Other·January 3, 2020

F000 INITIAL COMMENTS

F000 DEFICIENCY) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreaviated survey regarding investigation of a complaint conducted on 12/30/19. For Complaint CA00668022 regarding Quality of Care/Treatment, a federal deficiency was identified (see F689). Also, a "B" Citation was issued. Inspection was limited to the specific complaint and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 42149, Health Facilities Evaluator Nurse.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on record review and interview the facility failed to ensure one resident (Resident 055798 12/30/2019 VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd Los Gatos, CA 95032 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 1) out of three sampled, had adequate interventions and supervision in place to prevent further falls. This failure resulted in Resident 1 sustaining four falls from 11/12/19 to 12/12/19 and had the potential to result in injury and decline. Findings: During a record review on 12/27/19, indicated Resident 1 was admitted to the facility on 11/12/19 with diagnoses that included malignant neoplasm of brain (brain cancer), muscle weakness, difficulty in walking, and anxiety. Additionally, Resident 1 was receiving chemotherapy (an aggressive form of chemical drug therapy meant to destroy rapidly growing cells in the body) and radiation to treat the brain cancer. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 11/19/19, indicated Resident 1 needed extensive assistance with activities of daily living (ADL's) including bed mobility and transfer that required two-person assistance and extensive assistance with walking with one-person assistance. During a review of Resident 1's progress notes indicated Resident 1 fell four(4) times from 11/12/19 to 12/13/19. Review of Resident 1's progress note dated 11/12/19, indicated "At 2030 [8:30 p.m.] patient was calling out for help. RN [registered nurse] quickly ran into the room and found the patient lying on his left side against the wall next to bed ...RN asked how patient fell onto the floor and patient responded 'the bedrail was down and I rolled out of bed.' ..." During a review of Resident 1's IDT 055798 12/30/2019 VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd Los Gatos, CA 95032 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE [interdisciplinary team] review dated 11/13/19, the IDT identified "Root cause: rolled out of bed". New interventions were "Oriented to facility, room, side rails, call light, bed controls and to request assistance as needed." Review of Resident 1's progress note dated 11/24/19, indicated "Resident was reported witness fall at 3 pm, in bathroom. He slowly felt [fell] down on the floor, no head injury, pain left ankle ...new order stat [immediately] x-ray left ankle ..." During a review of Resident 1's IDT review dated 11/25/19, the IDT identified "Root cause: Friend brought him to the bathroom without requesting assistance from staff. New interventions: Educated friend not to transfer patient and to put call light on and allow staff to transfer resident. Review of Resident 1's progress note dated 12/2/19 at 10:30 p.m., indicated "LN [licensed nurse] heard patient calling out, went to patients room and found patient on the floor face down. Patient states he did not fall but rolled put [out] of bed ..." During a review of Resident 1's IDT Notes dated 12/2/19, the notes stated "He continues to attempt getting up without assistance. Staff redirection is not remembered. Staff anticipates resident needs. Incremental monitoring for safety is being completed ...Plan: Continue with pressure alarm to wheelchair ...". Review of Resident 1's progress note dated 12/12/19 at 3:45 p.m., indicated "Upon rounds resident was found face down on the floor with head against the wall ...Resident is post radiation appt [appointment] and states that he is feeling weak and tired. Resident states that he was attempting to ask someone for thin 055798 12/30/2019 VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd Los Gatos, CA 95032 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE water as they exited his room. Pt states they did not hear him and he leaned over and fell frontwards out of the wheelchair." Review of Resident 1's progress note dated 12/13/19 at 3:14 a.m., indicated "Pt was found at beginning of shift on floor. Unwitnessed fall. Head was against wall ...Around 2000 [8:00 p.m.] noted pt was having right eye pain ...when asked to close left eye and look using just right eye pt verbalized that his vision was blurry ...Notified MD [medical doctor] and per MD send out via BLS [basic life support]. Called and pt was picked up approx. 2100 [approximately 9:00 p.m. to hospital]." During a review of Resident 1's IDT review dated 12/13/19, the IDT identified "Root cause: Pt [patient] is weak and tired post chemo [chemotherapy] and or radiation and has difficulty keeping himself upright in wheelchair. New interventions: Assist pt to bed post chemo and or radiation appt's. Recline pt wheelchair 10-15 degrees. Review of the baseline care plan [the initial care plan within 48 hours of admittance] indicated the Resident was identified a "Fall Risk". Review of the "Fall Care Plan" dated 11/12/19, indicated Resident 1 was care planned for the problem of "Fall Care Plan" with the following approaches: "Provide verbal reminders / cues to ask for assistance as needed"; "Provide proper, well-maintained footwear as indicated (Non-Skid Socks etc.)"; "Orient to new environment as indicated"; "Obtain PT [physical therapy] / OT [occupational therapy] consult as indicated"; "Medication Regimen Review as indicated PRN [as needed]."; 055798 12/30/2019 VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd Los Gatos, CA 95032 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE "Keep personal items and frequently used within reach."; "Keep call light within reach"; "Keep bed in lowest position with brakes locked". The "Fall Care Plan" was updated on 11/13/19 with the approach "Oriented to facility, room, side rails, call light, bed controls and to request assistance as needed." The "Fall Care Plan" was updated again on 11/25/19 with the approach "Educated friend not to transfer patient and to put call light on and allow staff to transfer resident". The "Fall Care Plan" was updated again on 12/3/19 with the approach "Pressure alarm to bed to remind resident not to get up without assistance"; The "Fall Care Plan" was updated again on 12/13/19 with the approaches "Assist pt to bed post chemo provide pt with reclining wheelchair and recline 10-15 degrees when out of bed". During an interview on 12/27/19 at 11:27 a.m., certified nursing assistant (CNA B) stated Resident 1 was very alert. CNA B stated when he cared for Resident 1, he would check to ensure the motion alarm was on because the Resident wanted to try and stand up and use the bathroom independently. CNA B stated Resident 1 was weak after he returned from radiation and chemotherapy treatment. CNA B stated he did frequent checks when Resident 1 was in his care because he did not want him to fall. CNA B stated there was no facility timeframe required to check on the resident. During an interview on 12/27/19 at 11:45 a.m., CNA C stated Resident 1 was a high fall risk. CNA C stated the nurses informed him of the 055798 12/30/2019 VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd Los Gatos, CA 95032 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE fall interventions associated with the resident and the information was also posted in the resident's room. CNA C stated Resident 1's interventions included checking frequently and a motion alarm. During an interview on 12/27/19 at 12:15 p.m., RN A stated she was Resident 1's nurse for the fall on 12/12/19. RN A stated Resident 1 was weak when he fell on 12/12/19, he had just returned from radiation and chemotherapy treatment. RN A stated Resident 1 was not as strong as he used to be and was not aware of his limitations. During a review of the facility's policy and procedure, "Falls and Falls Risk, Managing", revised December 2007, indicated "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and cause to try to prevent the resident from falling and to try to minimize complications from falling." 055798 12/30/2019 VASONA CREEK HEALTHCARE CENTER 16412 Los Gatos Blvd Los Gatos, CA 95032 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE