Valley Gardens Health Care & Rehabilitation Center
1517 East Knickerbocker Drive, Stockton, CA 95210
Citation Number: 030006639
Citation Date: 10/21/2009
Violation Date: 11/21/2007
Class: AA
Penalty: $ 90,000

Complaint(s): CA00132271

F279 - Comprehensive Care Plans 483.20(d), 483.20(k)(1) A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care.

The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.25; and any services that would otherwise be required under 483.25 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(b)(4).

F282 - Comprehensive Care Plans 483.20(k)(3)(ii) The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care.

F323 - Accidents And Supervision 483.25(h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

An unannounced visit was made to the facility on 11/21/07 at 1:15 p.m. to investigate Complaint # CA00132271.

The Department determined the facility violated the aforementioned regulations by failing to:

1. Provide supervision for Resident A to prevent an accident.

2. Review and revise the plan of care based upon assessments following recurrent falls.

Resident A was admitted to the facility from a general acute care hospital (GACH) on May 18, 2007 with pertinent diagnoses that included a transient ischemic attack (mini stroke), coronary artery disease (disease of the blood vessels of the heart), atrial fibrillation (an irregular heart rhythm), artificial heart pacemaker, previous surgery for prostate cancer, recent current urinary tract infection requiring antibiotic therapy and ground level fall at home. He was 92 years old.

According to the admission Minimum Data Set (an assessment tool) dated 05/29/07; Resident A had short and long term memory problems and needed assistance making decisions in new situations. His mental functioning varied during the day and cognitive status had declined in the past 90 days. He usually understood others and was usually able to make himself understood. He was documented to have both visual and hearing impairments. He required one person physical assist with ambulation, toilet use and activities of daily living. Resident A was continent of bowel but occasionally incontinent of bladder, had an unsteady gait and had fallen in the past 30 days.

According to the Resident Assessment Protocol (RAP) summary dated 05/29/07, Resident A triggered for being at risk for falls related to having fallen in the past 30 days, was incontinent of bladder, had an unsteady gait, had cognitive changes, was on diuretics (medications that causes the body to get rid of excess water through urination) and had poor safety awareness. The RAP for urinary continence documented he became restless when needing to urinate, got out of bed without calling for assistance or using the call light and was at risk for more falls with injury. Resident A's medical record revealed a physician's order dated 05/18/07 documenting Resident A was a full code (all available medical procedures to be used to sustain life). It was initially planned that he might be able to be discharged to a board and care facility when stabilized and would require training and rehabilitation. His medications included Aspirin 81 milligrams daily for stroke prevention and Coumadin 4 milligrams, an anticoagulant medication to prevent blood clotting, every evening. His laboratory results dated 05/24/2007 documented his coagulation times (Pro-Time was 23.00 and his INR was 1.8) He required a walker to assist with ambulation.

On 05/18/07 the nursing staff completed a fall risk assessment documenting Resident A was a high risk for falls with a score of 21 (total score of 14 or above represented a high risk). Resident A's clinical record included a care plan dated 05/19/07 for Fall/Injury risk related to "recent ground level fall" which indicated the following goals: Resident will demonstrate decreased risk for injury, falls and falls will be prevented daily x3 months. The following approaches were documented (in part): #1. Check resident every 1-2 hours 6. Instruct not to get up without assistance. #10. Place motion monitor alarm to alert staff of any unsafe activity. #11. Place resident in front of nursing station for closer observation. Check on Resident A every 2 hours and as needed for need to toilet.

A review of Resident A's clinical record revealed a condition change form in the Nurses Notes dated 05/21/07 at 1:45 a.m. documenting, Resident A was found on the floor next to his bed laying on his back. The condition change form documented Resident A stated he got up because he had to go to the bathroom (to urinate) and lost his balance and landed on the floor and hit his head. The "FALL CIRCUMSTANCE ASSESSMENT" dated 05/21/07 also documented Resident A had a bladder infection and was on a diuretic (a medication that gets rid of excess fluids via urination by increasing urine output). Resident A stated he got up because he had to urinate and lost his balance. "Recommendations to Prevent Further Falls" documented: Resident A was to continue to have a personal alarm while in bed and in wheelchair, and was to be checked every 1 to 2 hours "at least" to anticipate needs.

A "Care Plan Update" dated 05/21/07 after the fall recorded "will have no further fall in 72 hours." The approaches were, "Vital signs every shift, Notify the MD and family, Resident to use call light for assistance, Will monitor for 72 (hours), Neuro (neurological) checks."

Resident Progress Notes dated 05/21/07 PM documented, "Move patient to MediCare 103 A with current meds and personal belongings. On admission, Resident A had been placed in Room 220 A. Room 103 A was closer to the nursing station, but was not in front of the nursing station.

On 03/03/08 at 5:00 p.m., a phone interview was conducted with CNA 2 The CNA stated she had taken Resident A to the bathroom on 05/21/07 and then put him back in his wheelchair. After she left his room, she believed he wheeled himself over to the bed and tried to get into bed and had an un-witnessed fall.

A Care Plan Update, dated 05/24/07, documented the fall on 05/21/07, with the goal of no further falls in 72 hours. The approaches listed were to monitor vital signs, notify MD and family, encourage to use call light for assistance and neurological checks initiated. There were no revisions for actual fall prevention. There was no documented evidence that Resident A had been checked every 1 to 2 hours, taken to the toilet upon arising, or before or after each meal, as indicated in the initial Plan of Care.

Resident A's clinical record included a "BLADDER STATUS EVALUATION" form dated 05/30/07 that documented he had urinary urgency, needed to urinate frequently and was to be placed on a Habit/Scheduled toileting program.

On 06/04/07, a Care Plan for "Fall/Injury Risk" directed staff to... respond promptly,... place motion monitor alarm to alert staff of any unsafe activity, check (every 2 hours) Q2HRS & prn (as needed) for needs to toilet and take as needed. There was no documented evidence the Resident was checked on every two hours for the need to go to the toilet. There were no new interventions to prevent a fall and the resident was still not located in front of the nursing station.

A Nurse's Note dated 06/12/07 at 9:45 p.m. documented "Found Resident on the floor inside the BR (bathroom) lying on his (right) side. [He] was able to remove his motion monitor. A "FALL CIRCUMSTANCE ASSESSMENT" dated 06/12/07 documented Resident A had fallen in his room when he was ambulating to the bath room and had removed his motion alarm. The additional comments documented [LN] instructed CNA to check on Resident every 2 hours for needs.

The facility's policy and procedure titled "Accidents and Supervision to Prevent Accidents" dated 08/06/07 documented (in part) the following, "The center provides an environment that is free from accident hazards over which the center has control and provides supervision each resident to prevent avoidable accidents....Center has monitoring processes in place to ...Ensure that interventions are implemented correctly and consistently ...Evaluate the effectiveness of interventions...Modify or replace interventions, as necessary...Evaluates the causal factors leading to a resident fall to help support relevant and consistent interventions to try to prevent future occurrences. Proper actions following a fall include:...Addressing the factors for the fall...Revising the resident's plan of care and/or center practices, as needed to reduce the likelihood of another fall."

On 11/21/07 at 3:30 p.m. an interview was conducted with a LN on duty 6/12/07 The LN stated a CNA found Resident A on the bathroom floor and called out for help. The LN responded to the CNA's call and went into the bathroom and saw Resident A on the floor. The LN stated "Resident A did not have any injuries or complaints so he did not report the incident." The LN stated he directed the CNA's to check on Resident A every 2 hours because he was "noncompliant, stubborn and tried to be independent, he would try to get up by himself to use the bathroom."

On 03/04/08 at 10:30 a.m. a telephone interview was conducted with a CNA who had taken care of Resident A. CNA stated, "that if she heard his alarm go off that meant he usually had to use the bathroom, because he was always trying to get up to use the restroom by himself and that was when I checked on him to see if he needed to use the bathroom." CNA stated the "alarm was clipped to Resident A's clothing and to the bed. When he attempted to get up, the clip came off and the alarm sounded." Therefore, the alarm would only sound when Resident A was getting out of or had already been able to get out of the bed or chair.

On 03/04/08 at 9:44 a.m. an interview was conducted with Resident A's family member. She related that the family found out about the 05/21/07 fall when visiting on approximately 05/24/07. A CNA had stated to her "Resident A was doing very well since his fall." The family member went to the Administrator and "reamed them up and down about not notifying them of the fall and told him that the family wanted to be notified if anything happened to Resident A." Family received a phone call from the facility on the evening of 06/12/07 and was told that Resident A was found on the floor and he had "no injuries."

After the fall on 6/12/07, Resident A rapidly developed a change in condition manifested by agitation and then a decrease in his level of consciousness. Nurses Notes dated 06/13/07 at 1:30 a.m. documented Resident A had increased confusion, was thrashing about in bed and yelling out. The doctor and daughter were notified at that time. An ambulance was called and Resident A was transferred to the GACH at 2:15 a.m. on 06/13/07.

The Admission History & Physical documented in part..."he fell about 2 hours prior to becoming confused.....He was sent to the emergency room, where he was shown to have subdural hematomas (bleeding into an enclosed space between the brain and the skull) and some early brain herniation (evidence of the brain being pushed into the opening at the base of the skull as a result of the increased pressure from the injury) already." The ending assessment stated," This patient has subdural hematomas and he is already anti-coagulated. His pro-time was 52.8 and his PTT was 43.5, INR 3.5 (laboratory tests to evaluate the patient's ability to develop a blood clot). He cannot be operated on immediately to help reverse this. He already has brain herniation, so it is a very grim prognosis. (The Neurosurgeon) thinks this is a non-surgical case "because of the likelihood of no recovery, by the time we are able to reverse his Coumadin." Resident A was unable to breathe well on his own and required immediate support for mechanical ventilation via a tube into his air passages.

It was planned that he would be made a No Code (no resuscitation in the event of a cardiac arrest). He remained on artificial support of his respirations until the family could arrive. Resident A expired on 06/14/07 at 3:12 a.m. The Discharge Summary stated, in part, This 92 year old male was admitted with "bilateral severe subdural hematomas...he "was comatose at the time of admission responding only with withdrawal of his feet reflectively but not even responding to deep pain, and showed poor corneal reflex. ....His coagulation level was too high to do emergency surgery...Even with an artificial pacemaker his cardiac function ceased."

The Certificate of Death listed the cause of death as accidental from falling down on his head in the bathroom on 06/12/2007 at the estimated time of 2145 (9:45 p.m.) which resulted in an acute subdural hematoma from blunt force trauma.

On 8/21/09 family recalled that Resident A had been an active golfer until just two weeks prior to his admission. He had always been significantly embarrassed by his urinary urgency and occasional loss of urine and was "meticulous about his hygiene". She stated that he knew how to "monkey with the alarm to disconnect it and facility staff was aware" She felt "very saddened that he had passed away in such a manner."

Therefore, the facility failed to:

1. Provide adequate supervision or assistive devices to prevent an accident.

2. Revise the plan of care after prior falls with new interventions to attempt to prevent recurrence of falls according to stated facility policy and failed to implement the plan to move the resident to a room in front of the nursing station when other approaches or alarm systems were not effective.