the facility from GACH at 2:30 PM with admitting diagnosis of right hip hemiarthroplasty. A record review of Patient 1’s Morse Fall Scale Report dated 7/29/2024, indicated Patient 1 is at high risk for falls. A review of Patient 1’s SBAR communication form dated 8/2/2024 entered by LVN 1 at 10:42 AM, the note indicated, at 9:25 AM, Charge Nurse (LVN 1) was notified by a CNA (CNA 1) that she had observed patient slowly “slip off” her wheelchair; CNA had attempted to prevent patient from touching the ground but was unable to fully support patient; patient was assisted slowly and carefully to the floor. The SBAR also indicated, Patient 1 was observed by Charge Nurse (LVN 1) in the hallway, at the East Station, on the floor, in kneeling position, with CNA at her side and Patient 1 stated repeatedly, “I am hurt,” whilst guarding her right hip and leg. A review of GACH 2’s ED record dated 8/2/2024 timed at 10:51 AM, indicated Patient 1 was “bib” (brought in by ambulance) for a fall from chair, coming in from a SNF (skilled nursing facility) for rehabilitation from recent right hip surgery for fracture, arrived with internally rotated right hip, complained of severe pain. Patient 1’s Xray (a form of electromagnetic radiation, similar to visible light. Medical x-rays are used to generate images of tissues and structures inside the body) of the right hip and pelvis dated 8/2/2024 timed at 11:50 AM, result showed right hip replacement, right hip dislocation. The ED record also indicated, right hip hemiarthroplasty posterior (back part) dislocation after falling from her wheelchair on 8/2/2024 status post close reduction. The ED record indicated Patient 1 will likely require non-emergent revision with primary surgeon as right hip grossly unstable following reduction. During an interview on 8/19/2024 at 1:50 PM with CNA 1, CNA 1 stated, on 8/2/2024 (unable to recall time) she was wheeling a patient to the activities room when she passed by Patient 1 in her wheelchair, asleep in the hallway across the East Nursing Station. CNA 1 added, Patient 1 did not have an order to apply a lap belt (a seat belt that goes around a person’s lap used while a patient is in a wheelchair to prevent sliding out of the wheelchair) prior to the patient’s fall on 7/24/2024 and 8/2/2024. CNA 1 stated when she came back, Patient 1 was already on the floor, right foot was still in the wheelchair footrest and left knee on the floor, head leaning on the side of the treatment cart. CNA 1 stated, there was no facility staff present to supervise Patient 1 at the time she passed by Patient 1. During an interview on 8/19/2024 at 2:15 PM with CNA 2, CNA 2 stated, on 8/2/2024 after giving Patient 1 morning care, she got her up to the wheelchair and left patient in the hallway across the Nurses’ station where LVN 1 was there to monitor patient and other staff that pass by can also see the patient. CNA 2 stated, “I assumed LVN 1 will monitor Patient 1.” CNA 2 stated, it is not safe to leave fall risk patient alone in the hallway while sitting on the wheelchair as they may get up and fall, especially Patient 1 since patient has a history from falling out from her wheelchair. CNA 2 stated, she knew not to leave patient alone in the room that was why she left the patient in the hallway assuming other staff can see patient. During a concurrent interview and record review on 8/19/2024 at 2:54 PM with LVN 1, SBAR notes dated 8/2/2024 was reviewed in the electronic chart. The SBAR indicated, at 9:25 AM, Charge Nurse (LVN 1) was notified by a CNA that she had observed patient slowly slip off her wheelchair; CNA had attempted to prevent patient from touching the ground but was unable to fully support patient; patient was assisted slowly and carefully to the floor. LVN 1 stated she did not see Patient 1 sliding off her wheelchair and she was only called by CNA 1 to notify her that Patient 1 had fallen. LVN 1 stated she was in another room when the incident happened, and she was not notified by CNA 2 that she will leave Patient 1 at the hallway. LVN 1 added, she last saw Patient 1 on 8/2/2024 at 9:10 AM when she gave Patient 1 Lorazepam (medication to treat anxiety and can make you feel sleepy) one tablet PRN (meaning pro re nata in latin meaning “as needed”) for verbal aggression and fidgeting in her wheelchair. LVN 1 also gave Tramadol (medication used to treat moderate to severe pain, for example after an operation or a serious injury. Common side effects include feeling sleepy, tired, dizzy, or spaced out) PRN for pain at 7:00 AM. During a concurrent interview and record review on 8/19/2024 at 4:26 PM with Minimum Data Set Nurse (MDSN), Patient 1’s record of falls dated from 7/8/2024 to 8/2/2024 were reviewed. The records indicated Patient 1 had incident of fall on 7/24/2024, and 8/2/2024. MDSN stated Patient 1 had a fall last 6/30/2024 at the Memory Care Unit and was transferred to GACH 1 and returned to the facility’s Skilled Nursing Facility on 7/8/2024. During the same concurrent interview and record review on 8/19/2024 at 4:26 PM with Minimum Data Set Nurse (MDSN), care plans from 7/8/2024 to 8/19/2024 were reviewed. MDSN stated there were no care plans initiated for Patient 1’s actual falls on 7/24/2024 and 8/2/2024. MDSN stated, if care plan was initiated for the actual fall on 7/24/2024, interventions to avoid fall such as monitoring/supervising Patient 1 while in the wheelchair or use of a lap belt while patient is in the wheelchair, Patient 1’s fall on 8/2/2024 could have been prevented. During a concurrent interview and record review on 8/20/2024 at 9:18 AM, with LVN 1, Care Plan focused on “Impaired Cognition” dated 7/8/2024 and 7/30/2024 were reviewed. Care plan indicated intervention to supervise as needed. LVN 1 stated, supervision was not specific to Patient 1, because it did not indicate how often the facility staff needs to supervise Patient 1. During the same interview and record review on 8/20/2024 at 9:18 AM, with LVN 1, Care Plans dated 7/8/2024 and 7/30/2024 were reviewed. LVN 1 stated, the care plan focused on “High risk for falls” did not include interventions to not leave patient unattended while in the wheelchair and provide frequent supervision. LVN 1 stated leaving Patient 1 unattended, without supervision was unsafe. LVN 1 added that patient-centered care plans were important for the patient’s safety and needs, for staff to know what to do for that specific patient and important to revise when there were new behaviors manifested and new problems that arose. During a concurrent interview and record review on 8/20/2024 at 10:55 AM with MDSN, Care Plan for high risk for fall dated 7/9/2024 and 7/30/2024 were reviewed. Patient 1’s care plan indicated goal to minimize risk of major injury for 90 days, interventions did not include constant and visual monitoring. MDSN stated for high fall risk patients, interventions should include constant, visual monitoring, and if patients were anxious-check the cause. MDS added with the additional interventions mentioned, fall would have been prevented. During a concurrent interview and record review on 8/20/2024 at 10:55 AM with MDSN, Patient 1’s Care Plan titled “At risk for Impaired Cognition,” dated 7/8/2024 and 7/30/2024 were also reviewed. The care plan indicated interventions included to cue, reorient, and supervise as needed. MDSN stated the intervention to supervise as needed was general and should be specific to what the patient need. MDSN stated it should include how often the patient should be supervised, how and/or when should patient be supervised like for example while in the wheelchair since patient had a history of falling or sliding out from the wheelchair last 7/24/2024 and patient sustained an injury and needed surgery at that time. During a concurrent interview and record review on 9/16/2024 at 3:20 PM with LVN 1, order summary for July 2024 and August 2024 for Patient 1 were reviewed. LVN 1 stated, there were no orders for a lap belt or seat belt and/ or bed and chair alarm to be applied prior to Patient 1’s fall on 7/24/2024 and 8/2/2024. LVN 1 stated, the order for bed and chair alarm was placed on 8/9/2024 after patient had fallen. A review of facility’s Policy and Procedure (P&P), titled “Care Plans – Comprehensive,” revised on 11/2023, indicated to include interventions unique to this patient and avoid routine standard of practice that is provided to all patients.     A review of facility’s P&P, titled “Fall Prevention Policy and Procedure,” revised in March 2023, indicated falls and recommendations will be discussed by the Interdisciplinary Team (IDT, staff involved in patient’s care) at the weekly Medicar