Health inspection·January 8, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to ensure neuro checks (used to assess an individual's neurological functions and level of consciousness) was completed after a resident ' s (Resident 1) fall for one of three sampled residents. This failure had the potential to place Resident 1's health at risk. Findings: On 1/2/24, an unannounced onsite at the facility was conducted related to a complaint on quality of care. During a review of the facility's admission Record, dated 6/23/21, the admission Record, indicated, Resident 1 was admitted to the facility, with diagnoses which included dyskinesia (uncontrolled, involuntary movement). During a review of Resident 1 ' s minimum data set (MDS, an assessment tool), dated 6/30/21, indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was 14, which meant Resident 1's cognition was intact. During a review of Resident 1 ' s acute care hospital (ACH) record dated 8/19/21 at 6:59 A.M., the Emergency Department Physician documented Resident 1 had bruises on her head and scrapes to right forehead and temporal region. During a review of Resident 1 ' s Family Nurse Practitioner (FNP) consultation note dated 8/19/21 at 10:30 A.M., the FNP documented Resident 1 had multiple bruising, scrapes and swelling on right forehead secondary to a fall on 8/18/21. During an interview with a Certified Nursing Assistant (CNA) 1 on 1/2/24 at 1:18 P.M., CNA 1 stated Resident 1 required total assistance. CNA 1 stated she remembered Resident 1 to not use the call lights, She doesn ' t know how to use it, so I remember we check on her. During a joint review of Resident 1 ' s medical record and an interview with the Minimum Data Set Nurse (MDSN) on 1/2/24 at 1:44 P.M., the MDSN stated per the medical record, Resident 1 had an unwitnessed fall on 8/18/21 in the evening shift. The MDSN stated the Licensed Nurse (LN) 1 who wrote the progress notes no longer work in the facility. The MDSN stated the interdisciplinary team (IDT, group of healthcare professionals to plan, coordinate and deliver personalized health care) notes, dated 8/20/21, indicated, one of the new interventions implemented was neuro checks. The MDSN stated Page 1 of 2 055078 055078 01/08/2024 Parkway Hills Nursing & Rehabilitation 7760 Parkway Drive LA Mesa, CA 91942

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there was no documentation of monitoring Resident 1, the entry was at 2:55 A.M., and the next entry was at 6:02 A.M. when the staff found Resident 1 unresponsive. The MDSN stated there should be a neuro checks for an unwitnessed fall to see if there was any side effect or late reaction from the fall. The MDSN stated it could have been in a separate sheet. During a telephone interview with Licensed Nurse (LN) 2 on 1/4/24 at 7:07 A.M., LN 2 stated he and the CNA did the neuro check on Resident 1 and that the resident was stable. LN 2 stated there was no neuro check sheet on hand but would ask the medical records. During a telephone interview with the Director of Nursing (DON) on 1/4/24 at 5:49 P.M., the DON stated there was no neuro checks that was found in Resident 1 ' s medical record. The DON stated neuro checks should have been started on Resident 1 to monitor changes and interventions should have been done. During a review of the facility ' s policy, titled, Assessing Falls and Their Causes, revised March 2018, the policy indicated, The purposes of this procedure are to provide guidelines for assessing a resident after a fall .Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure: 1. Equipment to assess vital signs, such as stethoscope; sphygmomanometer or electronic blood pressure device; and oral or rectal thermometer; 2. Tools to assess resident ' s level of consciousness and neurological status, if necessary . Steps in the Procedure, After a Fall: 1. If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities .7. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings . 055078 Page 2 of 2