Health inspection·March 5, 2025

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 the interview and record review, the facility failed to ensure the half side rails were installed after obtaining the informed consent for one of three sampled residents (1) to help him reposition and stabilize in bed. This failure resulted in Resident 1's falling out of bed within six and half hours after being newly admitted to the facility on [DATE] and was transferred back to an acute hospital for further evaluation and management, and jeopardized Resident 1's health and safety during the short stay in the facility and caused Resident 1 to have a transfer to the acute hospital where he was diagnosed with intraparenchymal hemorrhage of brain (bleeding within the brain's functional tissue). FINDINGS: The clinical records of Resident 1 were reviewed. Resident 1's Face Sheet (document that summarizes a person's medical information) indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including non-specified sequelae (late effects) of nontraumatic intracerebral hemorrhage (ICH, also known as hemorrhagic stroke, condition where bleeding occurs within the brain tissue itself, caused by a ruptured blood vessel, causing damage and potentially life-threatening consequences). A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, a communication tool) change of condition (COC) 911 Transfer notes, dated 2/5/25, indicated, he was admitted on [DATE] at 2:28 p.m. and the incident occurred on the same day at 9:00 p.m. for an unwitnessed fall with possible head strike and Resident 1 was found turning to his left side on the bedside floor. A review of Resident 1's acute hospital records dated 2/5/25 at 11:20 p.m. indicated, Note Type: ED NOTES indicated, PRE-HOSPITAL NOTIFICATION REPORT . Alert: Trauma: Blood Thinners? Yes? LOC? Unknown Mechanism Fall from bed. Medical/Chief Complaint: FROM SNF, unwitnessed fall from bed 2-3ft, on blood thinner, c/o head pain. Recent CVA with left side deficit. A review of acute hospital record dated 2/7/25 2:52 p.m. indicated: Clinical Summary: . He comes in after being found down on the floor of his SNF and was brought in as a trauma. CTH (computed tomography of the head, is a noninvasive diagnostic imaging procedure) shows mild expansion of his IPH (intraparenchymal hemorrhage), two other small foci of hyper density are also minimally increased in size. A review of Resident 1's acute hospital neurocritical care records, dated 2/6/25, indicated, . who presents from skilled nursing facility (SNF) status post (s/p) fall from bed. Systolic blood Page 1 of 3 056116 056116 03/05/2025 Los Altos Post-Acute 809 Fremont Avenue Los Altos, CA 94024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pressure (SBP, the pressure in your arteries when your heart beats)150 on arrival, computed tomography of the head (CTH, is a noninvasive diagnostic imaging procedure) with stable to slight interval increase in IPH (intraparenchymal hemorrhage). Further review of the history of present illness (HPI) indicated that he was discharged from the hospital yesterday afternoon 2/5/2025 to a skilled nursing facility (SNF), where he sustained an unwitnessed approximate 2-to-3-foot fall and was found to be in a prone position next to his bed. Per brother at bedside in the ED, the patient was placed in a bed without guardrails at the facility. The family requested guardrails and stayed with the patient until late evening but left prior to the patient's unwitnessed fall from bed. A review of Resident 1's interdisciplinary team (IDT, an approach to healthcare that integrates multiple disciplines through collaboration) facility notes, dated 2/6/25 indicated and documented, Resident found on floor by certified nursing assistant (CNA). Patient unable to verbalize how he fell. Patient impulsive and has poor safety awareness. Patient also has left side (L) weakness, status post (S/P, is a medical term for a previous treatment, diagnosis, or event) stroke and leans to the left. Patient was sent out to emergency room (ER) for further evaluation. Upon return IDT recommend to place wedge on L side to keep patient at midline. Continue strengthening and mobility with Therapy. During a review of Resident 1's facility physician assistant notes, dated 2/5/25, indicated, He was found on the floor to the left side of his body by the CNA. He had an unwitnessed fall. The patient states that he turned towards his left side and fell over. States that he did hit the top of his head on the ground. Bed was in the lowest setting. No observed injuries or broken skin to his head. No bumps or bruises. The patient's range of motion is at baseline, weaker at the left side secondary to his diagnosis. During a review of intake information to the State Department of Public Health, dated 2/7/25, indicated, . Patient reports he was placed in a bed without rails. Patient was reaching for the call light when he rolled off the bed. During a review of Resident 1's Bed Rails -Safety Assessment, dated 2/5/25, indicated he had Poor trunk control at risk of gravity effects for rolling, sliding, or slipping from bed. Per wife patient uses siderail with strong side to assist with bed repositioning. During a review of Resident 1's facility's verification of informed consent, dated 2/5/25, it indicated the half side rails to be used in bed was signed and obtained from Resident 1's wife who is the legal decision maker, upon admission. During a review of Resident 's facility physician's orders, dated 2/5/25, indicated, SIDE RAILS: 1/4 rails up as per doctor's order as needed to promote full or partial independence with turning and repositioning in bed, to provide support, stability, and personal comfort during transfers. Reposition frequently and as necessary to avoid injury. A further review indicated Resident 1 was also prescribed Enoxaparin Sodium Solution (is a blood thinner to prevent blood clots) 40 milligrams (MG, a unit of mass)/0.4 milliliters (ML, a unit of volume), inject 40 mg subcutaneously two times a day for preventing blood clotting. During a review of Resident 1's fall risk assessment dated [DATE], it indicated he was at moderate risk (Scoring ranges 0-24 mean at low risk, scoring 25-44 at moderate risk and scoring 45 and higher at high risk) for falling with score of 35. Further review of Resident 1's post fall assessment, dated 2/6/25, indicated Resident 1 was at high 056116 Page 2 of 3 056116 03/05/2025 Los Altos Post-Acute 809 Fremont Avenue Los Altos, CA 94024

F 0689 risk for falls with a score of 65. Level of Harm - Minimal harm or potential for actual harm During a telephone interview on 2/19/25 10:29 a.m., with registered nurse A (RN A), RN A stated it was unfortunately too sudden when he turned himself in the bed and he fell out of the bed. RN A confirmed he did not install half side rails at that time because he was unaware side rail informed consent had been obtained already. Residents Affected - Few During an interview on 2/19/25, at 2 p.m., with the assistant of director nursing (ADON), ADON confirmed staff should have installed the side rails after obtaining the side rail informed consent as soon as possible. During a review of the facility's policy and procedure (P&P) titled, Fall Prevention and Response, dated 8/2023, the P&P indicated, Each Resident will be.assessed for fall risk factors and will receive care and services in accordance with individualized level of risk to minimize the likelihood of falls. 056116 Page 3 of 3