Other·March 7, 2023

The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported Incident #CA00524209 Event ID: 48JM11 Representing the Department, HFEN #26987 State Citation B was written F689 CFR 483.25(d) Accidents The facility must ensure that- 1) The resident environment remains as free of accident hazards as is possible; and 2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 2/28/17 at 00:00, an unannounced visit was conducted at the facility to investigate a facility reported incident in which Resident 1 successfully climbed out of a bathroom window and fell on 2/3/17. The facility failed to provide adequate supervision to Resident 1 when he was left unattended, climbed out of a bathroom window and fell approximately five feet to the ground. The fall resulted in a fracture of the atlas vertebrae of the cervical spine (a broken neck). Resident 1 was a 70-year-old male, admitted to the facility on 12/24/15. He had diagnoses that included bipolar disorder and psychosis (an abnormal condition of the mind which results in difficulties determining what is real and not real). A Brief Interview for Mental Status (BIMS), dated 5/7/16, indicated Resident 1 had severe impaired thinking ability and memory. Resident 1 was not his own responsible party for decision-making. A review of Resident 1's care plan regarding an incident between Resident 1 and another resident, dated 12/28/16, indicated, "...1:1 monitoring [when one staff member is assigned to monitor and care for one resident] ..." There was no documented evidence of an end date to discontinue the care plan for the 1:1 monitoring. A review of an interdisciplinary progress note, dated 1/3/17, indicated, "... [Resident 1] plc'd [placed] on 1:1 monitoring..." A review of a room change documentation, completed on 2/1/17, indicated Resident 1 was to be moved to another room because, "[Resident 1] stated...'I hear the voices. They are talking about killing me... [Resident 1] mad [with] white male roommate [because] he would not give him a knife to protect himself. [Resident 1] presents [with auditory hallucinations, hearing voices]. Pointed to two female [patients] whom [Resident 1] believes are aware that a white man wants to kill him..." A review of a Medication Record, dated February 2017, indicated Resident 1 had an order to monitor behaviors of auditory hallucinations and seeking a weapon for protection every shift starting on 2/1/17. A review of a nurse's note, dated 2/3/17 at 10 p.m., indicated, "... [Resident 1] was standing on the toilet in bathroom had removed the window pain (sic) and [with] a plastic knife and cut the screen, attempted to climb out of window had head and shoulders out of window. DON [Director of Nursing] notified, 1:1 placed on [Resident 1]." A review of a weekly progress note, dated 2/4/17, indicated Resident 1 needed limited assistance when using the toilet. A review of a nurse's note, dated 2/4/17, indicated, "...continues to display paranoid [behavior]...requesting male staff to assist [with] 'escaping from here.'" A review of a nurse's note, dated 2/4/17 at 1:30 p.m., indicated, "...one to one for safety. [Resident 1] continues to display paranoia towards staff...[physician] stated to continue one to one that meds were just recently increased..." A review of a nurse's note dated 2/5/17 at 2 a.m. and 2/6/17 at 2:30 a.m., each indicated 1:1 supervision was being implemented for Resident 1. A review of an SBAR (Situation, Background, Assessment, Recommendation) communication form, dated 2/6/17 at 7 a.m., indicated, "[Resident 1 had an] unwitnessed fall with injury... [Resident 1] found outside on ground supine [flat on back] position..." A review of a resident transfer record, dated 2/6/17, indicated, "[Resident 1] climbed through bathroom window landing in a supine position..." A review of an emergency medicine provider note dated 2/6/17 at 9:20 a.m., indicated, "... [Resident 1] presents s/p [status post] fall that occurred about two hours ago. EMS [Emergency Medical Services] reports resident was in the bathroom when he climbed through a window and fell about five feet... has an abrasion on his forehead and complains of right shoulder pain..." An observation was made on 2/28/17 at 10 a.m. of the Behavioral Management Intervention Room, while accompanied by the DON and Certified Nurse Assistant 1 (CNA 1). The room was large with space for 4 beds and a shared bathroom. On 2/6/17, there were three patients in the room (beds A, B, and D were occupied). Resident 1 was assigned bed D located next to the bathroom. There was one window in the bathroom above the toilet. The bathroom window had a bolt in the slider tray to prevent the window from opening more than two inches. The distance measured outside from the window to the ground was six feet. Each of the resident beds had privacy curtains. In a concurrent interview during the tour on 2/28/17 at 10 a.m., the DON stated there were always two CNAs assigned to the Behavioral Management Interventional Room. The DON further stated, if three CNAs were needed due to escalated behaviors, there would be a third CNA assigned. The DON explained, when the resident was assigned to the Behavior Management Interventional Room, they were to be on 1:1 supervision, meaning, "not out of sight of the CNAs". A review of the facility's investigation of Resident 1's cervical spine fracture reported on 2/27/17, dated 3/1/17, indicated, "...On February 3, 2017... [Resident 1] had cut the window screen with the plastic knife. [Resident 1] was continuing to make statements that the men and women were trying to kill him. Staff was able to redirect [Resident 1] and took the knife away. [Resident 1] was placed on one-on-one monitoring for the night shifts...On February 6 around 6:15 a.m. staff said [Resident 1] was sleeping in his bed with curtains pulled around the bed. His bed was positioned close to the bathroom. CNA's [sic]...assigned as am [morning] caregivers to the 'behavioral intervention and management room' did not see him go to the bathroom. The staff heard a bump noise and went into the bathroom and found him outside his bathroom window lying on his back. Staff said they heard no other noises from the bathroom prior to the bump sound. When staff looked at the bathroom window it was open. The window had a bolt placed to stop the window from opening no more than approximately 2 inches but, [Resident 1] had lifted the window up over the bolt...orders received to send to...hospital for evaluation...On February 27, 2017, the corners [sic] office notified administrator that [Resident 1] had expired and he had a C1 [cervical spine] fracture..." In an interview on 6/1/17 at 8:54 a.m., CNA 1 confirmed he was assigned to work in the Behavior Management Intervention Room with Resident 1. CNA 1 stated two CNAs were always assigned to the room to provide supervision. CNA 1 further stated Resident 1 required continuous 1:1 supervision because he was a danger to himself and others in the facility. CNA 1 stated Resident 1 had a history of hiding utensils under his hat and hoarding them in his room, verbally repeating, "They are coming to kill me." CNA 1 confirmed he was unable to see Resident 1 from where he was positioned in the room and was unaware Resident 1 had gone into the bathroom. In an interview on 6/1/17 at 9:15 a.m., CNA 2 confirmed she worked in the Behavior Management Interventional Room with Resident 1 on 2/6/17. CNA 2 stated there were two CNAs assigned to the room. CNA 2 further confirmed the purpose was to provide 1:1 supervision to the residents. CNA 2 stated Resident 1 was able to go into the bathroom, climb out the window, and had an unwitnessed fall on 2/6/17. CNA 2 confirmed she could not see Resident 1 from where she was positioned in the room. CNA 2 also confirmed the order for 1:1 supervision was for Resident 1's safety. In an interview on 6/1/17 at 9:56 a.m., the Don confirmed the 1:1 supervision for Resident 1 had never been discontinued. The DON stated the purpose of the Behavior Management Interventional Room was to provide 1:1 supervision to protect the resident and staff should allow residents to move about, but not out of sight. A review of a facility policy dated 7/3/08, titled "Healthcare Management Services 1:1 Observation/Line of Sight/Q15 Minute Checks" indicated, "...1:1 Observation...is indicated for residents who exhibit behaviors that present a safety risk to self or others or staff, which has or may result in injury...Responsibilities of 1:1...The staff member assigned must remain within arm's length of the resident unless otherwise directed..." A review of an undated facility policy titled "Behavior Intervention and Monitoring Program" indicated, "...CNA's (sic) assigned to room will accompany residents...and keep the resident in line of site to protect other residents..." In violation of the above cited standard, the facility failed to ensure residents' environment remains as free of accident hazards as is possible and residents receive adequate supervision to prevent accidents, including but not limited to providing adequate supervision to Resident 1 when he was left unattended, climbed out of a bathroom window and fell approximately five feet to the ground. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.