Health inspection·December 16, 2021

Bethel Lutheran Home CA00636077 22 CCR 72637 72637. General Maintenance. (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 5/16/19 at 10:40 a.m., an unannounced visit was conducted at the facility to investigate Complaint CA00636077, regarding Resident 1's fall which resulted in the fracture of Resident 1's ribs. The facility failed to ensure the facility grounds were maintained in good repair at all times when the facility's exterior asphalt ramp in the parking lot patio was uneven and broken. As a result of this failure, Resident 1, who was in his electric wheelchair was unable to pass through the uneven ramp and suffered a fall on 3/27/19. Resident 1 was hospitalized because of the fall on two different occasions in less than 24 hours. The first hospitalization was on 3/27/19 for fractured (broken) ribs to the left side of his chest (ribs four, five, six, and seven). The second hospitalization was on 3/28/19 due to pneumothorax (collapsed lung that occurs when air enters the space around lungs). Resident 1 was a 64-year-old male, who was admitted to the facility on 12/20/10, with generalized weakness (decrease in the strength in one or more muscles), left hand contracture (shortening and hardening of muscles, tendons), and debility due to CVA (cerebral vascular accident- stroke- blood flow to a part of your brain is stopped). During a review of Resident 1's record, the "Minimum Data Set" (MDS) assessment (an assessment used to identify resident care needs) - "Brief Interview for Mental Status" (BIMS, an evaluation of attention, orientation and memory recall), dated 3/23/19, indicated Resident 1's BIMS score was "15." A BIMS score of 0-7 indicate severe cognitive impairment, 8-12 indicate moderate cognitive impairment, and 13-15 indicate no cognitive impairment). The MDS assessment also indicated Resident 1 was independent while in his (electric) wheelchair. During a review of Resident 1's record, the "Physician's Order (PO)" dated 5/1/19, indicated "... [Resident 1] may go outside in electric wheelchair (w/c)] independently [Monday/Wednesday/Friday] in facility courtyard/patio [at] staff's discretion between [10 a.m. - 4 p.m.]." During a concurrent observation and interview with Resident 1 on 5/16/19, at 12:20 p.m., in Resident 1's room, Resident 1 sat up in his bed and watched television. Resident 1 stated, on 3/2019, he had a fall in the facility's parking lot. Resident 1 stated, as he passed through the ramp, the wheel on his electric wheelchair passed through the broken ramp and he fell in the parking lot patio. Resident 1 stated the ramp was uneven. Resident 1 stated he notified nursing staff but he was unable to recall what nursing staff he spoke to. Resident 1 stated the ramp was fixed after he was injured. Resident 1 stated he suffered a few broken ribs from the fall. During a concurrent interview and record review, with Licensed Vocational Nurse (LVN) 2, on 5/20/19, at 3:36 p.m., LVN 2 reviewed the "Nurses Notes" dated 3/27/19 at 8:45 p.m. LVN 2 stated, on 3/27/19 at 7:35 p.m., Resident 1 requested to go outside and smoke. LVN 2 stated, at approximately 7:42 p.m. the Licensed Nurse (LN) on duty was notified by a community member that [Resident 1] had fallen out of the motorized wheelchair. LVN 2 stated the LN found Resident 1 lying face down on the ground with his left arm under his body. LVN 2 stated Resident 1 complained of pain on his left arm and left ribs. LVN 2 stated Resident 1 asked to be turned on to his back but was instructed he could not be moved until paramedics arrived. LVN 2 stated Resident 1 was transferred to the General Acute Care Hospital (GACH) on 3/27/19 at 8:20 p.m. LVN 2 reviewed the "Nurses Notes" dated 3/28/19 at 12:50 a.m. and stated Resident 1 returned from the GACH at 12:50 a.m. via gurney (wheeled stretcher used for transporting hospital patients)/ambulance. LVN 2 stated the LN on duty received report from the ambulance driver. LVN 2 stated Resident 1 returned with fracture of the left fourth rib, a superficial abrasion (a wound that's caused by the skin rubbing against a rough surface) to left side of the forehead and his right middle finger was swollen. Resident 1 stated he was able to move his finger, but it would hurt. LVN 2 reviewed the "Nurses Notes" dated 3/28/19 at 3 a.m. and stated Resident 1 had trouble getting comfortable; he had denied pain but with movement he would yell out. LVN 2 stated Resident 1 was transferred back to the GACH for vomiting coffee ground emesis (dark colored vomit) two times. LVN 2 stated the Medical Director was called and recommended to transfer Resident 1 to the GACH. LVN 2 stated ambulance services were called and Resident left via gurney at 3:20 a.m. LVN 2 reviewed the "Nurses Notes" dated 3/28/19, at 9:40 a.m., she stated Resident 1 was admitted to the GACH with fracture of ribs four, five, six, and seven on the left side, and a tiny pneumothorax of the left lung. During a review of the GACH clinical record for Resident 1, the "Emergency Department Notes" dated 3/27/19 at 8:54 p.m., indicated, "The patient presents following fall and Patient brought in by ambulance... status post fall from wheelchair... Patient is complaining of some left chest wall pain... Patient states the pain is worse with palpation (the process of using one's hands to check the body) and deep breaths... Radiology (for example, X-rays) results... Fracture of the left fourth rib..." During a review of the GACH clinical record for Resident 1, the "History and Physical Examination" dated 3/28/19, at 4:13 pm., indicated, "64 [year old male] ... presents to the [Emergency Department] for hematemesis (vomiting of blood) after a fall yesterday evening resulted in left-side multiple rib fractures. Patient reported he lives at [Skilled Nursing Facility] and he fell out of his wheelchair yesterday evening, landed on his left side onto concrete... Patient complains of left-sided chest wall pain, anterior (front of the body) and posterior (back of body), sharp, constant, [8/10- (level of pain measured at 8 on a scale of 1-10, 1-3 mild, 4-6 moderate, 7-10 severe], aggravated by breathing and movements, alleviated by rest... [Chest X-ray showed: Acute left posterior fifth rib fracture. [Computerized Tomography (CT)] (Uses several X-ray images and computer processing to create cross sectional images) acute fractures of the left fourth through seventh ribs: a tiny pneumothorax..." During an interview with the Administrator (ADM), on 5/20/19, at 3:50 p.m. the ADM stated, on 3/26/19 he was notified there was an issue with the facility ramp that needed to be corrected. The ADM stated he was unable to recall who notified him the ramp was uneven and broken. The ADM stated he immediately contacted the Contractor (CON) on 3/26/19 and scheduled a repair for 3/28/19. The ADM stated he did not notify staff of the uneven ramp and did not implement hazard alert to the area. During a concurrent observation and interview, with the Director of Nursing (DON), on 5/20/19 at 4 p.m., in the facility parking lot, she pointed to the ramp that led from the parking lot into the facility park. The DON stated she had not seen the ramp prior to Resident 1's fall. The DON stated the ramp was fixed after Resident 1's fall. During a concurrent interview and record review with the CON, on 11/18/19 at 3:46 p.m., he reviewed the construction forms dated 3/28/19 and stated that on 3/28/19, the ADM notified him that the ramp in the main parking lot needed to be fixed right away. The CON stated the ramp was made of asphalt, had cracks in it and was uneven. The CON stated he replaced the ramp with cement on 3/28/19. During an interview with the Maintenance Director (MDir), on 11/21/19, at 3:52 p.m., he stated he had been working at the facility for 30 years. The MDir stated he had been doing monthly observations of the physical environment since 1/19. The MDir stated his observation consisted of looking to ensure there were no debris around the facility patio, the walking areas in the facility park, and any hazardous potholes. The MDir stated he would not document his findings, but he would take some notes of the items that needed to be repaired. The MDir stated he was notified the facility ramp needed repair on 3/28/19. The MDir stated he was unable to recall who notified him. The MDir stated the ADM set up the repair with the CON. The MDir stated he observed the facility ramp before it was fixed and stated he saw a piece of broken asphalt off the ramp from where Resident 1 had fallen. The facility policy and procedure titled, "Fall Risk Assessment" dated 3/18, indicated, "The staff will seek to identify environmental factors that may contribute to falling..." The facility policy and procedure titled, "Falls and Fall Risk, Managing" dated 3/18, indicated, "Fall Risk Factors... Environmental factors that contribute to the risk of falls include... obstacles in the footpath..." The facility document titled "Director of Plan Operations" undated, indicated, "1. This position is accountable for administering and director environmental services to provide a safe, clean and operational facility for residents..." The facility failed to ensure the facility grounds were maintained in good repair at all times when the facility's exterior asphalt ramp in the parking lot patio was uneven and broken. The ADM was notified of the need to fix the facility ramp on 3/26/19, but did not notify staff nor implement hazard alert to the area. On 3/27/19, Resident 1, who was in his electric wheelchair on his way to smoke outside, was unable to pass through the uneven ramp and suffered a fall. Resident 1 was hospitalized because of the fall due to fractured ribs on the left side of his chest and for treatment of pneumothorax. This violation had a direct relationship to the health, safety and security of Resident 1 and therefore constitute a class "B" citation.