Health inspection·April 10, 2025

Class B Citation- The Rehabilitation Center of Oakland The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident (ERI)# CA00937135 Survey Event ID: Y0NP11 State Citation B was written. § 72311 Nursing Services- General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 2/6/25 at 10:15 am, an unannounced visit was conducted at the facility to investigate an Entity Reported Incident regarding accidents allegation. Resident 1 was elderly with a diagnosis of cervical spinal stenosis (space in back bone in the neck area becomes small pressing the nerves going through the spinal cord), gout (a painful form of inflammation of joints), bilateral osteoarthritis (when tissues in the joint break down) of knees and left shoulder. Resident 1 was admitted to the facility in 2023. Resident 1's mental status was moderately impaired. Resident 1 was a smoker and utilized facility's smoking area to smoke cigarettes. Resident 1 used wheelchair for mobility. Resident 1 had decreased functional mobility along with poor seating and positioning while in wheelchair. Resident 1 required staff's assistance with wheelchair mobility. On 12/13/24 around 10:00 am when Resident 1 was being taken to the smoking area, a facility staff failed to assist Resident 1 to push her wheelchair safely, while she was in her unlocked wheelchair. Resident 1 slid down the slope of the ramp (ramp is a slope or an incline, a surface that tilts from one level to another) to that goes into the smoking area. Resident 1 fell out of wheelchair facing downwards, sustaining a contusion (bruise caused by direct blow to the body that can cause damage to the surface of the skin and to deeper tissues as well) of nose, closed fracture (broken bone) of nasal bone and felt embarrassed. During a record review of Resident 1's untitled Care Plan dated 11/28/23, the care plan indicated Resident 1 had impaired physical mobility, she was at risk for decline in Activities of Daily Living (ADLs) and functional mobility. The Care plan indicated to assist Resident 1 in performing movements/tasks and monitor for environmental barriers to mobility. Review of an untitled care plan dated 12/11/24, indicated Resident 1 had decreased functional mobility with wheelchair, had poor seating and positioning and there was a need for assistance with personal care. During a concurrent observation and interview on 2/6/25 at 10:38 a.m. with Director of Environment (DOE), facility's smoking patio area on the left side of building was observed. There was a ramp on the left side of the facility guarded by a gate going into smoking facility. The ramp was made of brown plastic board slacks, and the first two slacks were uneven with cracks in the cement. The ramp had twelve pieces of black nonskid straps spaced out and taped on it. The DOE stated the first two boards created a divot (small hole) and became uneven at times. During an interview on 2/6/25 at 10:48 a.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 1 had previous falls in the past and was at high risk for falls. LVN 1 stated Resident 1 was a smoker, and she was the charge nurse for Resident 1 on 12/13/24. LVN 1 stated on 12/13/24 around 10:00 a.m., Resident 1 was going outside to smoke with a Certified Nurse Assistant (CNA 1). LVN 1 stated Resident 1 slipped and fell on her left side and succumbed an injury to nose and left arm. LVN 1 stated after injury Resident 1 was alert and responsive but was bleeding "heavily" from nose. LVN 1 stated 911(a call placed for immediate emergency assistance from police, fire or medical services) was called, Resident 1 went to the emergency room and returned the same day in the evening. During an interview on 2/6/25 at 10:55 a.m. LVN 1 stated she recalled that on 12/13/24, CNA 1 tried to wheel two residents (Resident 1 and Resident 2) at the same time. LVN 1 stated it was not safe for one staff member to push two wheelchair bound residents at the same time because staff needed two hands to push one wheelchair safely. During an observation and interview on 2/6/25 at 11:26 a.m. Resident 1 was sitting upright in a wheelchair in Activity Room. Resident 1 stated staff usually wheeled her whenever she needed to go through the ramp to go the smoking area; Resident 1 stated on 12/13/24, she was under the impression that CNA 1 was pushing and controlling her wheelchair from the behind, but she was unaware CNA 1 was pushing Resident 2's wheelchair at that time. Resident 1 stated she went down the ramp too fast and fell out of wheelchair. Resident 1 stated she felt "embarrassed" after falling out of wheelchair as that had never happened before. Resident 1 stated she was bleeding from nose and was taken to the emergency room after the fall. During an interview on 2/6/25 at 12:08 p.m. Director of Nursing (DON) stated facility had designated staff monitoring the smoking residents all the time. The DON stated, on 12/13/24 CNA 1 was the assigned staff to monitor the smoking area at the time of incident. The DON stated CNA 1 was behind Resident 1 but was pushing Resident 2 down the ramp. The DON stated Resident 1 fell down ramp and out of wheelchair. The DON stated the incident was avoidable, if CNA 1 communicated with Resident 1 that she was not pushing Resident 1 wheelchair at the time, she was pushing Resident 2. The DON stated facility installed twelve pieces of black reflector nonskid tape on the ramp after Resident 1's fall. The DON also stated CNA 1 did not work at the facility anymore. During an interview on 2/6/25 at 12:25 p.m. Resident 2 stated she remembered the incident when Resident 1 fell out of wheelchair on 12/13/24. Resident 2 stated she was in her wheelchair, behind Resident 1 when they were going down the slope of the ramp, to the smoking area. Resident 2 stated she witnessed Resident 1 wheeled herself, without any assistance from the staff, fell out of her wheelchair, got bloody nose and was taken by ambulance. During a review of Resident 1's nursing progress notes dated 12/13/24, the notes indicated "[Resident 1] fell outside of the building from the wheelchair when going out for smoke at 11:30 am, fell on the cemented floor and she was bleeding the left side of the nose. Per [staff] she fell on her left arm. Kept resident flat on the floor with sheet underneath and covered with blanket, gave pressure on the left nose with gauge. Applied ice top of the nose. 911 called...sent out to [Acute Care Hospital- ACH]." During a review of Resident 1's After Visit Summary (AVS) from the post fall hospitalization at ACH dated 12/13/24, the AVS indicated Resident 1 sustained contusion of nose and closed fracture of nasal bone. In violation of the above cited standards, the facility failed to provide appropriate assistance with wheelchair ambulation to Resident 1 when she was in an unlocked wheelchair, sliding down from the ramp. This failure resulted in Resident 1 falling out of wheelchair, fracture of nasal bone, contusion of nose, and feelings of embarrassment. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.