Health inspection·December 31, 2024

California Code of Regulations, Title 22, Section    § 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.  § 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.  (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee.  Code of Federal Regulations, Title 42  F689  § 483.25 Quality of care  Quality of care is a fundamental principle that applies to all treatment and care provided to facility Patients. Based on the comprehensive assessment of a Patient, the facility must ensure that Patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the Patient's choices, including but not limited to the following:    § 483.25 (d) Accidents.   The facility must ensure that the Patient environment remains as free of accident hazards as is possible; and each Patient receives adequate supervision and assistance devices to prevent accidents.  On 12/3/2024 at 8:25 AM, an unannounced visit was made to the facility to investigate a complaint and facility reported incident (FRI) regarding an incident of patient fall with injury. The facility failed to ensure Patient 1, who was assessed at risk for falls and diagnoses of dementia (a progressive state of decline in mental abilities) and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) was free from falls and injury in accordance with the Patient’s care plan by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 prevented Patient 1, who was assessed as totally dependent to staff for bathing/showers, from falling in the Shower Room while sitting on the shower chair. On 11/30/2024, Patient 1 fell on her left side when the Patient opened the arm rest of her shower chair while CNA 1 bent over to fix the hem (an edge that is folded over and stitched down to prevent threads coming loose) of her [CNA 1] pants. 2. Ensure CNA 1 notified Registered Nurse (RN) 1 when Patient 1 fell from the shower chair and placed the Patient back on the shower chair, after the Patient fell on 11/30/2024 timed at 10:30 AM. 3. Ensure CNA 1 did not move and transfer Patient 1 back to the shower chair, prior to a licensed nurse assessing the Patient for injuries in accordance with the facility’s Policy and Procedure (P&P) on “Incidents and Accidents.” As a result of the investigation, the California Department of Public Health (CDPH) determined on 11/30/2024 at around 11:10 AM, RN 1 heard Patient 1 screaming and yelling from Patient 1's room and observed Patient 1 with left upper arm swelling (the enlargement of organs, skin, or other body parts), moaning and grimacing in pain, with sad/frightened/frown. The X-ray (electromagnetic [relating to the electrical and magnetic forces produced by an electric current] waves that create pictures of the inside of your body) report taken at the facility indicated the Patient had a moderately displaced oblique (having a slanting direction or position/angle) fracture (a broken bone that happens suddenly due to a traumatic injury) of the distal diaphysis (the main or midsection of a long bone) of the left humerus (upper arm bone), consistent with an acute fracture (a broken bone that happens suddenly due to a traumatic injury, like a fall causing immediate pain and noticeable damage to the bone). Patient 1 was transferred to the general acute care hospital (GACH) on 11/30/2024 at 8:11 PM for further treatment. It was determined in the GACH that Patient 1 was not a good candidate for surgery and therefore received non-operative treatment (medical treatment that does not involve surgery) at the GACH that included medication management for pain control. A left humerus fracture splint [a brace that supports and immobilizes the shoulder or arm to help with healing after an injury] was placed to the Patient’s left arm and to continue with non-weight bearing (you are not allowed to put any weight on a specific body part) to the left upper extremity. A review of Patient 1’s Admission Record [AR], the AR indicated a 102-year-old, female patient, admitted to the facility on 6/22/2021, with diagnoses including history of falling, age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) without current pathological fracture (a broken bone that occurs when a disease weakens the bone, making the bone more likely to break than normal), and abnormalities in gait (a person’s manner of walking) and mobility (a change to a person’s walking pattern). A review of Patient 1’s Fall Risk form dated 6/20/2024, the Fall Risk form indicated the Patient had intermittent (fluctuating) confusion. The Fall Risk form indicated the Patient was assessed at risk for falls. A review of Patient 1’s History and Physical (H&P) dated 6/23/2024, the H&P indicated additional diagnosis that included dementia. The H&P indicated Patient 1 was dependent on staff for all activities of daily living [ADL, basic tasks people need to do to take care of themselves that included eating, bathing]. The H&P indicated the Patient did not have the capacity to understand and make decisions. A review of Patient 1’s Care Plan for Self-Care Deficit: Bathing revised on 6/28/2024, the Care Plan indicated interventions that included facility staff would evaluate the Patient’s ability to perform ADLs. A review of Patient 1’s Care Plan for Age-related Osteoporosis revised on 6/28/2024, the care plan indicated the goal for the Patient was to remain free of injuries or complications related to Osteoporosis. The Care Plan interventions included to monitor/document for risk of falls to reduce risk of falls. A review of Patient 1’s Care Plan for Risk of Falls revised on 6/28/2024, the care plan indicated a goal for the Patient to be free of falls and minor injury. The Care Plan interventions included anticipating the Patient’s needs, reminding the Patient to call for help when needed, and educating the Patient about safety reminders and what to do if a fall occurs. A review of Patient 1’s Minimum Data Set (MDS – a federally mandated [a law or court ruling that the federal government imposes on state and local governments to address issues that affect the United States] Patient assessment tool) dated 9/19/2024, the MDS indicated the Patient had severe cognitive impairment (problems with a person’s ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Patient 1’s speech was unclear and was “sometimes” able to understand and be understood. During further review of the MDS, the MDS indicated under “Self-Care,” that assessed the Patient’s safety and quality of performance, Patient 1 was assessed as dependent (helper did all of the effort and the Patient did none of the effort to complete the activity; or the assistance of two or more helpers was required for the Patient to complete the activity) to facility staff with showering/bathing. The MDS indicated shower transfers (the ability to get in and out of a tub/shower) was not applicable (not attempted and the Patient did not perform this activity prior to the current illness). A review of Patient 1’s Care Plan for an Actual Fall that happened to the Patient, dated 11/20/2024, the care plan indicated Patient had an actual fall on 11/20/2024 [10 days prior to Patient 1’s fall in the shower room on 11/30/2024]. The Fall care plan goal for Patient 1 was to provide a safe environment that minimizes complications associated with falls. A review of another Fall Risk evaluation form for Patient 1, dated 11/20/2024, the Fall Risk form indicated Patient 1 continued to be at risk for falls. A review of Patient 1’s Situation, Background, Assessment, and Recommendation (SBAR) dated 11/30/2024 timed at 2:11 PM, the SBAR indicated the Patient had a left upper arm swelling and was moaning and grimacing when moving the left upper arm. The SBAR indicated the Patient had pain with non-verbal signs of occasional moan or groan (make a deep inarticulate [not able to express yourself clearly or effectively] sound in response to pain), low-level of speech with a negative or disapproving quality, and sad/frightened/frown. The SBAR indicated the Patient’s family (FM) was at the bedside during the assessment and the physician was notified with an order for a STAT (is derived from the Latin word “statim,” which means instantly or immediately) left shoulder upper arm X-ray. A review of Patient 1’s Physician’s Order dated 11/30/2024, the Physician’s Order indicated left upper arm X-ray STAT due to pain and swelling. A review of Patient 1’s Final X-ray Report taken at the facility on 11/30/2024, the X-ray Report indicated the exam was for the left humerus due to swelling, mass/lump (a noticeable bump or swelling on the body) of unspecified site. The X-ray report indicated the Patient had a moderately displaced oblique fracture of the distal diaphysis of the left humerus, consistent with an acute fracture. The X-ray Report indicated clinical follow-up was recommended. A review of Patient 1’s Physician’s Order dated 11/30/2024, the Physician’s Order indicated to administer Acetaminophen (a pain reliever) oral tablet 325 milligrams (mg, a unit of measurement of weight), two (2) tablets by mouth every four (4) hours as needed (PRN) for mild pain (one [1] to three [3]/10) for 30 days. A review of Patient 1’s Medication Administration Record (MAR) dated 11/30/2024 at 2:17 PM, the MAR indicated the Patient received two 325 mg Acetaminophen tablets by mouth for mild pain. A review of Patient 1’s Nurses Progress Note dated 11/30/2024 timed at 8 PM, the Note indicated the Patient was in bed complaining of pain and swelling on the left upper arm and an x-ray done at 4 PM, that showed a left upper arm fracture. The Nurses Progress Note indicated the family requested the Patient be transferred to the GACH. The Nurses Progress Note indicated the facility staff gave report to the GACH at 5 PM, the ambulance arrived at the facility on 11/30/2024 at 7:50 PM, and the Patient was sent to the GACH at 8:11 PM. A review of Patient 1’s GACH Emergency Room (ER) Triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) Notes dated 11/30/2024 timed at 8:54 PM, the ER Triage Notes indicated the Patient had left upper arm swelling, tenderness, and the Patient was in a left arm sling (a device that supports and immobilizes an injured body part) upon arrival to the GACH ER. A review of Patient 1’s GACH Left Humerus Computed Tomography (CT – a medical imaging technique that uses X-rays and a computer to create detailed pictures of the inside of the body) Radiology Report dated 11/30/2024, the CT Radiology Report indicated there was a complete displaced fracture involving the distal humeral diaphysis. The CT report indicated there was posterior displacement of the distal humeral diaphyseal (relating to the diaphysis of a bone) fragment. A review of Patient 1’s GACH Left Humerus X-ray Radiology Report resulted on 12/1/2024, the X-ray Radiology Report indicated there was a complete oblique displaced fracture of the distal humeral diaphysis and a posterior displacement of the distal humeral fragment. A review of Patient 1’s GACH Orthopedic (the branch of medicine dealing with the correction of deformities of bones or muscles Consult) H&P dated 12/1/2024, the GACH H&P indicated the Patient’s affected side revealed intact thin skin, swelling and edema (a condition that occurred when fluid builds up in the body’s tissue and caused swelling), significant ecchymosis (a bruise), and tenderness (pain or discomfort) along the left upper extremity. The GACH H&P indicated Patient 1’s left humerus x-ray was a spiral fracture (a type of fracture characterized by a complete break in a bone that occurs when a twisting force causes the bone to split into at least two pieces) of the distal humerus. The GACH H&P indicated the original plan was to perform an open reduction internal fixation (ORIF, to realign broken bone pieces and secure them) of the humerus but decided against surgery due to comorbidities (condition of having two or more disease at the same time). The GACH H&P indicated Patient 1 would receive non-operative treatment that included medication management for pain control application, a left humerus fracture splint (a brace that supports and immobilizes the shoulder or arm to help with healing after an injury) was placed to the Patient’s left arm and to continue daily with non-weight bearing to the left upper extremity. During an interview on 12/3/2024 at 2:47 PM, RN 1 stated on 11/30/2024, CNA 1 was providing care to Patient 1 inside the Patient’s room around 11 AM, and she heard the Patient screaming and yelling. RN 1 stated at around 11:10 AM, when she entered Patient 1’s room, she observed the Patient’s left arm was swollen but the skin was intact and there was no discoloration. RN 1 stated Patient 1 would not move her left arm or let the facility staff touch the left arm. RN 1 stated the attending physician was notified around 12 PM and ordered a STAT x-ray. RN 1 stated CNA 1 did not inform her that Patient 1 had a fall on 11/30/2024. During an interview on 12/3/2024 at 3:54 PM, CNA 2 stated Patient 1 required “total care (providing a person with all the necessary support and assistance they need to manage their health and daily life, including medical care, personal hygiene, and other needs)” and could also use hands to gesture what the Patient wants. CNA 2 stated Patient 1 usually sits down in the wheelchair. CNA 2 stated on 11/30/2024 during the 3 PM to 11 PM shift, Patient 1 was sitting in the wheelchair and was not moving her left arm. CNA 2 stated Patient 1’s x-ray was performed around dinner time and shortly after the Patient was sent to the GACH. During an interview on 12/4/2024 at 7:18 PM, the Administrator (ADM) stated CNA 1 contacted the Director of Staff Development (DSD) on 12/3/2024 at 9:18 PM and stated she did not provide accurate information when CNA 1 witnessed Patient 1 falling from the shower chair in the Shower Room and did not tell any staff. The ADM stated that according to CNA 1, on 11/30/2024 at 10:30 AM, CNA 1 took Patient 1 to the Shower Room and as CNA 1 was turning on the shower, Patient 1 opened the safety arm to the shower chair and fell. The ADM stated, CNA 1 took Patient 1 back to the Patient’s room and noticed swelling and informed RN 1 of the swelling. The ADM stated CNA 1 did not inform RN 1 of the fall and what actually happened on 11/30/2024. During a telephone interview on 12/4/2024 at 7:39 PM, CNA 1 stated on 11/30/2024 P