Health inspection·May 19, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's nursing staff failed to ensure one of four sampled residents (Resident 1), who required an extensive two-person physical assist during toileting, was supervised while in the bathroom. CNA 2 left Resident 1 alone in the bathroom while she attended to another resident. Resident 1 became frustrated when no one came to his assistance, attempted to leave the bathroom, and fell from the shower chair As a result of Resident 1 falling from the shower chair he hit the floor causing pain to his back, right hip, and right leg. Resident 1 was transferred to a General Acute Care Hospital (GACH) where he was diagnosed with a fracture of the vertebrae (a series of small bones that form the backbone). Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke), hemiplegia (paralysis to one side of the body), hemiparesis (a slight paralysis or weakness on one side of the body), diabetes mellitus ([DM] a chronic condition associated with abnormally high levels of sugar in the blood) and hypertension ([HTN] high blood pressure). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 9/14/2022, the MDS indicated Resident 1 was able to make independent decisions that were reasonable and consistent and Resident 1 required an extensive two-person physical assist to complete his activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting). The MDS indicated Resident 1 was not steady when moving from a seated to standing position, moving on and off the toilet, surface to surface transfers, and could only stabilize with staff assistance. During a review of Resident 1's Fall Risk Evaluation (FRE) dated 9/14/2023, the FRE indicated Resident 1 was a medium risk for falls due to balance problems while walking and/or standing, use of psychotropic (drug that affect a person's mental state) medication, use of hypoglycemics (drugs that lowers blood sugar levels) and use of antihypertensive (drugs that lowers the blood pressure) medications. During a review of Resident 1's Care Plan (CP), dated 12/14/2022, the CP indicated Resident 1 has actual self-care performance deficits related to his disease process. The CP's goal was for Resident 1 to be supervised and assisted during his ADLs. The CP's interventions indicated Resident 1 required extensive assistance to transfer onto and off of the toilet with one to two staff support. Page 1 of 4 055353 055353 05/19/2023 Shoreline Healthcare Center 4029 East Anaheim Street Long Beach, CA 90804

F 0689 Level of Harm - Actual harm During a review of Resident 1's CP, dated 12/14/2022, the CP indicated Resident 1 had impaired physical functioning, impulsive behavior, and poor safety awareness. The CPs goal indicated Resident 1 was to have minimal injury and/or would not sustain serious injury. The CP's interventions indicated to provide a safe environment and reminders to Resident 1 of safety precautions. Residents Affected - Few During a review of Resident 1's Situation Background Assessment Recommendation ([SBAR] a tool and a guide to communicate a patient's information with other healthcare professionals) dated 10/7/2022 and timed at 4:40 p.m., the SBAR indicated Resident 1 was heard screaming for help at 3:45 p.m., (10/7/2023) and found sitting on the floor by the bathroom door after scooting in the bathroom chair and was in no pain and discomfort. During a review of Resident 1's Diagnostic Result (DR) dated 10/13/2023 and timed at 5:16 p.m., the DR indicated Resident 1's x-ray of his right femur (hipbone) and the right femur (thigh bone) were negative for a fracture (break in the bone) or dislocation (bones pushed out of their proper place). During a review of Resident 1's Progress Notes (PN) dated 10/21/2022 and timed at 2:32 p.m., by the Nurse Practitioner, the PN indicated Resident 1 had no initial injury from Resident 1's fall on 10/7/2022 but began complaining of right lower extremity/hip pain during mobility with physical therapy (PT). Due to continued complaints of pain an order was placed for an urgent CT ([computed tomography] a computerized x-ray in which a narrow beam of x-rays is aimed at ta patient and quickly rotated around the body) of the pelvis and right femur to rule of fracture. During a review of Resident 1's Physician's Order (PO), dated 10/21/2022, the PO indicated to transfer Resident 1 to a GACH's emergency room (ER) on 10/22/2022 for CT of the right hip and the right femur. During a review of Resident 1's Nurse Progress Notes (NPN) dated 10/22/2022 and timed at 4:32 p.m., the NPN indicated Resident 1 was transferred to the hospital for computerized scanning of the right hip and the right leg. During a review of the GACH Face Sheet, dated 10/22/2022, the Face Sheet indicated Resident 1 was admitted to the GACH on 10/22/2023 at 7:54 p.m. During a review of the GACH's CT scan dated 10/23/2022 and timed at 1:37 a.m., the CT scan indicated Resident 1 had an acute comminuted fracture (bone broken in two places) anterior column (directed forward) of the 4th lumbar spine with 15% loss of vertebral (backbone) height with no retropulsion (no displacement of bone into the spinal canal [a bony channel located in the vertebral column that protects the spinal cord and nerve roots]). During a review of GACH's Neurosurgery (surgery performed on the nervous system, especially the brain and spinal cord) Consult (NC) dated 10/25/2022 and timed at 6:10 p.m., the NC indicated an order for Resident 1 to wear a brace used to limit motion in the thoracic, lumbar (relating to the lower part of the back) and sacral (tailbone) regions of the spine) and an order for a lumbar MRI ([magnetic resonance imaging] a procedure that uses radio waves and a computer to make a series of detailed pictures of areas inside the body). During an observation and interview on 5/19/2023 at 11:51 a.m., Resident 1 was sitting in his bed and observed with a contracted (tightening of the muscles causing stiffness) right knee. Resident 1 stated his right leg felt stiffer since he fell, and he was frustrated because it was hard for him to 055353 Page 2 of 4 055353 05/19/2023 Shoreline Healthcare Center 4029 East Anaheim Street Long Beach, CA 90804

F 0689 Level of Harm - Actual harm Residents Affected - Few sit up in his wheelchair and roll himself around the facility like he did before he fell. Resident 1 stated, CNA 2 helped him to the bathroom but left him there alone and said she would be back. Resident 1 stated he finished using the toilet and put on the call light, but CNA 2 did not come back right away (unknown amount of time). Resident 1 stated the shower chair he was sitting on was uncomfortable and he needed to be cleaned so he tried to leave the bathroom to find CNA 2. Resident 1 stated he tipped over out of the shower chair onto the floor and hit his bottom, back and maybe his right leg and right hip on the floor. During a telephone interview on 10/28/2022 at 7:38 a.m., with Resident 1's Responsible Party (RP), the RP stated Resident 1 was in the GACH and told him that he (Resident 1) was having extreme pain in his back. The RP stated he was concerned that Resident 1 wasn't being supervised and assisted by the nursing staff in the facility while he was using the toilet. The RP stated Resident 1 was alert but was unsteady on his feet and could be forgetful and impatient and required constant supervision. During a telephone interview on 10/26/2022 at 1:22 p.m., with CNA 2, CNA 2 stated Resident 1 needed maximum assist by 1 person when using the toilet. CNA 2 stated Resident 1 understood the need to use the call light although she observed Resident 1 was being more impatient and more frustrated with the nurses lately. CNA 2 stated she assisted Resident 1 to the bathroom and left him to go assist another resident in another room. CNA 2 stated when she was on her way back to assist Resident 1 in the bathroom, she heard Resident 1 scream, heard a sound of commotion (disturbing noise) and when she entered Resident 1's room, she found him sitting on the floor outside the bathroom. CNA 2 stated Resident 1 was freaking out (losing emotional control because of extreme shock and fear) and yelling for help. During an interview on 10/26/2022 at 11:23 a.m., with Restorative Nursing Assistant (RNA) 1, RNA 1 stated Resident 1 was alert and coherent but was impatient and the staff should not leave Resident 1 alone in the bathroom because Resident 1 may try to do things beyond his capacity. During an interview and a concurrent record review on 10/26/2022 at 11:32 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 required maximum assistance with ADL care. Prior to his fall, he could move in his bed using his left extremities (left arm and leg) however, after Resident 1 fell he mostly wanted to stay in bed, probably because of pain. During an interview on 10/26/2022 at 3:43 p.m., with Registered Nurse Supervisor (RNS) 2, RNS 2 stated Resident 1 required maximum assistance with 1 to 2 persons during ADL care and Resident 1 needed supervision and assistance while using the toilet and routine personal hygiene to always ensure Resident 1's safety. During an interview on 5/19/2023 at 12:25 p.m., with RNS 1, RNS 1 stated Resident 1 was readmitted at the facility on 10/30/2022 with an order to wear a back brace when he was out of bed. RNS 1 stated all nursing assistants were reminded during huddle at the start of the shift to ensure safety precautions for all residents, and it was a basic rule for all nurses to never leave a resident alone in the bathroom because the resident might forget to call for help, try to get up unassisted, perform tasks beyond their capabilities and end up falling and hurting themselves. During an interview on 5/19/2023 at 1:15 p.m., with the Administrator (ADM), the ADM stated there was no policy related to resident Supervision and/or accident prevention. During an interview on 5/19/2023 at 1:27 p.m., with the Director of Nursing Services (DNS), the DNS 055353 Page 3 of 4 055353 05/19/2023 Shoreline Healthcare Center 4029 East Anaheim Street Long Beach, CA 90804

F 0689 stated CNA 2 should not have left Resident 1 in the bathroom alone because of safety reasons. Level of Harm - Actual harm During a review of the facility's Policy and Procedure titled Quality of Care- ADL, Services to carry out, revised 11/2007, the P/P indicated the facility provides the appropriate treatment and services to the residents to maintain and improve their abilities and this includes but not limited to grooming and personal hygiene. Residents Affected - Few 055353 Page 4 of 4