Health inspection·April 17, 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 document an accurate fall risk assessment (an evaluation to determine a resident's risk for fall based on different variables) for one of three sampled residents, (Resident 1). This deficient practice had the potential to place Resident 1 at risk for fall(s) causing injuries or even death. Findings: A review of Resident 1's admission Record indicated the facility admitted this [AGE] year old female on 2/15/2024 with diagnoses including Osteoporosis (brittle bones) with current pathological fracture (broken bone), Atherosclerotic heart disease (thickening or hardening of the vessels that return blood back to the heart), Chronic Kidney Disease stage 4 (very decreased functioning of the kidney's ability to filter), Sick Sinus Syndrome (type of heart dysrhythmia), presence of cardiac pacemaker, Hyperlipidemia (high cholesterol), Essential Tremor (neurological condition that causes your hands to shake rhythmically), hearing loss left ear, history of Malignant neoplasms (cancer) of breast, large intestine and skin, history of falling. A review of Resident 1's History and Physical (H&P: the physician's examination and plan of care of the patient) dated 2/15/2024 indicated Resident 1 was admitted to the facility after a fall that resulted in a T 10 hyperextension fracture (spinal fracture) that required no intervention. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/21/2024 indicated Resident 1's cognition (the mental ability to make decisions of daily living)was moderately impaired. Resident 1 required an assistive device (walker) and moderate assistance (helper does more than half the effort) with ambulation (walking) and toileting. During a concurrent interview and record review on 4/17/2024 at 10:06 a.m. with the licensed vocational nurse (LVN), Resident 1's Fall Risk assessment dated [DATE] was reviewed. Resident 1's Fall Risk Assessment indicated Resident 1 had no falls in the past three months; Resident 1 was at low risk for fall. The LVN stated, When I completed this assessment, I did not look at her H&P that indicated she had a fall prior to admission. Each section of the assessment is assigned points and you tally the points to determine if the resident is at low, medium, or high risk for fall. If I would have looked at her H&P that may have changed her score and identified her as a risk for fall. During an interview on 4//17/2024 at 10:43 a.m. the Director of Nursing (DON) stated, Fall risk Page 1 of 2 055711 055711 04/17/2024 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessments should be completed at admission, after a fall incident and quarterly. The information used to complete the assessment should include all facility documentation as well as the history and physical from the physician to determine if the resident has a history of falls . A review of the facility's policy and procedures titled, Falls Clinical Protocol revised 3/2022 indicated: Assessment and Recognition: 1.Nursing staff and IDT will identify individuals with a history of falls and risk factors for falling. a. Staff will ask the resident and the caregiver or family about a history of falling. b. The staff and physician will document in the medical record a history of one or more recent falls. 2. In addition, the nurse shall assess and document/report the following: a. Vital signs; b. Recent injury, especia11y fracture or head injury. c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; d. Change in cognition or level of consciousness. e. Neurological status; f. Pain; g. Frequency and number of falls since last physician visit; h. All current medications, especially those associated with dizziness or lethargy; and i. All active diagnoses. 3. Staff will review each resident's risk factors for falling, inform resident and / or resident's representative (if resident has no capacity to understand or make decision). a. Examples of risk factors for falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, hypotension, and medical conditions affecting the central nervous system. 4.The physician will identify medical conditions affecting fall risk (for example, a recent stroke or medications that cause dizziness or hypotension) and the risk for significant complications of falls (for example, increased fracture risk in someone with osteoporosis or increased risk of bleeding in someone taking an anticoagulant). a. Falls often have medical causes; they are not just a nursing issue. 055711 Page 2 of 2