Santa Cruz HealthCare Center
1115 Capitola Road, Santa Cruz, Ca 95062
Citation Number: 070007755
Citation Date: 12/17/2010
Violation Date: 11/14/2010
Class: AA
Penalty: $ 80,000

F 3 23 - 483. 25(h) Free of Accident Hazards /Supervision /Devices

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 prevent an accident for one of three sampled residents ( 1). Resident 1 fell while unsupervised in her room on 11/14/10. The resident had a physician's order for a mobility alarm. The resident's mobility alarm clip was not attached to her clothing at the time of the fall. The facility failed to reassess and implement new interventions, such as a pad alarm in a wheelchair when Resident 1 had repeated falls. Resident 1 sustained a fracture of the neck and died as a result of the fall on 11/14/10.

Resident 1 was admitted with diagnoses including an irregular heartbeat and osteoporosis. The 9/23/10 Minimum Data Set (MDS) assessment indicated she had memory problems and needed assistance to transfer and ambulate. The MDS indicated she had fallen in the past 30-180 days.

Resident 1's record was reviewed on 1 1/1 8/10. A 9/10 fall prevention care plan indicated Resident 1 was at risk for falls due to a prior history of falls, visual impairment, use of medications, dementia, impaired physical mobility, and impaired judgment. The goal was reduced risk of injury with falls. Interventions included the use of a bed pad alarm (a flat pad which is pressure sensitive and will cause an attached device to emit a sound if a person moves off the pad), a restorative nurse aide program (a schedule of exercises to improve walking), and supervision as needed.

Physician 's orders dated 7/20/10 indicated, "Placement of mobility alarm" (a device which will emit a sound when the resident stands up from a chair) and "Placement of pad alarm to bed."

A 1/18/10 post fall evaluation form indicated Patient 1 fell while trying to go the bathroom from her bed and sustained an injury. A 7/20/10 post fall evaluation form indicated Patient 1 fell while trying to walk unassisted from the bed to the bathroom at 5:45 a.m. and sustained an injury. The Summary of Interdisciplinary Team (lOT) section of the 7/20/10 post fall evaluation form indicated to assist Patient 1 to the bathroom between 5 a.m. and 6 a.m., and to ensure the alarm was on.

A post-fall evaluation form dated 8/21/10 indicated Resident 1 fell while trying to go to the bathroom from her wheelchair without assistance or supervision. The form indicated X-rays were done to assess pain in her right knee, left hip, and pelvis. The Summary of lOT (interdisciplinary team) section of the 8/21/10 post fall evaluation form indicated "Will continue with bed pad alarm. " However, the form indicated on 8/21/10 Resident 1 fell after leaving her wheelchair, not her bed.

An 11/14/10 post-fall evaluation indicated the resident fell at 1 :10 p.m. while walking unassisted. The form indicated Resident 1 was found on the floor in front of the bathroom on her right side with a large amount of blood from an apparent head wound. The form indicated an alarm was not in use at the time of the fall. The form indicated " 911" was called.

A nurse's note dated 11/14/10 at 1 :30 p.m. indicated Resident 1 was pronounced dead b y emergency medical personnel at 1 :23 p.m. The note indicated a sheriff arrived at 1 :40 p.m., and a coroner came to Resident 1 's room at 2:40 p.m.

During an interview on 11/18/10 at 9 :10a.m. licensed nurse A (LN A) stated she was called to Resident 1 's room on Sunday, 11/14/10 around 1 :10 p.m. by certified nurse assistant A (CNA A) and CNA B. She stated she entered the room and saw Resident 1 on the floor lying on her right side, up against the bathroom door and about two to three feet from her wheelchair, with blood on the floor around Resident 1's head. She stated she immediately called out to another staff member to summon paramedics. She stated Resident 1 said "Help" several times. LN A stated Resident 1 then started to show purple discoloration of her right arm and right side of her face, and began to breathe in an abnormal manner, slow and shallow. She stated paramedics entered the room and then Resident 1 died. LN A stated when she first entered the room she observed a tab alarm (a dark plastic device about three inches tall by two and one-half inches wide and about one inch deep containing a speaker) hooked to the back of Resident 1's wheelchair. LN A stated she observed the tab alarm lanyard and clip (a cord with a pin on one end and a clip on the other, about 18 inches long) draped over the back of the chair and dangling to the front. LN A stated the pin was not pulled from the tab alarm. She stated the tab alarm had not gone off. LN A stated the usual procedure was to clip the lanyard to the resident's clothing. She stated when the resident stood up and/or moved forward, the lanyard would pull the pin out of the speaker box, setting off the alarm and alerting staff. LN A stated she asked CNA B if she placed the clip and CNA B stated she placed the clip on Resident 1's clothing that morning. During an interview on 11/18/10 at 1 :40 p.m., CNA C stated on 11/14/10 she served a lunch tray to Resident 1, who was seated in her wheelchair with a small portable table in front of her. She stated Resident 1 was alone in the room. She stated the resident had a call light near her, but did not observe whether or not the tab alarm clip was attached to Resident 1 's clothing. CNA C stated she had seen Resident 1 pulling at her clip and trying to remove it on several previous occasions. the most recent on 11/12/10. CNA C stated Resident 1 was unsteady on her feet but tried to walk. CNA C stated after leaving the meal tray, she and CNA D moved to the adjacent room to serve lunch trays to other residents. She stated between three to five minutes after leaving Resident 1' s room, CNA A called out loudly for help. She stated she went to Resident 1's room and saw her on the floor.

During an interview on 11/18/10 at 2:20 p.m., CNA B stated she was assigned to care for Resident 1 on 11/14/10. She stated Resident 1 needed help to walk. She stated Resident 1 was wearing black pants and a blouse. She stated she secured the tab alarm clip to Resident 1 's blouse that morning, and observed it in place at 10:45 a.m. when Resident 1 was in the hallway. CN A B said, "Sometimes the clip comes off."

During an interview on 11/19/10 at 10:30 a.m., CNA A stated he was helping in the assisted dining area at lunchtime on 11/14/10. He stated he took some laundry in a bag down the hallway and past Resident 1 's room. He stated he observed Resident 1 on the floor and called for help. He said CNA C and CNA D were in an adjacent room. He stated Resident 1 sometimes removed the tab alarm clip from her clothing. He stated when it occurred, "we put it back on. " He stated nursing staff knew Resident 1 removed her alarm clip. CNA A stated a chair pad alarm (an alarm which sounds when pressure is removed from a pad placed on the seat of a chair) was useful for residents who were able to disarm the tab alarm.

During an interview and record review on 11/19/10 at 11 :20 a.m., the director of nurses (DON) reviewed the 8/21/10 post -fall evaluation form. She stated new interventions were not recommended after this fall. She stated existing interventions were not modified. The DON reviewed the 11/14/10 post -fall evaluation form. She stated the mobility alarm was not clipped in place on Resident 1 at the time of the fall, but should have been. The DON reviewed the 9110 fall prevention care plan and stated the use of a mobility alarm was not on the care plan but should have been. She stated Resident 1' s behavior of removing her mobility alarm clip should have been addressed on the care plan but was not. She said the more reliable chair pad alarm was not used for Resident 1 but could have been.

On 11/23/10, a review of Resident 1 's 11/19/10 preliminary Certificate of Death indicated cause of death was a fracture of the neck following a fall with an impact to the forehead.

On 11/19/10 a review of the 816/07 facility policy and procedure, "Accidents and Supervision to Prevent Accidents" indicated the facility provided supervision and assistive devices to each resident to prevent avoidable accidents. The policy indicated this included identification and evaluation of hazards and risks and implementation of interventions to reduce hazards and risks. The policy indicated the process included monitoring to ensure interventions were implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as necessary, and evaluating new interventions when necessary to make them more effective in addressing hazards and risks.

The facility failed to provide supervision and assistive devices to prevent an avoidable accident for Resident 1. The facility did not evaluate the effectiveness of interventions to prevent falls and failed to modify or replace interventions as necessary. Resident 1 had an unsteady gait and poor judgment and was able to remove her mobility alarm. She fell on 1/18/10, 7/20/10, and 8/21/10. After the fall on 8/21/10, new interventions were not tried. Subsequently on 11/14/10, Resident 1 got out of her wheelchair while unsupervised, fell, fractured her neck, and died.

The above failure 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.