Health inspection·November 14, 2024

F 689 CFR §483.25 (d)(2) Accidents. The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. §483.25(d) Accidents. The facility must ensure that – §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. An unannounced visit was conducted by California Department of Public Health on 10/2/2024 at 11:10 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 revise Patient 1’s care plan for moderate risk for fall related to gait/ balance problems after the resident’s Minimum Data Set (MDS, standardized care and screening tool) and Physical Therapy Treatment Encounter Notes (PT Note - documents sequential implementation [executing one task at a time, in order] of the plan of care established by the physical therapist, including changes in patient/client status and variations and progressions of specific interventions used) were completed on 7/15/2024 and 7/16/2024 to reflect the resident’s, need for partial moderate assistance (helper does less than half the effort. Helper lifts, holds or support trunk or limbs. But provides less than half the effort) and contact guard assist (CGA, maintaining close contact with the resident to provide immediate support and prevent falls without fully taking over their movements) when ambulating. 2.Failing to provide partial moderate assistance and/ or CGA to Patient 1 when the resident was ambulating on 9/22/2024 in the dining/ activity room in accordance with the resident’s MDS and PT note. These deficient practices resulted in Patient 1 falling on 9/22/2024 at 3:20 PM. On 9/23/2024 at 9 AM, Patient 1 complained of left hip pain and was sent to general acute care hospital (GACH) 1 at 6:12 PM and was found to have sustained left sub capital fracture (these fractures occur in the neck of the thighbone). On 9/24/2024 at 5:07 PM, Patient 1 had surgery of left total hip arthroplasty (the surgical reconstruction or replacement of a joint). A review of Patient 1’s Admission Record (Face Sheet), the Face sheet indicated Patient 1 is a 61-year-old- male patient who was initially admitted to the facility on 4/8/2024 with diagnoses that include lack of coordination, anxiety (a feeling of fear, dread, and uneasiness), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Patient 1’s History and Physical (H&P) dated 4/9/2024 indicated Patient 1 is not competent to understand his medical condition. A review of Patient 1’s Minimum Data Set (MDS, standardized care and screening tool), dated 7/16/2024, indicated Patient 1 was assessed to be cognitively impaired (process of thinking and reasoning). The MDS also indicated Patient 1 was assessed to need partial moderate assistance (helper does less than half the effort. Helper lifts, holds or support trunk or limbs. But provides less than half the effort) on walk 10 feet ([ft., a unit to measure the length or distance] once standing, the ability to walk at least 10 ft. in a room, corridor, or similar space) and walk 50 ft. with two turns (once standing, the ability to walk at least 50 ft. and make 2 turns). A concurrent interview and record review on 10/2/2024 at 11:33 AM with the License Vocational Nurse (LVN 1), Patient 1’s Fall Risk Assessment (checks to see how likely it is that you will fall) dated 4/8/2024 and timed at 4:09PM was reviewed. LVN 1 stated the Fall Risk Assessment score was nine (9) which means the resident is at moderate risk for fall. During a concurrent interview and record review on 10/2/2024 at 11:40 AM with LVN 1, Patient 1’s Situation, Background, Assessment, and Recommendation (SBAR- is a structured communication framework that can help teams share information about the condition of a patient or team member or about another issue your team needs to address) dated 9/22/2024 and timed at 9:28 PM was reviewed. The SBAR indicated Patient 1 had a fall in the afternoon, resident lost his balance in the dining room/activity room. During a concurrent interview and record review on 10/2/2024 at 11:45 AM with LVN 1, Patient 1’s SBAR dated 9/23/2024 and timed at 9 AM was reviewed. The SBAR indicated Patient 1 was complaining of pain on his left hip and primary physician (PMD) ordered STAT (without delay) X-ray (imaging creates pictures of the inside of your body) of the left hip. The SBAR indicated X-ray result indicated acute left sub capital fracture. PMD ordered to transfer Patient 1 to GACH 1. A review of Patient 1’s Radiology (a branch of medicine that uses imaging technology to diagnose and treat disease) Result Report (done in the facility) examination date 9/23/2024 timed at 12:15 PM, the radiology result report indicated the resident have a left sub capital fracture with 2.3- centimeter (cm, unit of measure in the metric system) displacement and with history of falling. A review of Patient 1’s Order Summary Report for the month of September 2024, indicated an order dated 9/23/2024 to transfer Patient 1 to GACH 1 for further evaluation, due to status post fall and fracture of left hip X-ray result. A review of Patient 1’s progress notes dated 9/23/2024 timed at 3:45 PM, the progress notes indicated, Patient 1 was sent to GACH 1. During an interview on 10/2/2024 at 11:55 AM, with the Certified Nursing Assistant (CNA 1), CNA 1 stated Patient 1 ambulates and used wheelchair as a walker with no assistance or supervision by staff on 9/22/2024. CNA 1 also stated on 9/22/2024 at around 3 to 4 PM, in the activity room, CNA 1 saw Patient 1 on the floor lying flat on his left side and CNA 1 called the charge nurse for help. During an interview on 10/2/2024 at 1:49 PM with Registered Nurse (RN 1), RN1 stated on 9/22/2024 prior to Patient 1’s fall incident in the activity room, RN 1 saw Patient 1 walking using the back of the wheelchair and no facility staff was assisting the resident walking down the hallway. RN 1 stated, RN 1 was not aware that Patient 1 needs partial moderate assistance or contact guard assist while walking. During a concurrent interview and record review on 10/2/2024 at 1:55 PM with RN 1, Patient 1’s GACH 1’s record was reviewed. RN1 stated the GACH 1 record indicated under MD (medical doctor) Progress notes entered on 9/24/2024 timed at 5:07 PM, Patient 1 had left hip arthroplasty. RN1 also stated, Patient 1 had left total hip arthroplasty with 10 cm incision. During a concurrent interview and record review on 10/2/2024 at 2:30 PM with the RN 1, Patient 1’s MDS dated 7/16/2024 was reviewed. RN 1 stated Patient 1’s MDS indicated the patient was assessed requiring partial/moderate assistance on walk 10 ft. and walk 50 ft. with 2 turns. RN 1 stated this means Patient 1 needs assistance while the facility staff holds the resident’s back when walking. RN 1 also stated if somebody was there to provide partial moderate assistance while Patient 1 was ambulating/ walking, “we could have prevented Patient 1 from falling on 9/22/2024 which caused the resident to have left hip fracture and surgical procedure.” Patient 1 stayed at GACH 1 for 5 days from 9/23/2024 to 9/27/2024. During an interview on 10/2/2024 at 2:54 PM with Activity Coordinator (AC), AC stated on 9/22/2024 between 3:30 PM to 4 PM while AC was in the activity room and giving snacks to the other residents, Patient 1 went to activity to get his snacks. Patient 1 walked to the activity room by walking behind the wheelchair and pushing on the handles to walk by himself with no assistance by the facility staff. AC also stated, AC heard the “thud sound” and when she turned around to check, Patient 1 was on the floor lying flat on his left side. AC also stated if facility staff was with Patient 1 at that time to provide moderate assistance while Patient 1 was walking, the patient’s fall could have been prevented. During a concurrent interview and record review on 10/2/2024 at 4PM with LVN 2, Patient 1’s MDS dated 7/16/2024 and the PT notes dated 7/15/2024 timed at 8:59AM was reviewed. LVN 2 stated, Patient 1’s MDS and PT note indicated the resident needed assistance when walking and it was not implemented on 9/22/2024. LVN 2 stated, it was important to follow the MDS and PT note recommendation to give the resident the care they needed. During a concurrent interview and record review on 10/3/2024 at 3:56 PM with LVN 1, Patient 1’s Care Plan for moderate risk for fall dated 5/1/2024 was reviewed. LVN 1 stated the care plan indicated Patient 1 is at moderate risk for fall related to gait/ balance problem. LVN 1 stated Patient 1’s care plan was not person- centered (focusing care on the needs of the individual) and it should be indicated in the care plan that Patient 1 should be assisted during ambulation/ when walking. LVN 1 also stated, there should be a care plan to address Patient 1’s need for partial moderate assistance in accordance with the resident’s MDS completed on 7/16/2024. LVN 1 also stated, Patient 1’s care plan should have reflected the resident’s need for four-wheel walker (FWW) and CGA with gait/ when walking in accordance with Patient 1’s PT note that was completed on 7/15/2024. LVN 1 stated the FWW was only used for Patient 1 during Rehabilitative Nurse Assistant (RNA, an exercise program to help a patient complete under the supervision of licensed physical therapist or certified nurse assistant [CNA] who has additional training) exercise. During a concurrent interview and record review on 10/3/2024 at 9:40 PM with the Physical Therapy Assistant (PTA), Patient 1’s PT note dated 7/15/2024 entered at 8:59 AM was reviewed. The PT note indicated for Patient 1’s gait, the resident needed CGA x 225 ft with FWW. PTA stated CGA means to hold and guide the resident while walking. PTA also stated, a facility staff needs to be with the resident when ambulating to assist the resident while holding the resident’s back area when walking for safety and to prevent the resident from falling. A review of facility’s P&P titled “Care Plans, Comprehensive Person Centered” revised date12/2016 indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident. A review of facility’s Policies and Procedure (P&P) titled “Falls and Fall Risk, Managing” revised date 3/2018 indicated, based on previous evaluations and current data, the staff will identify interventions related to the resident’s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P also indicated the staff will implement resident centered fall prevention plan to reduce the specific risk factor(s) of fall for each resident at risk or with history of fall. The facility failed to prevent multiple falls of Patient 1 by: 1. Failing to revise Patient 1’s care plan for moderate risk for fall related to gait/ balance problems after the resident’s MDS and PT Note - were completed on 7/15/2024 and 7/16/2024 to reflect the resident’s, need for partial moderate assistance and CGA when ambulating. 2. Failing to provide partial moderate assistance and/ or CGA to Patient 1 when the resident was ambulating on 9/22/2024 in the dining/ activity room in accordance with the resident’s MDS and PT note. These deficient practices resulted in Patient 1 falling on 9/22/2024 at 3:20 PM. On 9/23/2024 at 9 AM, Patient 1 complained of left hip pain and was sent to GACH 1 at 6:12 PM and was found to have sustained left sub capital fracture (. On 9/24/2024 at 5:07 PM, Patient 1 had surgery of left total hip arthroplasty. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.