Health inspection·May 7, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision and interventions for one of three residents ( Resident 1) when: Resident 1, extensive assist with bed mobility per MDS section G, rolled out of bed during incontinent care. This failure resulted in Resident 1 hitting the side of the table and sustained laceration on the forehead. Findings: During a review on 5/7/24 at 10 AM, of admission Record, dated 5/7/24, indicated, admitted to facility on 4/26/23 with diagnoses including: Congestive Heart Failure (a condition in which the heart does not pump as it should), Atrial Fibrillation (an irregular heartbeat that causes heart to beat too quickly), Abnormalities with Gait and Mobility(abnormal walking and movement).Resident discharged to acute 5/10/23. During an interview on 5/7/24 at 10:48 AM, with CNA, per CNA who have worked at facility for 14 years, to prevent falls, put bed on low position, mattress on the floor, read the fall sticker or dot on the patient ' s bed or wheelchair, that indicates patient I s fall risk. Meeting every day at 11 am, they talk about Fall risks patients .involve activities. If patient falls, do not touch the patient till assessed by Licensed Nurse and tells us what to do next. During an interview on 5/7/24 at 11:43AM, with Director of Nursing (DON), per DON, the patient had a fall, unwitnessed fall in the room and nurse found him on the floor at change of shift. Patient admitted on [DATE], had been here before, alert and oriented, more debilitated from last time. admitted for short term rehab, plans to go back to group home. Daughter is emergency contact #1. Per DON, when asked for the report to state agency and Ombudsman, per DON, not reportable, it ' s a minor injury only a laceration. Will know the extent when patient is seen in the hospital. Patient was sent to ER on [DATE]. Per DON, the daughter called her and told her that her dad was sent home from ER with Home Health. Per DON daughter upset with facility for sending him to ER, concerned about ambulance bill. Hearing aid is kept in the medication cart for safe keeping, since it was early, 911 came already, patient left without the hearing aid. No documentation found of reporting incident to state agency and Ombudsman. Review of PT Evaluation and Plan of Treatment dated 4/27/23, Start of Care is 4/27/23, total Page 1 of 3 055116 055116 05/07/2024 Linda Mar Care Center 751 San Pedro Terrace Road Pacifica, CA 94044

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dependence with bed mobility and transfers. PT discharge Summary, indicated, Total dependence with bed mobility and transfers. Review of OT Evaluation and Plan of Treatment, indicated, start of care is 4/28/23. Reason for referral/Current Illness: Patient referred to OT due to new onset of compromised physical exertion level during activity, decreased functional mobility and functional limitation with self-care. Vision: patient wears glasses 24 hrs (needs glasses replaced by VA). Review of SLP Evaluation and Plan of Care indicated, start of care is 5/1/23. Cognition: Alertness = Intact, Oriented to person, place, time, purpose and caregivers. Problem Solving: Mild, Memory: mild. During an interview on 5/7/24 at 12:30PM, with Licensed Vocational Nurse (LVN), per LVN, she remembers patient, she was a new nurse. CNA reported that he turned patient to the side to change his diaper, hit the bedside table, rolled out of bed. Patient was alert and verbally responsive, no behavior. Walked in and assess the body, took Vital Signs, he is on blood thinner, was bleeding in the forehead, in the middle. Patient was not unresponsive, no loss of consciousness, I called 911. Protocol to call the DON on every fall. After assessment, patient put back to bed using Hoyer lift, usually two people but don ' t remember how many people were there. DON called the family. During a review of MD orders, MD order indicated, Eliquis Oral tab 2.5 mg give 1 tablet every 12 hours related to Paroxysmal Atrial Fibrillation. Hold if SBP below 100 or Pulse below 60. Review of Untitled Progress notes, dated 5/10/23 at 8:30 AM, indicated, Resident with incident of rolling off bed during incontinent care with CNA. CNA stated, while providing care to resident, resident was turned on his side with minimal assistance .while retrieving linen from bedside table, resident begun moving further towards edge of opposite side of bed and rolled over the edge before he could reach him. CNA stated prior to incident, resident was noted to have increased confusion .he stayed with resident student nurses came to the room and reported incident to charge nurse. After nurse assessment, resident was transferred back to bed and 911 was called. CNA educated going forward when providing care to resident to have stuff secondary to resident ' s impulsiveness. CNA involved not available per DON. Out of the country from 4/30/24 to 6/1/24. Unable to interview. Review of MDS Section C- dated 5/3/23, indicated, BIMS Score - 13, no cognitive impairment. Review of MDS Section G- Functional Status, dated 5/3/23, indicated, 3= extensive assist for bed mobility, transfers, walk, locomotion, eating and toilet use. Support= 2, means one person physical assist. Review of facility document, Fall Risk Assessment, dated 4/26/23, Score- 16. High Risk. Review of facility document. Care Plan, dated 4/26/23, At risk for falls and injuries due to decline in function, impaired mobility .Intervention: Identify resident ' s needs . staff anticipates and attends to needs. Keep environment hazard free. Fall Risk care plan does not address visual deficit. Review of undated facility Policy and Procedure, Accidents and Incidents, indicated. All accidents 055116 Page 2 of 3 055116 05/07/2024 Linda Mar Care Center 751 San Pedro Terrace Road Pacifica, CA 94044

F 0689 Level of Harm - Minimal harm or potential for actual harm or incidents involving residents, employees, visitors, vendors, etc. occurring on our premises shall be investigated and reported to the Administrator. 1. The Nurse Supervisor/Charge Nurse and /or the department director or designee shall promptly initiate and document investigation of the accident or incident Residents Affected - Few No Investigation Summary found/sent to State agency office. Review of facility Policy and Procedure, Falls and Fall Risk, Managing, dated 3/2019, indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall Risk Factors: 2. Residents conditions that may contribute to the risk of falls may include: 1. Visual deficits . Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with history of falls. 055116 Page 3 of 3