Health inspection·February 26, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility's failed to ensure their skilled nursing licensed staff provided care based on professional standards for one of three sampled residents (Resident 1) when licensed nurse did not immediatelly assess and notify the doctor following Resident 1's fall. Residents Affected - Few This failure resulted in unnecessary pain and a delay in treatment for Resident 1's fractured hip. Findings: During a record review of the Resident 1's clinical document titled, admission Record dated 2/6/2025,the admission record showed, the facility admitted Resident 1 in September 2019. Resident 1 had multiple medical diagnoses including hemiparesis and hemiplegia following a cerebral infarction(weakness and paralysis due to a stroke). Record review of the Resident 1's clinical document titled, Progress Notes dated 1/13/2025, the document showed, Physical Therapy Assistant (PTA) had a session with Patient 1 on 1/10/2025 between 1:30 p.m to 2 p.m. Patient 1 had agreed to the plan of sitting at the edge of the bed to promote trunk (core) strength. Patient 1 was assisted into a sitting position. Once she sat up in bed she scooted to the edge of the bed and planted her feet on the floor. Patient 1 suddenly leaned forward to face the floor. PTA held her and guided her onto her knees before sitting her on the floor. During the evening shift at 3:45 p.m., Patient 1 was noted Crying with pain. The certified nursing assistant reported to the charge nurse that Patient 1 had reported she had fallen earlier that day. At 6:00 p.m. on 1/10/2025, (3.5 to 4 hours post fall) the charge nurse notified the doctor and Patient 1 was transferred to the hospital. Record review of Resident 1's clinical document titled, Progress Notes dated 1/11/2025 indicated, the hospital notified the facility that Resident 1 had sustained a left hip fracture. During an interview on 2/7/2025 at 10:46 a.m. with PTA, PTA confirmed, he had been working with Resident 1 on strengthening her core. On 1/10/2025 they had done a few exercises when she Suddenly started to lean forward. PTA stated he held onto her shoulder and back and lowered her down to the floor. Licensed Vocational Nurse 1 (LVN 1) helped PTA assist Patient 1 back to bed. PTA stated he reported the fall at that time to LVN 1 as well as to the Director of Rehabilitation. There was no documentation in the clinical record which showed the doctor had been notified regarding the fall or an immediate assessment for injury had been completed. During an interview on 2/7/2025 at 10:52 a.m. with LVN 1, LVN 1 stated following a patient fall, staff are to assess the patient for injuries and notify the doctor. LVN 1 stated she had not done that Page 1 of 2 056280 056280 02/26/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0684 after assisting Patient 1 back to bed and it was important to do so, To ensure the resident is okay. Level of Harm - Minimal harm or potential for actual harm Resident 1 no longer resides at the facility and could not be interviewed. Residents Affected - Few Record review of the facility's Policy and procedure (P & P) titled, Fall Management Program dated March 13,2021 , the P &P indicated the purpose was To provide residents a safe environment that minimizes complications associated with falls. The licensed nurse will notify the Director of Nursing (DON) and/or the Administrator regarding the fall incident as soon as possible. The licensed nurse will notify the Resident ' s attending physician and Resident ' s responsible party of the fall incident. 056280 Page 2 of 2