Health inspection·March 6, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow up and promptly report the results of an x-ray for one of three sampled residents (Resident 1) who were sampled due to falls in the facility when Resident 1 fell on her knee and her physician ordered an x-ray and the facility did not recognize they had not received the x-ray results for two days. Residents Affected - Few This resulted in Resident 1 experiencing unnecessary severe left knee pain and a delay in treatment for two days due to a broken bone. This delay in treatment had the potential for Resident 1 to experience ongoing severe pain and negatively impact her physical, emotional, and psychosocial well-being. Findings: Review of a facility policy titled,Change in a Resident's Condition or Status dated July 2024, indicated 1. The nurse will notify in a reasonable timely manner the resident's attending physician or physician on call when there has been a(an): e. need to transfer the resident to a hospital/treatment center. Review of admission records for Resident 1 indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a condition that changes how the brain works and can cause confusion, memory loss, and loss of consciousness), fracture of right ankle and fibula (a long bone in the lower leg positioned on the outer side of the calf), effusion right knee (an abnormal accumulation of fluid in a body cavity or body tissues), asthma, acute respiratory failure, dementia (loss of memory and ability to make sound decisions), dysphagia (difficulty swallowing), difficulty walking, muscle weakness, seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), cognitive communication deficit (an impairment in thought organization, attention, memory, problem solving, and safety awareness). Review of Resident 1's BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) admission assessment dated [DATE], showed a score of 8 out of 15, which indicated Resident 1 had a moderate cognitive impairment. During an interview on 3/6/25 at 12:16 PM, with Resident 1 in her room, Resident 1 stated that she had pain from her knee down related to her fall. Review of Resident 1's Progress Note dated 3/1/25 at 8:45 PM, written by Licensed Nurse (LN) C, Page 1 of 2 055510 055510 03/06/2025 Redding Post Acute 1836 Gold Street Redding, CA 96001

F 0684 indicated that Resident 1 had a fall in her room and had pain in her left knee with redness and swelling. Level of Harm - Minimal harm or potential for actual harm Review of Resident 1's, Post Fall Evaluation dated 3/2/25 at 4:18 AM, completed by LN C, indicated that Resident 1's left lower leg had bruising, swelling, redness, pain. Residents Affected - Few Review of Resident 1's, Pain Evaluation dated 3/2/25 at 4:18 PM, completed by LN C, indicated that Resident 1 described her pain as aching. Review of Resident 1's Progress Note dated 3/2/25 at 9:56 AM, written by LN D, indicated that an order for left knee x-ray (images taken of the bones) was requested from the physician. Review of Resident 1's, Physician's Orders dated 3/2/25 at 10:44 AM, indicated that an x-ray to Resident 1's left knee/shin was ordered by the Medical Doctor (MD). Review of Resident 1's x-ray results that were done on 3/2/25, no time, indicated, Left Tibia/Fibula [the shin bone and the calf bone] X-Ray results were, Acute avulsion of the tibial tuberosity [a break in the bony bump at the top of the tibia where the knee is connected] the front of the tibia just below the kneecap) with effusion [swelling]. Review of Resident 1's Progress Note dated 3/4/25 at 5:53 PM, written by LN E, indicated, Resident vocal complaint of continuous pain 8-10 [10 being the worst pain imaginable], in LLE [left lower extremity]. Bruising, and swelling noted. Orders to send to the hospital. During a concurrent interview and record review of Resident 1's x-ray report dated 3/2/25, with the Director of Nursing (DON) on 3/6/25 at 2:44 PM, in the DON's office, the DON confirmed that a physician's order for an x-ray of Resident 1's left knee was obtained on 3/2/25 at 10:45 AM. The DON confirmed that an x-ray of Resident 1's knee was completed on 3/2/25 and the x-ray had indicated that Resident 1 had a broken tibia. DON confirmed that the facility had not received the x-ray report for Resident 1 on 3/2/25, and had not followed up on getting those results. DON confirmed Resident 1's physician was not notified of the x-ray results until 3/4/25, when the facility recognized they never received the x-ray report from 3/2/25. The DON indicated her expectation would be if the facility does not receive x-ray results within 24 hours, they should call and ask the imaging company about the x-ray results in order to prevent a delay in getting treatment for a resident. 055510 Page 2 of 2