Health inspection·July 10, 2024

Santa Cruz Post Acute EVENT ID: TH2C11 Provider # 056065 Representing the Department: HFEN, 46001 Exit date: 6/25/2024 Class B Citation F689 FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES §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. The REQUIREMENT is not met as evidenced by: The facility failed to ensure supervision and assistance were provided for one of three sampled patients (Patient1), who was dependent on staff for transferring, when Patient 1 was left sitting in her wheelchair in her room and fell on the floor on 2/19/2024 without staff watching and/or supervising her. This failure resulted in Patient 1 falling on the floor and sustaining a laceration (a deep cut or tear in skin) on her forehead that required hospital transfer on 2/19/2024 where she had 18 stitches (a way doctors can close certain types of cuts). A review of Patient 1's face sheet (a document that gives a patient's information) indicated Patient 1 was admitted to the facility on 3/1/2023 with diagnoses including unspecified dementia (a range of neurological conditions affecting the brain including loss of the ability to think, remember, and reason to levels that affect daily life and activities), difficulty in walking, muscle weakness, and history of falling. A review of Patient 1's "Fall Risk" assessment, dated 11/21/2023, indicated a score of 22 (score of 16-42 indicates high risk of falling), Patient 1 was at high risk of falling. A review of Patient 1's care plan, initiated on 3/2/2023, indicated Patient 1 had an "Activities of daily living (ADLs, a person's daily self-care activities) self-care performance deficit related to impaired balance and limited mobility... TRANSFER The resident (Patient 1) has [sic] requires staff participation with transfers." A review of Patient 1's admission minimum data set (MDS, an assessment tool) dated 11/21/2023 indicated a brief interview for mental status (BIMS, cognition [includes memory, problem-solving, and thinking skills] level) score of 8 (score of 8-12 indicates moderate cognitive impairment). A review of Patient 1's MDS section GG, dated 11/21/2023, indicated Patient 1's level of performance was coded "1" which indicated Patient 1 was dependent, and helpers did all of the effort, the patient did none of the effort to complete the activities; and Patient 1 required assistance of 2 or more helpers to complete the activities of bed mobility, transfer, and toileting. A review of Patient 1's Interdisciplinary Team's (IDT, team composed of members from different departments involved in resident (patients)'s care) Fall Follow up notes dated 2/20/2024, indicated, "the resident (Patient 1) was found lying on her right side next to her wheelchair in her room, bleeding from right forehead and hand noted... Several minutes prior to the incident, the resident (Patient 1) participated in group activities and was assisted back to her room via wheelchair... resident (Patient 1) was sent to the hospital via 911 per physician's order for further evaluation and treatment as indicated...the resident (Patient 1) 's previous fall incident was about a month ago with no injury noted... The staff had been providing redirection and assistance with ADLs... Resident(Patient 1) appeared to have tried to self-transfer without staff assistance and lost balance... Prior lntervention (s): Preventive measures prior to event: frequent checks for needs, assistance with ADLs and re-direction as needed... Resident (Patient 1) returned on the same day with sutures to scalp." A review of Patient1's clinical records from the hospital, titled "Emergency Room (ED) Physician Report," dated 2/19/2024, indicated that "...patient was presenting to the ED via ambulance after an unwitnessed fall...Patient was found on the ground after she had fallen out of her wheelchair. The patient was noted to have a large laceration to her forehead and scalp. No other injuries were noted..." During an interview with the MDS coordinator (MDSC) on 6/13/24 at 10:30 a.m., the MDSC reviewed Patient 1's MDS section GG, and she confirmed Patient 1 was dependent, required helpers (staff) to do all of the effort, the patient did none of the effort to complete the activities. Patient 1 required the assistance of 2 or more helpers(staff) to complete the activities of bed mobility, transfer, and toileting. During an interview with the Activity Director (AD) on 6/13/24 at 2:42 p.m., the AD confirmed the concerned activity staff C (ASC) who brought Patient 1 back to her room no longer work in the facility. The AD stated the activity staff should not leave patients alone in their room without notifying nursing staff. During a phone interview with Registered Nurse (RN) A on 6/13/24 at 3:04 p.m., RN A recalled Patient 1 falling inside her room on 2/19/2024 around noon time. RN A stated the AS C brought Patient 1 back to her room without notifying the nursing staff. RN A confirmed that Patient 1's MDS and ADL care plan indicated Patient 1 needed helpers to help with the transfer. RN A further stated Patient 1 was at risk of falling and should not have been left alone in her room. she also stated Patient 1 returned from the hospital on the same day (2/19/2024) with 18 stitches on her forehead. During a phone interview with CNA B on 6/13/24 at 3:57 p.m., CNA B confirmed she was the assigned CNA for Patient 1 on 2/19/2024. CNA B confirmed that Patient 1 cannot transfer by herself and required staff help during wheelchair-to-bed transfer. CNA B stated AS C brought Patient 1 back to her room without informing her. When CNA B came to Patient 1' room to answer the call light, Patient 1 already fell on the floor. CNA B further stated that the AS C should not have left Patient 1 alone in her room. During an interview with the Director of Nursing (DON) on 6/13/24 at 4:11 p.m., the DON reviewed Patient 1's MDS and ADL care plan. The DON confirmed that Patient 1 was a high risk for falling and needed help with the wheelchair to bed transfer. The DON stated that the AS C should have stayed with Patient 1 and notified the CNAs and/or nurses that Patient 1 was back in her room. A Review of the facility's undated policy and procedure (P&P) titled "Falls and Fall risk, Managing," the P&P indicated, "...several possible interventions may be identified considering resident fall risks, and the staff may prioritize certain interventions based on the circumstances..." In violation of the above cited standards, the facility failed to ensure that each patient receives adequate supervision and assistance to prevent accidents, including but not limited to: the facility failed to ensure supervision was provided to Patient 1 who was assessed to be high risk for falls, totally dependent on staff for transferring, when Patient 1 was left sitting in her wheelchair in her room and fell on the floor without staff watching and/or supervising her on 2/19/2024. This failure resulted in Patient 1 falling on the floor and sustaining a laceration (a deep cut or tear in skin) on her forehead that required hospital transfer on 2/19/2024 where she had 18 stitches (a way doctors can close certain types of cuts). The violations had a direct or immediate relationship to the health, safety or security of patients or residents.