Health inspection·November 18, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure for one of one sampled resident (Resident 1), a morse fall risk assessment (a tool used to assess a resident's risk of falling in a hospital setting) was completed every shift in accordance with the facility's policy regarding Fall Risk Assessment and Prevention. Residents Affected - Few These deficient practices had the potential to cause a delay in determining Resident 1's fall assessment and/or provision of proper fall intervention needed, which could result in fall that could cause Resident 1 harm or even death. Findings: During a review of Resident 1's History and Physical (H&P), dated 10/21/2024, the record indicated Resident 1 was a [AGE] year-old female with ongoing medical problems including history of hemorrhagic cerebrovascular accident (occurs when a blood vessel in or on the brain breaks or leaks, causing bleeding) June 2022, and seizure (a temporary episode of abnormal electrical activity in the brain that causes a sudden change in behavior, movement, or consciousness) disorder diagnosed March 2024. Resident 1 was admitted to the hospital for breakthrough seizures. During a concurrent interview and record review of Resident 1's electronic medical record (EMR) on 11/18/2024 at 11:43 a.m., with the Assistant Nurse Manager (ANM), the EMR indicated Resident 1 had an unwitnessed fall incident on 10/26/24 at 1:15 a.m., and Resident 1's bed was alarming and Resident 1 was found on the floor by a facility certified nursing assistant. The last morse fall risk assessment (a tool used to assess a Resident's risk of falling in a hospital setting) prior to Resident 1's fall incident was completed on 10/25/24 at 7:26 a.m.; approximately 17 hours before the fall incident. Resident 1 was missing two morse fall risk assessments prior to the fall incident. The ANM stated that a morse fall assessment must be completed every eight-hour shift. During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment and Prevention, last revised 4/2021, the P&P indicated the following: 1. General precautions are taken to prevent all patients from a fall. 2. Each patient is assessed at time of admission, transfer, each shift and change in condition (e.g., Page 1 of 2 056499 056499 11/18/2024 Providence Little CO of Mary Transitional Care Ctr 4320 Maricopa Street Torrance, CA 90503

F 0641 change in ambulation status and/or recent fall incident) for fall risk and risk for sustaining injury. Level of Harm - Minimal harm or potential for actual harm 3. Residents Affected - Few The Morse Fall Assessment is the tool used to assess fall risk. A score of 24 or greater is considered an increased fall risk and triggers fall prevention actions. 4. Brain dead and/or comatose patients and patients receiving paralytics do not need to be assessed. 5. Patients' mobility is assessed using the Basic Mobility Tool to accurately assess how much assistance and what mobility assist devices should be utilized to safely mobilize the patient. 6. Upper side rails are customarily kept up for patient to use in getting up while lower side rails are kept down. 7. Patients at the highest risk for injury from a fall are those a. over age [AGE] b. frail due to a medical condition c. with a history of orthopedic conditions d. on anti-coagulation therapy e. with a bleeding disorder f. post-surgery or post-procedure. 056499 Page 2 of 2