Newport Nursing and Rehabilitation Center
1555 Superior Avenue, Newport Beach, CA 92663
Citation Number: 060008776
Citation Date: 11/08/2011
Violation Date: 9/6/2011
Class: AA
Penalty: $ 100,000

The following reflects the findings of the Department of Public Health during a Licensure Complaint visit:

CLASS AA CITATION-- PATIENT CARE 06-2207 -0008776-S
Complaint(s): CA00283981

Representing the Department of Public Health:
Surveyor ID # 27007, HFEN

The inspection was limited to the specific facility event investigated and does not represent the findings of a full inspection of the facility.

72311 (a)(2). Nursing Service- General
(a) Nursing service shall include. but not be limited to, the following:
(2) Implementation of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan.

The facility failed to implement the care plan for Patient 1 when they failed to provide adequate safety measures and supervision, resulting in Patient 1 being left unattended in the bathroom. Patient 1 was found face down and unresponsive in the bathroom on 9/6/11 at 1058 hours, and died on 11 at 1507 hours, from a cervical spine fracture secondary to a fall.

On 10/13/11, clinical record review was initiated for Patient 1. Patient 1 was admitted to the facility on with diagnoses including status post hip replacement secondary to a fall, and osteoporosis (brittle bones).

Patient 1 was a year old female who was living at home with family when she fell and broke her right hip. Patient 1 was admitted to the facility from an acute care hospital on ·/11, to recover and rehabilitate from the surgically repaired broken hip.

On 9/6/11 at 1058 hours, Patient 1 was found by the maintenance director face down in the bathroom, nonresponsive and without a . pulse. Patient 1 was transferred to the emergency department in full arrest {without a heart beat or breathing) and was pronounced dead at 1507 hours.

Review of Patient 1's Minimum Data Set (MOS - an assessment tool) dated 8/18/11 . showed she required extensive assistance from two staff members to assist her for toileting, including transfers on· and off the toilet and cleansing self after elimination. Patient 1's balance for moving on and off the toilet showed she was not steady and was only able to stabilize with human assistance. In addition, Patient 1 had a history of falling within the last month prior to admission to the facility, and sustained a fracture (broken bone).

Review of Patient 1's Care Area Assessment (CAA) for "Falls" showed an analysis of her findings as being at risk for falls/injuries related to dementia, osteoporosis, impaired balance during transitions and an unsteady gait.

Review of Patient 1's Fall Risk Assessment dated 8/6/11, shows a score of 12 (a score of 10 or above represents a high risk for falls).

Review of Patient 1's Licensed Nurse Weekly Summaries dated 8/24/11 and 8/31/11 , showed Patient 1 had no behavioral problems and was at risk for falls. Her functional status for activities of daily living (ADL) showed she required extensive assistance with transfers and toileting.

Review of Patient 1's Nurse's Notes dated 8/30/11 at 1840 hours, 8/31111 at 1330 hours and 1800 hours, 9/1/11 at 1445 hours and 2000 hours, 9/2/11 at 1940 hours, 9/3/11 at 1400 hours, 1600 hours, 9/4/11 at 1030 hours and 1700 hours, 9/5/11 at 1400 hours and 1900 hours and 9/6111 at 0100 hours, showed she required extensive assistance with her ADLs. An entry dated 9/6/11 at 1058 hours, showed Certified Nursing Assistant (CNA) 1 assisted Patient 1 to the bathroom, went to get another CNA, and Patient 1 had fallen and was unresponsive. Cardiopulmonary resuscitation (CPR) was initiated.

Review of Patient 1's care plan problem dated 8/6/11, to address her alteration in thought process related to dementia showed an approach plan to anticipate her needs, while observing safety.

Review of Patient 1's care plan problem dated 8/6/11 , to address her risk for falls/injuries related to a recent dedine in her functional status and history of falls, showed an approach plan to assist with ADLs, anticipate needs and observe safety precautions.

Review of Patient 1's care plan problem dated 8/6/11, showed she required extensive assistance with toileting needs.

Review of Patient 1's care plan problem dated 8/12/11 , to address her risk for spontaneous fracture related to osteoporosis showed an approach plan to handle gently during transfers and mobility.

Review of Patient 1 's Physical Therapy Treatment Encounter Notes dated 9/4/11 , showed she required stand by assistance with transfers, her standing balance was fair and had impaired safety awareness.

Review of Patient 1 's Physical Therapy Discharge Summary dated 9/6/11. showed Patient 1 required stand by assistance with transfers.

Review of Patient 1's Occupational Therapy Treatment Encounter Notes dated 912111, showed she required stand by assistance with toilet transfers, and needed stand by assistance with completing pencare (deaning of the perineal area - urinary and rectal orifices) and putting her pants on and off. Patient 1's standing balance was fair.

Review of Patient 1's Occupational Therapy Discharge Summary dated 9/7/11, showed Patient 1 continued to need stand by assistance with toileting and 20% verbal cues (verbal reminders 20% of the time) for safety awareness and for safety while turning.

Review of the facility's Investigation Follow-Up dated 9/6/11 , showed Patient 1 was assisted to the bathroom by CNA 1. Patient 1 had asked for privacy; CNA 1 closed the bathroom door. CNA 1 left Patient 1 in the bathroom to endorse to another CNA that Patient 1 was in the bathroom. A short time late, another staff member called for help and Patient 1 was assessed and found unresponsive.

Review of the DON's written statement dated 9/6/11 , showed CNA 1 took Patient 1 to the bathroom. CNA 1 left Patient 1 in the bathroom alone, to check on another patient, and returned to check on Patient 1 again. Patient 1 requested more time in the bathroom. CNA 1 went to the hallway to find another CNA to watch Patient 1 in the bathroom. While CNA 1 was asking the other CNA to watch the Patient. another staff member was yelling for help when he found Patient 1 on the floor in the bathroom.

Review of the maintenance director's written statement dated 9/7/11, showed he was performing monthly call light inspections. When he entered Patient 1's room, he did not see Patient 1 or a staff member. He knocked on Patient 1's bathroom door and nobody answered. He opened the door and found Patient 1 face down on the bathroom floor.

Review of CNA 1 's written statement dated 9/6/11, showed at 1045 hours, she assisted Patient 1 to the bathroom. She documented she had closed the door and stood in the hallway for Patient 1's privacy. CNA 1 documented, since her lunch was at 1100 hours, around 1057 hours, she went to tell another CNA to check on Patient 1. While she was telling the CNA about the situation, she saw a staff member running to the nurses' station to alert the nurses of the code. Patient 1 had fallen from the toilet and was lying on the floor.

Review of CNA 1's Employee Warning/Discipline Memo dated 9/6/11, showed her performance problem was leaving Patient 1 unattended in the bathroom. The memorandum further showed the corrective action was to never leave the patient unattended, finish what you are currently doing with the patient, and call somebody to come to the room by using the call light, without leaving the patient.

During an interview on 10/13/11 at 1015 hours, the DON stated Patient 1 was alert and forgetful. She stated on 9/6/11 at approximately 1045 hours, CNA 1 assisted Patient 1 to the bathroom, waited outside the bathroom door and left to get a replacement CNA. The DON stated, on 916/11 at 1058 hours, the maintenance director found Patient 1 face down on the bathroom floor, unresponsive_ She stated CNA 1 is no longer employed at the facility.

During an interview on 10/13/11 at 1115 hours, the maintenance director stated, on 9/6/11 at 1058 hours, he was doing his monthly inspection of the patients' call lights. He stated he knocked on Patient 1's bathroom door, got no response, so he opened the bathroom door and found Patient 1 face down in front of the toilet bowl. The maintenance director stated no staff members were present and he immediately called for help. He stated he did not see any movement from Patient 1 and she was not verbally responsive.

Review of Patient 1's Prehospital Care Report dated 9/6/11 at 111 0 hours, showed Patient 1 was found at the facility in cardiac arrest (no vital signs - pulse, respirations or blood pressure). She had a hematoma (bruise) to her forehead. CPR was started.

Review of Patient 1 's Emergency Physician Record dated 9/6111 at 1131 hours, showed she was unresponsive, had no vital signs and had a frontal hematoma with an abrasion. CPR continued. At 1140 hours, Patient 1's heart rate was 138 beats per minute and a blood pressure of 141/104,. CPR was stopped.

Review of Patient 1 's computed tomography (C1) scan of the brain without contrast dated 916/11 at 1301 hours, showed Patient 1 had a large area of soft tissue swelling/hematoma over the bifrontal region of her scalp (the area across the forehead at the hairline). In addition, a small, nondisplaced subtle fracture would be difficult to entirely exclude.

Review of Patient 1 's CT scan of her cervical spine without contrast dated 9/6/11 at 1302 hours, showed a minimally displaced type II dens fracture (the result of a severe force including rotation across the cervical spine), a nondisplaced right posterior C1 arch fracture (occurs when the head is hyperextended and the posterior neural arch of C 1 is compressed between the occiput [back of the skull] and the strong, prominent spinous process of C2), and a mild posterior subluxation of the left C1-C2 facet (a partial or incomplete dislocation).

Review of Patient 1's hospital Physician Progress Notes dated 9/6/11 at 1522 hours, showed Patient 1 apparently fell. hit her head and sustained a frontal hematoma. She was found unresponsive and CPR was initiated. At the emergency room, her Glascow Coma Scale (GCS - a scale for measuring level of consciousness. especially after a head injury, in which scoring is determined by three factors: amount of eye opening, verbal responsiveness, and motor responsiveness, a score of three is compatible with brain death) was a score of three post advanced cardiac life support measures. At 1325 hours, Patient 1 was placed on comfort care per the family's request, was taken off the ventilator at 1431 hours and expired at 1507 hours.

Review of the Coroner's autopsy report showed Patient 1 's cause of death as a cervical spine fracture due to a faiL The coroner's anatomic summary showed Patient 1 had epidural hematomas (traumatic accumulation of blood in the spinal canal) of T (thoracic vertebra) 1 through T10, a fracture of the right transverse process and the right lateral vertebral body of C4 and. had hemorrhage (bleeding) of the spinal cord at the level of C1 through C4.

During an interview on 11/8/11 at 1130 hours, CNA 2 stated Patient 1 had no behavioral problems. She stated, when she assisted Patient 1 to the bathroom, she stayed with her to prevent her from falling. CNA 2 stated she would not dose the bathroom door completely, but she would leave the bathroom door open slightly so she could watch Patient 1 to make sure she was all right.

During an interview on 11/8/11 at 1140 hours, CNA 3 stated Patient 1 had no behavioral problems. He stated Patient 1 was able to take a couple of steps, but required stand by or minimum assistance in ambulating. CNA 3 stated the facility's policy is to stay with the Patient while they are in the bathroom. He stated when he assisted Patient 1 to the bathroom, he would stand outside the bathroom door with the door slightly open to monitor Patient 1, and listen to make sure the patient was all right.

This violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and was a direct proximate cause of death of the patient.