Health inspection·October 24, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Medical Director (MD) in a timely manner with a change of condition for one of 24 sampled residents (Resident 1) when Resident 1 fell and sustained a visible injury and possible non-visible injuries. This failure resulted in the MD not having immediate knowledge of the fall and/or the opportunity to order new treatment which could have provided comfort to Resident 1 and/or prevented his subsequential death. Findings: During a review of the facility's document titled, Discharge Summary, dated [DATE], at 3:20 PM, by the Nurse Practitioner (NP), indicated, Resident 1 had a fall at [MEMORY CARE FACILITY NAME]. Prior to the fall, Resident 1 was on Eliquis (blood thinning medication to reduce blood clots) for Atrial fibrillation (A-Fib, an irregular, rapid heart rhythm that can lead to blood clots in the heart and cause a stroke [when something blocks blood supply to the brain]). Resident 1 was brought in by ambulance to [ACUTE CARE HOSPITAL NAME] complaining of neck pain. Hospital Course: Resident 1 was evaluated and the work-up was significant for a Large Left Subdural Hematoma with a midline shift (buildup of blood on the surface of the brain which shifts brain tissue across the center line of the brain) and skin tears/scrapes to the right upper extremity (arm). Resident 1 received treatment in [ACUTE CARE HOSPITAL NAME] for six days. Resident 1 was discharged from [ACUTE CARE HOSPITAL NAME] to a Skilled Nursing Facility (SNF) for further Physical Therapy (PT) treatment. A review of Resident 1's clinical record titled, admission RECORD (a document which contains the resident's demographic information), indicated, Resident 1 was admitted to the facility (SNF) with a diagnosis of a recent traumatic subdural hemorrhage (head injury related to a fall or blow to the head resulting in a brain bleed), weakness, dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life), and A-Fib. During an interview on [DATE] at 3:52 AM, with the Administrative Director of Nursing - Licensed Nurse (ADON-LN), stated, the facility's protocol after a fall would be to immediately notify the MD (to possibly receive new orders) and for the Licensed Nurse to inform the resident's representative of the fall. ADON-LN stated, if unable to reach the MD, he would try to contact the MD at least two more times on his shift. The ADON-LN stated two hours was too long to wait to notify MD of Resident 1's fall. During an interview on [DATE] at 11:25 AM, with LN 1, LN 1 stated, after Resident 1 fell, the MD Page 1 of 3 055662 055662 10/24/2023 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should have been notified immediately, not two hours later. LN 1 stated the importance of notifying the MD immediately was to receive new orders and possibly transfer Resident 1 to an acute care hospital to receive medical care the SNF was unable to provide. LN 1 stated, Resident 1 was at increased risk of a brain bleed and death due to taking blood thinning medication. During a follow up interview on [DATE], at 1 PM, with the ADON-LN, the ADON-LN stated, he was unsure why the Licensed Nurse did not notify the MD immediately after Resident 1 fell. The ADON-LN stated, the Licensed Nurse possibly did not want to wake up the MD from his sleep and would inform the MD of the fall later in the morning. The ADON-LN stated, there shouldn ' t have been any delay in notifying the MD of the fall because the MD may have transferred Resident 1 to a hospital to receive a higher level of care sooner. During a phone interview on [DATE], at 10:45 AM, with the MD, the MD stated, it was his expectation to be notified of Resident 1's fall immediately, and not two hours after the fall. The MD stated, if he had been notified right away, he may have discontinued the blood thinning medication to possibly prevent bleeding in the brain. During a phone interview on [DATE], at 5:34 PM, with LN 2, LN 2 stated, she had been working at the facility for two months when Resident 1 fell. LN 2 stated, she was unsure of the protocol to follow following a fall. LN 2 stated, looking back, the MD may have given her additional orders to care for Resident 1 and she should have called the MD immediately and not waited two hours. A review of Resident 1's clinical record titled, NURSES NOTE, dated [DATE] at 7:23 AM, by LN 2 indicated, at approximately 5:10 AM, Resident 1 had an unwitnessed fall (second fall in five days) in his room. Resident 1 was found lying on the side of the bed on his stomach/face. Resident 1 had a bloody nose and an abrasion to the left knee. MD was notified at 7:05 AM. A review of Resident 1's clinical record titled, NURSES NOTE, dated [DATE] at 8:27 AM, by the ADON-LN, the record indicated, Resident 1 was noted to have a change of condition with an elevated temperature, low oxygen saturation (amount of oxygen in the blood), and loud rales (small clicking, bubbling, or rattling sounds in the lungs that is heard when fluid is in the lungs) in all areas of the lungs. A review of Resident 1's clinical record titled, NURSES NOTE, dated [DATE] at 9:10 AM, by the ADON-LN, the record indicated, at approximately 8:49 AM, Resident 1 was noted to be absent of all vital signs (heart rate per minute, respiratory rate per minute, oxygen saturation percentage, and blood pressure). A review of Resident 1's clinical record titled, Physician Discharge Summary, dated [DATE], by MD, indicated, Resident 1's cause of death on [DATE], was due to a subdural hemorrhage (brain bleed). A review of Resident 1's clinical record titled, Care Plan (an individualized plan of care which includes problems, goals, and a list of interventions to assist in meeting the goal), indicated, Resident 1 was at risk for falls. The interventions implemented to assist Resident 1 in meeting the goal of having no traumatic injuries from falls were: using a wheelchair for mobility, bed kept in the low position, review information on past falls and attempt to determine the cause of falls. Record possible root causes of falls and educate Resident 1, family, and caregivers as to the causes of the falls. 055662 Page 2 of 3 055662 10/24/2023 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on [DATE], at 12:45 PM, with the Admininistator (Admin) and ADON-LN, the facility's Policy and Procedure (P&P), titled, FALLS, undated, was reviewed. The P&P indicated, POLICY: To assure a procedure is followed by all Licensed nurses when a fall occurs. PROCEDURE: 1. When a fall occurs it is immediately to be reported to the Licenses Nurse on duty . 2. A. No noted injury or minor injury i.e.: skin tear, bruise .3. The Licensed Nurse will notify the physician, and the resident's designated representative . B. Significant injury/potential significant injury i.e.: possible fracture or concussion . 4. The LN will notify the physician of incident. The LN will notify the resident's designated representative. The License Nurse will notify the on-call administrative nurse of incident . The Admin and ADON -LN acknowelged the P&P and the facility's expectations were not followed when the LN did not call MD immediately after Resident 1 fell. During a concurrent interview and record review on [DATE], at 1:00 PM, with the Admin and ADON-LN, the facility's P&P titled, Change of Condition Notification (Revised), dated [DATE], was reviewed. The P&P indicated, Purpose: To observe, record and report any change of condition to the physician so proper treatment may be implemented. Responsibility: It is the responsibility of the facility, through the nursing staff, to report any change of condition to the resident ' s attending physician or his designee, the resident, and/or the resident representative. Procedure: A. The Nursing Supervisor, or her designee, will notify the attending physician of the following: . 8. Any fall of a resident, with or without apparent injury, will be reported promptly . 8. Notification will be by personal contact or voice mail and indicated in the resident ' s chart . The Admin and ADON -LN acknowelged the P&P and facility ' s expectations were not followed when the LN did not call the MD immediately after Resident 1 fell. The ADON-LN and Admin stated the two-hour delay in notification of Resident 1 ' s fall to MD does not constitute prompt reporting to the physician. A review of the Job Description titled, Charge Nurse/ RN or LVN - Job Description, dated [DATE], indicated, . Summary: . Essential Duties and Responsibilities include the following . Their responsibilities include taking charge in an emergency of any kind and directing activities toward the safety and security of the residents according to policy and procedure . Notify the physician according to policy and procedure . Competencies . Problem Solving - Identifies and resolves problems in a timely manner; . 055662 Page 3 of 3