Health inspection·September 22, 2023

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 observation, interview, and record review, the facility failed to implement a fall intervention for one of two sampled residents (Resident 1) when a fall mat was not placed on the floor while Resident 1 was in bed. This failure had the potential for Resident 1 to sustain further injuries due to a fall. Findings: During a review of Resident 1's admission Record, indicated Resident 1 had diagnoses of osteoporosis (a medical condition in which bones become weak and brittle) and fracture (a break in the bone) of the right shoulder. During a review of Resident 1's Minimum Data Set, (MDS-an assessment tool) dated 7/20/23, the MDS indicated Resident 1 scored 8 out of 15 in a Brief Interview for Mental Status (BIMS) which suggested Resident 1 had moderate cognitive impairment (reasoning, understanding and memory are affected). During a review of Resident 1's Fall Risk Form, (an assessment tool to determine fall risk factors and target interventions to reduce risks) dated 7/7/23, indicated Resident 1 scored 75. A score of 45 and higher was considered high risk for falls. During a review of Resident 1's Nurses Notes, dated 9/10/23, indicated Resident 1 was seen on the floor lying on her left side. The Nurses Notes further indicated on 9/11/23, Resident 1 had swelling and bruising to her right shoulder. The x-ray results indicated, .a fracture of the right humeral head/neck . (commonly known as the ball of the shoulder's ball-and-socket joint). During a review of Resident 1's Order Summary Report, dated 9/18/23 indicated, . may have floor matt [sic] by bedside, monitor for placement q [every] shift when in bed for safety. During an observation on 9/22/23, at 11:51 a.m. in Resident 1's room, Resident 1 was observed in bed sleeping. There was no floor mat by the bedside. A folded blue mat was observed under the wooden television stand. During an interview on 9/22/23, at 12:29 p.m. with Licensed Nurse (LN) 1, LN 1 stated the fall interventions to minimize incidents of falls or injuries from falls should always be implemented to ensure the safety of residents identified as high risk for falls. LN 1 stated the fall interventions including the placement of a fall mat while the resident was in bed should be followed. Page 1 of 2 055662 055662 09/22/2023 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 9/22/23, at 1:01 p.m. with CNA 1 and CNA 2 in Resident 1's room, Resident 1 was asleep in bed without a floor mat by the bedside. Both CNA 1 and CNA 2 confirmed the floor mat was not in place. CNA 2 confirmed the floor mat was folded and kept under the wooden TV stand. CNA 2 stated the floor mat should have been always on the floor while resident was in bed except when performing care or resident was eating her meals at a bedside table. CNA 1 explained he did not return the floor mat back on the floor after providing care to Resident 1. CNA 1 further stated he should have placed the floor mat by the bedside before leaving Resident 1. CNA 1 also stated the floor mat would help Resident 1 prevent further injuries from fall. During a review of Resident 1's Fall Care Plan titled, I AM AT RISK FOR FALLS, dated 7/28/23, one of the interventions indicated, .I HAVE A BEDSIDE MAT, ENSURE PLACEMENT WHEN I AM IN BED . During an interview on 9/22/23, at 2:23 p.m. with the Director of Staff Development (DSD), the DSD stated CNAs were trained to follow and implement interventions that would prevent falls and reduce the risk for injuries due to falls. The DSD also stated the fall interventions that would apply to CNAs were documented in the [NAME] (a paper system in which nursing staff write out information for each resident daily as a means of communication among the nursing staff) including placement of floor mats for residents who were high risk for falls. The DSD further stated she expected the CNAs to follow the information on the [NAME] as well as facility procedures for fall prevention. The DSD stated the placement of floor mat should have been done. During a review of the facility's policy and procedure titled, Fall Prevention Program Policy and Procedure, dated 7/26/22, indicated, .To identify residents at risk for falls and provide interventions to reduce risk of falls and major injuries related to falls .Safety measures will be included in the plan of care for residents identified as having fall risks . 055662 Page 2 of 2