Health inspection·September 19, 2024

Health and Safety Code Section 1424 (d): Class "A" violations are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. Title 42, Federal Code of Regulations, Section 483.25, Subdivision (d) Quality of care is a fundamental principle that applies to all treatment and care provided to facility patients. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: (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. Title 22 Section 72311 (C) (2) 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. The Department determined during the investigation of a Facility Reported Incident (FRI) that the facility failed to provide adequate supervision to Resident 1 while smoking in accordance with Resident 1's, smoking and impaired balance care plans. The facility's failure resulted in Resident 1 falling from his wheelchair and sustaining an acute minimally displaced fracture of the proximal humerus neck (partial or complete break in the upper arm bone, between shoulder and elbow) on 2/6/24 at 5p.m., while smoking Review of Resident 1's clinical record (face sheet) set forth that Resident 1 was admitted to the facility on 2/23/23 with diagnoses including history of traumatic brain injury (head injury), generalized muscle weakness, flaccid (not firm), and hemiplegia (loss of ability to move one side of the body). Review of Resident 1's comprehensive assessment dated 12/22/23, indicated, Resident 1 was cognitively intact. Resident 1 used wheelchair for locomotion, was independent in bed mobility, and required supervision to stand and for transfers. During a concurrent observation and interview on 2/12/24 at 10:03 a.m. in Resident 1's room, the resident was observed to be awake in bed with the left forearm resting on a pillow. Resident 1 stated after he had finished smoking a cigarette, while headed back to the facility, he tried to step up on the curb and slid and fell forward on his left shoulder. Resident 1 also stated, it was raining and made it slippery. During an interview on 2/12/24 at 12:10 p.m. the Director of Nursing (DON), acknowledged sometimes residents' wheel themselves on the sidewalk. During a concurrent interview on 2/12/24 at 10:18 a.m. with a Certified Nursing Assistant (CNA) and the Director of Staff Development Assistant (DSDA), the CNA confirmed, it was raining the day, Resident 1 fell. During a concurrent observation and interview on 2/12/24 at 11:44 a.m., with the Assistant Director of Nursing (ADON), of the location where Resident 1 fell. Located beside the facility's parking lot away from the facility's front/entrance door to a medical clinic's parking lot. ADON stated "Residents aren't supposed to go past the ashtray to smoke," and further verbalized the area was past the smoking area. The ADON further pointed to an area in the medical clinic's parking lot and indicated, that was the location where the resident fell. The ADON further explained that she was in the office when she noticed that staff were going outside and was told someone fell outside. The ADON indicated she then went outside and saw staff assisting Resident 1 and saw Resident 1 was face down with a soft helmet (a protective head covering) on, and the wheelchair was off to the side. The ADON further confirmed, Resident 1 had a lack of safety awareness, however, Resident 1 was independent in wheeling himself, but he was reminded of safety precautions. During a concurrent interview on 2/12/24 at 1:20 p.m., with both the Administrator (ADMIN) and Director of Nursing (DON), the ADMIN stated, "Resident 1 can leave the unit... He knows how to get out but doesn't elope or wander." The ADMIN verbalized Resident 1 sometimes goes out in front to hang out and the resident knew the code to go out. The DON stated, "I'm not sure if staff recalled seeing Resident 1 leave prior to the incident, but usually he will come into the entry way, and we tell him it's not safe for you there." The DON further explained that the front staff usually will help him out when he comes to the front. Review of Resident 1's Care Plan (CP), titled, "At Risk for Injury related to Smoking" date initiated 7/6/23, indicated under Interventions, "Staff member to stay with resident while he is smoking." Review of Resident 1's CP titled, "Resident at risk for falling related to impaired balance, motor agitation, pain, poor condition, unstable health condition, unsteady gait, use of psychotropic medications," dated 2/23/23, indicated under Interventions, "Give resident verbal reminders not to ambulate/transfer without assistance; Observe frequently and place in supervised area when out of bed; Teach safety measures: remind to call for assistance, staff to frequently monitor need for assistance and check safety." Review of Resident 1's "Nurses' Notes," dated 2/6/24, indicated at 1700 (5 p.m.) Resident 1 had a witnessed fall outside. Resident 1 was smoking with other resident while he went to smoke and was found on the ground face down. Resident 1 stated he was trying to go up the curb and slid resulting in a fall. Upon assessment resident presents no obvious active bleeding, no injury, but c/o (complained of) L (left) shoulder pain ... MD (physician) notified, Family ... made aware. New order received for (L) should x-ray. A review of Resident 1's Radiology Report dated 2/7/24, indicated, there was an acute minimally displaced fracture of the proximal humerus neck. During an interview on 2/12/24 at 1:20 p.m., the DON acknowledge, Resident 1 should be supervised when smoking and confirmed Resident 1 was not being supervised when he fell. During a telephone interview on 3/6/24 at 9:18 a.m. the DON verbalized, Resident 1 was not in a supervised area when he fell, and the facility's policies and procedures (P&P) for falls and fall risk managing was not followed. The facility failed to provide adequate supervision and failed to implement care plan interventions for Resident 1 while he was smoking as per Resident 1's care plans. This resulted in Resident 1 sustaining an acute minimally displaced fracture of the proximal humerus neck. The violation presented either imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result.