Other·August 2, 2023

The following reflects the findings of the California Department of Public Health during the investigation of Complaint number CA00827979 and Facility-Reported Incident number CA00828006. Event ID: UKYJ11. Representing the Department, HFEN #39939 and #48116. State Citation B was written. §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Title 22, §72637(a) The facility, including the grounds, shall be maintained in a clean and sanitary condition and in good repair at all times to ensure safety and well-being of patients, staff and visitors. On 3/2/23, at 10:55 a.m., California Department of Public Health conducted an unannounced visit at the facility to investigate a complaint and facility-reported incident regarding a fall by Resident 1. Resident 1 was unsteady walking, required the supervision of one person for locomotion on and off the unit, and had a history of a previous fall. Resident 1 was confused with faulty judgment and was assessed as at high risk for falls. While staff assigned to care for Resident 1 went to break simultaneously, Resident 1 walked the hall unsupervised and tripped and fell, resulting in Resident 1 obtaining a nasal fracture, facial bruise and laceration (cut) requiring stitches. The facility failed to implement the Interdisciplinary team (IDT, a group of healthcare professionals from various healthcare disciplines who collaborate to share expertise, knowledge, and skills to influence and improve patient care) intervention of, "monitor whereabouts," recommended after Resident 1 fell on 12/6/22, by not ensuring there was a designated staff member to supervise Resident 1 when all staff assigned to Resident 1's care simultaneously went on a work break, without assigning a replacement staff member for Resident 1's supervision. These failures resulted in Resident 1 falling down onto the right side of her face after running into another resident's wheelchair while walking unsupervised. Resident 1's fall caused a bruise and facial laceration (cut) on the right side of her forehead and a left nasal bone fracture (partial or complete break in the bone). Resident 1 required transfer to Acute Care Hospital for further evaluation and required two stitches to maintain closure of the laceration wound edges. During a review of Resident 1's "Resident Face Sheet," dated 3/2/23, the Face Sheet indicated Resident 1 was admitted to the facility in 2017, with diagnoses of dementia (memory loss that interferes with activities of daily living) and unsteadiness when walking. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool to guide care) dated 12/27/22, the MDS indicated Resident 1 was not steady walking and required the supervision of one person when walking. The MDS indicated Resident 1 was only sometimes able to understand others and only sometimes was able to be understood. During a record review of Resident 1's care plan titled, "Falls," start date 3/31/22, the care plan showed Resident 1 was at high risk for falls related to faulty judgements and diminished mental status. The care plan indicated Resident 1 had a witnessed fall on 12/6/22. The care plan showed the interventions initiated after the 12/6/22 fall were to: notify physician and responsible party, 72-hour check of neurological signs (examination to check for changes in mental status), and an IDT meeting to discuss the plan of care. During a review of the facility provided document, "Facility Observation Summary Report," dated 12/1/22 to 2/28/23, the Facility Observation Summary Report indicated Resident 1 had a witnessed fall on 12/6/22, and another witnessed fall on 2/18/23. During a review of Resident 1's Observation Detail List Report titled, "Risk Meeting Notes" dated completed 12/30/22, with three signatures of IDT staff, the Risk Meeting Notes indicated Resident 1's 12/6/22 fall was reviewed by IDT. The Risk Meeting Notes section titled, "Plan of Care and Recommendations," indicated, "Upon IDT review to continue resident plan of care...Monitor resident where abouts..." During an observation on 3/2/23, at 10:53 a.m., in Resident 1's room, Resident 1 paced around the room and mumbled words which were not understandable. Resident 1 was unresponsive when asked questions. Resident 1 had yellowish purple discolorations on both cheeks and a cut over the right eye with two (2) black sutures (stitches) holding the edges of the cut together. During an interview on 3/2/23, at 11:20 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she had been assigned to Resident 1 on 2/18/23, with RN 1 as her supervising charge nurse. CNA 1 stated at the time Resident 1 fell, she and RN 1 had been on their lunch break. CNA 1 stated she had not known who had supervised Resident 1 while she and RN 1 had both been on lunch break. CNA 1 stated prior to taking her lunch break, Resident 1 had been pacing in the hallway by herself. During an interview on 3/6/23, at 11:11 a.m., with RN 1, RN 1 stated he was on lunch break when Resident 1 fell on 2/18/23. RN 1 stated prior to leaving on his lunch break Resident 1 was in bed watching television, and LVN 1 was at the medication cart next to the North nurse's station. RN 1 stated he told LVN 1 and CNA 1 he was going to take his lunch break and left. RN 1 stated he expected LVN 1 to provide supervision to RN 1's assigned residents during his lunch break. RN 1 stated he knew Resident 1 was a fall risk and that Resident 1 walked fast, was confused, and often needed to be redirected. RN 1 stated when he returned from lunch break, LVN 1 reported Resident 1 had fallen and was bleeding "a lot" so he called an ambulance to transport Resident 1 to the hospital. During an interview on 3/2/23, at 11:01 a.m., with Licensed Vocational Nurse 1 (LVN 1), at the North nurse's station, LVN 1 stated on 2/18/23, she and Registered Nurse 1 (RN 1) were charge nurses at the North station. LVN 1 stated she had not witnessed Resident 1's fall but had been the first staff person to respond to Resident 1's fall. LVN 1 stated she was on break inside the charting/copier room at the North nursing station, where she could not see the nursing station area, when she heard residents yelling that Resident 1 had fallen. LVN 1 stated she left the charting/copier room and saw Resident 1 laying on the floor. LVN 1 stated she moved Resident 1 into a wheelchair with the assistance of Certified Nursing Assistant 2 (CNA 2). LVN 1 stated she had been unaware that Resident 1's assigned charge nurse, RN 1, had also been on break during the time of Resident 1's fall on 2/18/23. During a review of Resident 2's "Resident Face Sheet," dated 3/2/23, indicated Resident 2 was admitted to the facility in 2019. During a review of Resident 2's MDS assessment, dated 2/27/23, the MDS assessment indicated Resident 2 was able to make himself understood and was able to understand others. During an observation and interview on 3/2/23, at 11:03 a.m., with Resident 2, at the North nurse's station, Resident 2 stated on 2/18/23, he and Resident 3 had been sitting in their wheelchairs near the North nurse's station when he saw Resident 1 walk by herself toward the North nurse's station. Resident 2 stated he saw Resident 1 hit her foot on Resident 3's wheelchair footrest and fall forward. Resident 2 stated as Resident 1 fell, she hit her head on the solid nursing station countertop and continued her fall, hitting her head on the floor baseboard. Resident 2 stated Resident 1's face was "bleeding a lot." Resident 2 stated he yelled that Resident 1 had fallen and was bleeding and LVN 1 came out of the charting/copier room at the nurse's station, helped Resident 1 into a wheelchair, and used a pillowcase to stop the bleeding. During a concurrent interview and record review on 3/2/23 at 12:11 p.m., with the Director of Nursing (DON), Resident 1's risk meeting notes dated 12/6/22, were reviewed. The DON stated Resident 1 had tripped over another resident while walking and had fallen on 12/6/22. The DON stated Resident 1 was alert, but disoriented and confused, walked fast, and was unaware of personal safety. The DON stated IDT had a meeting on 12/30/22 to discuss Resident 1's falls, and the IDT recommended the intervention for staff to monitor Resident 1's "whereabouts." The DON stated she expected certified nursing assistants to know their assigned residents' care needs, and for licensed nurses to communicate with each other and the DON about when they took their breaks. During an interview and record review on 3/2/23, at 2:05 p.m., with DON, Resident 1's Fall Risk assessment, dated 12/14/22, was reviewed. The fall risk assessment form included the following areas of resident assessment: level of consciousness (measurement of a person's arousability and responsiveness to environmental stimuli), history of falls, mobility with elimination, gait/balance, medications, and diagnosis. The DON stated Resident 1 was marked as forgetful, no history of falls in the prior three months, required regular assistance with toileting, had a normal gait, did not take any psychotropic (a medication that affects how the brain works) medications, and had no active diagnosis predisposing her to falls. The DON stated Resident 1's fall risk assessment dated 12/14/22 should have been marked with a history of one to two falls in the past three months, and that she had been taking the psychotropic medication Buspar (a medication used to treat anxiety) within the last seven days. The DON stated Resident 1's fall risk score should have been 12 instead of six. The DON stated residents with a fall risk score of 10 or higher were considered at high risk for falls. The DON stated Resident 1 would have been placed on the Fall Prevention program if the December fall risk assessment had indicated the correct score of 12. The DON stated it was important to have the correct risk assessment, so the facility developed the correct plan of care for a resident at high risk of falls. During a record review of Resident 1's Emergency Department (ED) discharge report document dated 2/18/23, the report showed Resident 1 obtained a "facial hematoma" [bruise] requiring "sutured wound care and a nasal bone fracture (partial or complete break in the bone) on the left." During a record review of the facility's Policy and Procedure (P&P) titled, "Fall Prevention (Falling Star)," revised 8/9/13, the P&P indicated, "Falling Star program is designed to provide the patient/resident who is at an increased risk for falls/injury with adequate supervision and assistive devices to help minimize the risk of injury from falls. Each resident who is at increased risk for falls/injury, as identified from the Fall Risk Assessment, criteria for inclusion in the program, and clinical judgment of the facility's IDT, will have a plan of care and interventions implemented to manage falls/injury....The following criteria will be utilized by the IDT to determine the appropriateness of Patient/Resident to be included in the program...Patient/Resident has a score of 10 or above from Fall Risk Data Collection...If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions....The MDS/IDT Care Conference team will also update the resident's care plan accordingly...." In violation of the above cited standards, the facility failed to implement the Interdisciplinary team (IDT, a group of healthcare professionals from various healthcare disciplines who collaborate to share expertise, knowledge, and skills to influence and improve patient care) intervention of, "monitor whereabouts," recommended after Resident 1 fell on 12/6/22, by not ensuring there was a designated staff member to supervise Resident 1 when the assigned staff were all on a work break. This violation had a direct or immediate relationship to the health, safety, or security of residents.