San Tomas Convalescent Hospital
3580 Payne Avenue, San Jose, CA  95117
Citation Number: 070006439
Citation Date: 8/18/2009
Violation Date: 3/25/2009
Class: AA
Penalty: $ 80,000

The following reflects the findings of the Department of Public Health during a Complaint Investigation visit.

CLASS AA CITATION·· PATIENT CARE
CITATION NUMBER: 07-2098-0006439-F
Complaint(s): CA00193421

F323 - 483.25(h) Accidents and Supervision
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.

The facility failed to ensure the environment remained as free from accident hazards as possible and the resident received adequate supervision for one of one sampled resident (1) with an unsteady gait when the facility failed to update and implement a care plan regarding fall prevention. Resident 1's fall prevention care plan approaches included monitoring at all times and the use of a personal alarm. However, a personal alarm was not in use at the time of her last fall. A physical therapy recommendation dated 3/25/09 for Resident 1 to have assistance at all times while walking was not included in Resident 1's care plan. On 4/3/09, Resident 1 sustained her seventh fall while walking unobserved in her room. Resident 1 sustained fractures of her facial bones, and the orbit of her left eye, and a subdural hematoma (bleeding within the brain). On 4/16/09 Resident 1 expired. The death certificate indicated the immediate cause of death was from blunt trauma to the head.

Resident 1 was an 83-year-old female admitted to the facility on 3/3/09 with diagnoses including Alzheimer's dementia with agitation, history of frequent falls, restless leg syndrome and major depression. During closed record review on 7/1/09, Resident 1's admission Minimum Data Set (MDS), an assessment tool dated 3/16/09 indicated the resident had modified independence with some difficulty in decision-making in new tasks or situations and had short and long-term memory problems. The MDS also noted the resident had an unsteady gait, needed supervision and set-up help for walking, and needed limited and one person physical assistance in transferring, e.g., getting out of bed to a standing position.

During an interview on 7/1/09 at 3:35 p.m., certified nurses assistant A (CNA A) stated he was assigned to care for Resident 1 on the evening shift of 4/3/09. CNA A stated Resident 1 was very confused, anxious, and had difficulty sleeping. He stated Resident 1 walked independently in the hallways and in her room using a walker (a four legged device use to provide steadiness while walking) and also used a wheelchair. He stated Resident 1 was noted to walk at times with her eyes closed. He stated due to Resident 1's anxiety and restlessness, staff visited or helped Resident 1 "about every 5 minutes." He stated at approximately 8:00 p.m. he put Resident 1 to bed and then went to an adjoining room to care for another resident. He stated he left a wheelchair parked at the head of Resident 1's bed and a walker situated near the foot of the bed. He stated about three minutes after leaving Resident 1 he heard a loud crash, returned to Resident 1's room, and saw the resident lying in approximately the center of the room on her back. A dresser was lying across her lower body and a flat-screen television about 3 feet long and 3 feet wide lying on top of her head and chest. He stated the television was attached to the dresser with straps. He stated a corner of the television had injured Resident 1's head and there was bleeding from the back of her head. He stated Resident 1's walker was situated immediately adjacent to her body. CNA A stated he assisted other staff in removing the dresser and the television from on top of Resident 1 and noted it was difficult to do so. CNA A stated paramedics were summoned and Resident 1 was transferred to an acute care hospital. He stated regarding the fall he thought Resident 1 got out of bed and then using the walker approached the dresser and television. He stated for unknown reasons Resident 1 tried to remove the television from atop the dresser. The television was strapped down to the dresser, so possibly Resident 1 pulled the television and the dresser down on herself.

On 7/1/09 at 3:50 p.m. during observation of the room in which Resident 1 had resided, CNA A pointed to a dresser and stated it was the same one that fell on Resident 1. It was 30 inches tall, about 18 inches deep, and contained three drawers. On the top of the dresser were four small holes in a rectangular pattern corresponding to where securing straps may have been previously attached with screws. CNA A stated the television, which fell on Resident 1, was a large flat-screen (LCD) type which belonged to another resident who was discharged. He stated the family of that resident removed the television from the facility. He stated the television was damaged with a scratch on the screen from the fall incident. CNA A indicated a position about six feet from Resident 1's bed where Resident 1 was found on the floor with her feet pointing towards the bathroom door area, and indicated the television and dresser were formerly located near the bathroom door.

A review of Resident 1's record on 7/1/09 indicated a care plan titled "Care Plan on Falls" initiated on 3/7/09 with problems including psychiatric medications, a previous history of falls, an unsteady gait, and severely impaired safety judgment. The goal was for the resident to be free of injuries daily. Approaches included physical and occupational therapy evaluation and treatment, placing a walker within reach, and using a low bed. The care plan was updated on 3/25/09 to include monitoring the side effects of medications, redirecting the resident's behavior, checking the resident every two hours, and using a personal alarm in the bed (a device that alarms when the resident moves away from a bed or chair). The care plan was updated again on 3/28/09 to include the problem "Resident slipped on the bathroom floor." Updated approaches included "Kept monitored at all times," assist to the bathroom as needed, provide adequate lighting, and remind the resident to use her call light to ask for assistance. The care plan was updated again on 3/31/09 to include the problem, "Unwitnessed fall seen lying on her back." Approaches included check resident every two hours, and use "personal alarm as nursing measure." The care plan was updated again on 4/3/09 with the problem, "Unwitnessed fall seen sitting on the floor." No new interventions were added on this date. Approaches remained to redirect behavior, monitor every two hours, and use a personal alarm.

Record review on 7/2/09 indicated nurses notes documented seven falls in a one month period: 3/7/09 at 2:00 p.m., 3/20/09 at 2:00 p.m., 3/21/09 at 9:00 p.m., 3/28/09 at 11:45 p.m., 3/30/09 at 1:13 p.m., 4/3/09 at 2:10 p.m. and 8:10 p.m. The nurses notes indicated all of the falls were unwitnessed. Nurse's notes indicated on 3/21/09 at 7:00 a.m. Resident 1 had unexplained bleeding from the mouth area, and on 3/21/09 at 1:32 p.m. had a purplish discoloration on her right inner thigh and a purplish discoloration in the occipital (back of the head) area. The Post Fall Interdisciplinary Team Note dated 4/2/09 recommended checking Resident 1 every hour and having a certified nurse assistant sit by her room at night.

The Department determined the facility failed to:

During an interview on 7/2/09 at 8:30 a.m., the director of nurses (DON) recalled the resident was too confused to use the call light or ask for help. She stated the resident knew when she needed to go to the bathroom and always used the walker. She stated a personal alarm was tried and discontinued because the resident was able to remove the alarm. The DON examined the record and stated there was no documentation the personal alarm was tried. There was no evidence any other measure was implemented to ensure Resident 1's safety. The DON stated the care plan approach dated 3/28/09 to monitor at all times meant staff was to supervise Resident 1 at all times. The DON stated she did not know why the care plan had decreased supervision to monitor every two hours on 3/31/09 given that the resident had fallen again. The DON examined the record and stated there was no documentation Resident 1 was monitored at all times. She stated, "It did not happen." The DON stated constant supervision is not normally provided by the facility, and family members may elect to provide a caregiver to stay with a resident at all times at their cost. However, the DON stated if constant supervision was deemed necessary to ensure a resident's safety, then the facility would provide a caregiver to stay with that resident at all times. When asked why constant supervision was not provided for Resident 1, the DON stated caregivers were checking on Resident 1 frequently during the day, and at night, the DON stated she had instructed nurses assistants to sit on a chair near Resident 1's room to keep her under surveillance. The DON checked the record and stated there was no documentation the night surveillance was implemented

During an interview and record review on 7/2/09 at 11:55 a.m., licensed physical therapist A (LPT A) described the resident as anxious and staff needed to be present because Resident 1 became short of breath and her oxygen saturation (a measurement of how much oxygen is in the bloodstream) would drop. He stated toward the end of her stay Resident 1 was at higher fall risk because she was drowsy and tired and needed a standby wheelchair when walking to rest on. Review of the physical therapy (PT) evaluation dated 3/4/09 documented when walking with a front wheel walker, the resident needed minimum assistance. Review of the PT discharge note on 3/25/09 recommended Resident 1 required minimum assistance from staff members when she walked. LPT A stated minimum assistance meant physical contact was needed when Resident 1 walked. LPT A stated he gave verbal discharge physical therapy instructions to nursing staff.

A review on 7/2/09 of the undated Restorative Nursing Assistant (RNA) Program Policy directed PT/RNA to establish RNA programs when residents were discharged from rehabilitation services. It stated appropriate documentation was to be maintained in the medical record. Review of the medical record indicated there was no documentation the resident's functional status (ability to perform daily tasks such as walking) assessed by rehabilitation staff upon discharge was updated in the impaired physical functioning care plan dated 3/3/09. Also, there was no documentation discharge PT instructions were given to the RNA staff. In an interview on 7/2/09 at 9:00 a.m., the DON stated rehabilitation discharge instructions to nursing staff were to be completed on the RNA form but she could not locate the written instructions.

A review on 7/2/09 of Resident 1's "Care Plan on ADL's" (Activities of Daily Living) dated 3/3/09 indicated a problem of "impaired physical functioning based on ADL support needed." The care plan indicated Resident 1 required supervision to walk in her room, walk in the corridor, and walk on the unit. Approaches included physical therapy and occupational therapy evaluation and treatment. During an interview on 7/2/09 at 9:00 a.m., the DON stated the ADL care plan did not reflect the rehabilitation discharge instructions indicating Resident 1 required minimal assistance when walking.

On 7/2/09 at 10:00 a.m. review of nurses' notes of 4/3/09 at 8:10 p.m. indicated Resident 1 was found on the floor inside her room with a television on her face and table on her chest and legs. Facial grimacing and moaning noted. Resident 1 was noted to have a linear laceration (cut) on the forehead about one and one-half inches long, with moderate bleeding and hematoma (bruise) around laceration. Also, noted to have multiple skin discolorations to left leg. The physician was notified with an order to send the resident to the hospital.

A review on 7/14/09 of the 4/3/09 acute care hospital's Emergency Department record indicated Resident 1 arrived at 9:05 p.m. She had a large laceration involving the left facial and frontal area. A scan of her head revealed fractures of her facial bones and the orbit of her left eye, and a subdural hematoma (bleeding within the brain). She was lethargic but did follow some commands and was able to squeeze with both hands. The discharge summary dated 4/16/09 outlining Resident 1's hospital course indicated she was unable to eat. A feeding tube was placed in her stomach. However, she developed a severe infection in her colon and subsequently died within a few days.

On 7/14/09 a review of the resident's death certificate issued on 4/24/09 stated the immediate cause of death was from blunt trauma of the head with skull fractures and subdural hematoma (bleeding).

The facility failed to provide adequate supervision and update Resident 1's care plan to include her need for minimal physical assistance when walking, and failed to implement care plan interventions to monitor her at all times and the use of a personal alarm. Resident 1 fell while walking unassisted in her room on 4/3/09. Resident 1 was found on the floor in her room with a television set and dresser on top of her. Resident 1 sustained a fracture of her facial bones and a subdural hematoma. Resident 1 expired on 4/16/09.

The above violations presented either 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 the death of the resident.