Health inspection·August 10, 2023

F 0580 Level of Harm - Potential for minimal harm Residents Affected - Some 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, medical record review, and facility P&P review, the facility failed to notify the physician and family member of an unwitnessed fall incident in a timely manner for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to not receive the appropriate care and services in a timely manner. Findings: Review of the facility's P&P titled Change of Condition dated 3/2021 showed it isthe facility's policy that any changes in the residents' conditions be thoroughly assessed and evaluated with the physician's notification for early clinical management to avoid unnecessary readmission to the acute care hospitals. Medical record review for Resident 1 was initiated on 8/8/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's History and Physical examination dated 8/5/23, showed Resident 1 had the capacity to understand and make decisions. Review of the Resident 1's Care Plan dated 8/2/23, showed a care plan problem addressing high risk for falls with the interventions including to notify thephysician of any fall incidents. Review of Resident 1's Physician Order dated 8/2/23, showed to inject enoxaparin (blood thinner) prefilled syringe 40 mg/0.4 ml subcutaneously (inject to fatty tissue under the skin) every 24 hours. Review of the Resident 1's 72 Hours Neuro-check List showed the neuro check was initiated on 8/3/23 at 0245 hours, after Resident 1 had an unwitnessed fall. Review of the Nurses Notes dated 8/3/23, showed the following: - At 0315 hours, the continued neuro check was performed, and Resident 1 denied hitting his head. - At 0615 hours, the continued monitoring for unwitnessed fall was performed with 72 hours neuro check. - At 0700 hours, the family was notified and left a message for the on-call physician. Page 1 of 2 055816 055816 08/10/2023 Chapman Care Center 12232 Chapman Ave Garden Grove, CA 92840

F 0580 Level of Harm - Potential for minimal harm Residents Affected - Some - At 0715 hours, Resident 1 complained of pain to the back of his neck. Resident 1 received enoxaparin and had a risk of bleeding; and 911 was called for further evaluation. On 8/8/23 at 1413 hours, an interview was conducted with Resident 1. Resident 1 stated he remembered slipping from his bed to the fall mattress at night. However, Resident 1 was unable to provide a specific date and time for the occurrence. On 8/9/23 at 1114 hours, a telephone interview was conducted with LVN 1. LVN 1 stated on 8/3/23 at 0245 hours, a CNA reported she found Resident 1 on floor. LVN 1 stated she thenassessed Resident 1 and started a neuro check (a neurological assessment of a patient's neurological functions, motor and sensory response and level of consciousness). LVN 1 stated Resident 1 told her that he did not hit his head. LVN 1 stated on 8/3/23 at 0715 hours, Resident 1 reported a neck pain. LVN 1 stated Resident 1 was receiving enoxaparin and had a risk of bleeding, so she called 911 and Resident 1 was then taken to the acute care hospital. When asked LVN 1 if she reported the incident to the physician and family member of Resident 1, she stated she was busy and not able to notify the physician immediately after the fall incident. LVN 1 stated she attempted to call the physician and left a voice message on 8/3/23 at 0530 hours, approximately three hours after Resident 1 was found on the floor. She stated she notified the family member on 8/3/23 at 0700 hours (around four hours after the fall incident). LVN 1 acknowledged she should have notified the physician and family member immediately after the fall incident. Further review of Resident 1's medical record failed to show Resident 1's physician and family member were notified of the fall incident until on 8/3/23 at 0700 hours (approximately fourhours after the fall incident). On 8/10/23 at 0930 hours, a concurrent interview and medicalrecord review was conducted with the ADON. The ADON verified the above findings and stated the fall incident was a change of condition for Resident 1. The ADON stated LVN 1 should have promptly notified thephysician and family member after the fall incident. 055816 Page 2 of 2