Health inspection·September 8, 2021

Health and Safety Code §1424(c)(1)(2)(3)(d): (c) Class “AA” violations are violations that meet the criteria for a class “A” violation and that the state department determines to have been a direct proximate cause of death of a patient or resident of a long-term health care facility. Except as provided in Section 1424.5, a class “AA” citation is subject to a civil penalty in the amount of not less than five thousand dollars ($5,000) and not exceeding twenty-five thousand dollars ($25,000) for each citation. In any action to enforce a citation issued under this subdivision, the state department shall prove all of the following: (1) The violation was a direct proximate cause of death of a patient or resident. (2) The death resulted from an occurrence of a nature that the regulation was designed to prevent. (3) The patient or resident suffering the death was among the class of persons for whose protection the regulation was adopted. Health and Safety Code §1424(d): (d) Class “A” violations are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. Health and Safety Code §1424.5 (a)(1) Fines imposed on skilled nursing facilities or intermediate care facilities (a) In lieu of the fines specified in subdivisions (c), (d), (e), and (g) of Section 1424, fines imposed on skilled nursing facilities or intermediate care facilities, as specified in paragraphs (1) and (2) of subdivision (a) of Section 1418, shall be as follows: (1) A class “AA” citation is subject to a civil penalty in an amount not less than twenty-five thousand dollars ($25,000) and not exceeding one hundred thousand dollars ($100,000) for each and every citation. For a second or subsequent class “AA” citation in a skilled nursing facility or intermediate care facility within a 24-month period, the state department shall commence action to suspend or revoke the facility's license in accordance with Section 1294. 42 CFR Section 483.25(d)(1)(2) Accidents. The facility must ensure that – (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. Title 22, California Code of Regulations, Division 5, Chapter 3, Article 3, Section 72311(a)(1)(B)(C) (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient’s condition. Title 22, California Code of Regulations, Division 5, Chapter 3, Article 3, Section 72311(a)(2): (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. On 9/10/2020, an unannounced visit was conducted at the facility to investigate a complaint regarding Quality of Care/Treatment, Resident Safety/Falls. The facility failed to implement care plan interventions for a patient (Resident 1) and failed to provide adequate supervision to prevent an accident when the one-to-one sitter (1:1 sitter, staff designated to be with the resident at all times to ensure safety) went to the bathroom and did not get another staff member to stay with the resident. This resulted in Resident 1’s fall, head injuries, and subsequent death. Resident 1’s clinical record documented she was admitted to the facility on 6/1/18 and had the diagnoses of congestive heart failure (heart muscle does not pump blood as well as it should), dementia (mental disorder caused by brain disease or injury), macular degeneration (condition that causes loss of vision), abnormalities of gait (manner of walking) and mobility, atrial fibrillation (irregular heartbeat), psychosis (a severe mental disorder), osteoporosis (condition that causes the bones to become brittle and fragile) and history of falling. Resident 1’s Minimum Data Set (MDS, an assessment tool), dated 4/1/2020, documented Resident 1 had a brief interview for mental status (BIMS) score of 3 (a score of 0 to 7 indicates severe cognitive impairment). The MDS documented Resident 1 was totally dependent on staff for transfers and required extensive assistance (staff provide weight-bearing support) with all other activities of daily living (ADLs, basic tasks of everyday life such as bed mobility, walking, eating, dressing, personal hygiene, toileting and bathing). The MDS further documented Resident 1 was not steady and was only able to stabilize herself with staff assistance while moving from a seated to a standing position, walking, turning around, moving on and off the toilet, and transferring from surface to surface. Resident 1’s non-compliant care plan, dated 6/3/18, documented she refused to use her walker at times. Resident 1’s elopement risk care plan, dated 6/1/18, documented she was disoriented to place (did not know where she was), had impaired safety awareness, and had a history of wandering aimlessly. Resident 1’s fall risk care plan, dated 6/1/18, documented she was at risk for falls due to confusion, dementia, gait and balance problems, medications, wandering, and history of falls. Resident 1’s fall risk assessment, dated 4/1/2020, documented she had a fall risk score of 65 (a score of 45 or higher indicates high risk for falls). Resident 1’s Interdisciplinary Team (IDT, staff from different disciplines who work together to plan and provide care) Progress Notes, dated 10/23/19, documented Resident 1 was involved in an altercation with another resident. The IDT Progress Notes documented Resident 1 had a history of falls and noted multiple behaviors, including angry outbursts, pushing or tapping staff, difficulty sleeping, walking around facility hallways, repetitively touching or tapping facility surfaces (i.e. walls, rails, counters), attempting to go in other resident’s room, disrobing, and removing her brief (adult diapers). The IDT Progress Notes also documented that prior to coming to the facility, Resident 1 had an incident where she eloped (left without permission) from home and “went missing for some time.…” The IDT Progress Notes further documented the facility would implement “1:1 with [Resident 1] to maintain her safety and the safety of others.” Resident 1’s clinical record did not record any incident of falls for Resident 1 from the time the facility implemented the 1:1 sitter on 10/23/19, until 4/4/2020. Resident 1’s Progress Notes, dated 4/4/2020, documented Resident 1 had an unwitnessed fall. The Progress Notes noted that at 3:00 p.m., Resident 1 was on her wheelchair in the hallway with her 1:1 sitter. At 3:20 p.m., Resident 1’s nurse and the morning (AM) shift nurse were assisting another resident into bed when they heard a “loud slam noise.” The Progress Notes further documented the nurses went to assess the situation and noted Resident 1 lying flat on the ground. The Progress Notes documented staff, “Applied pressure and a cold compress on the occipital area [back of the head] of head where bleeding was noted.” The progress notes documented the AM shift nurse called 911 and Resident 1 was transferred to the acute hospital at 3:45 p.m. During an interview with licensed vocational nurse A (LVN A) on 10/13/2020 at 4:00 p.m., LVN A confirmed she was Resident 1’s assigned nurse at the time Resident 1 experienced the fall on 4/4/2020. LVN A stated at the beginning of her evening (PM) shift, Resident 1 was sitting in the hallway and the 1:1 sitter was sitting next to Resident 1. LVN A explained while she and the AM nurse were doing endorsement (reporting important information to each other) in another resident’s room, they heard a loud noise. When they went to check what happened, they saw Resident 1 lying in supine position (flat on her back) on the floor in the hallway. LVN A stated Resident 1 was bleeding from the back of her head. LVN A stated Resident 1 had a 1:1 sitter to help her with ADLs and to prevent her from falling. LVN A stated she did not pay attention to the whereabouts of the 1:1 sitter during Resident 1’s fall, as she was just worried about taking care of the resident. LVN A stated if the 1:1 sitter had to leave Resident 1’s side for any reason, she needed to inform another staff member so they could watch the resident. During an interview with certified nursing assistant B (CNA B) on 10/13/2020 at 4:45 p.m., she stated she was not the assigned 1:1 sitter for Resident 1 at the time Resident 1 experienced the fall, but was working on Resident 1’s station at the time of the fall on 4/4/2020. CNA B stated she knew Resident 1 fell, but she did not see the fall because she was taking care of another resident. CNA B stated Resident 1 had a 1:1 sitter because she had dementia and she was agitated and combative. CNA B explained the 1:1 sitter had to be with the resident all the time. If she needed to leave the resident, she had to call another staff member to watch the resident and make sure she did not fall. During an interview with the director of nursing (DON) on 10/13/2020 at 5:00 p.m., she stated Resident 1 was confused, agitated and combative with other residents. She stated Resident 1 had a 1:1 sitter to manage behaviors and prevent falls. The DON stated CNA D was the assigned 1:1 sitter when Resident 1 fell on 4/4/2020. The DON explained that CNA D went to the bathroom and did not ask another staff member to watch Resident 1. The DON stated CNA D should have informed another staff member she needed to use the bathroom so the other staff member could temporarily watch Resident 1 as 1:1 sitter. The DON stated the facility counseled CNA D about what happened and told her she should not have left Resident 1 without informing staff. During an interview with LVN C on 10/20/2020 at 2:45 p.m., she stated she was the nurse on the AM shift when Resident 1 fell on 4/4/2020. LVN C stated CNA D was Resident 1’s assigned 1:1 sitter when the fall occurred. LVN C explained that during shift change, she and LVN A were giving report (endorsement) in another resident’s room and heard a “smack” noise. They ran out of the room and saw Resident 1 lying on the ground. LVN C confirmed CNA D was not present at the scene at the time of the fall. LVN C stated she and other staff asked CNA D what happened and CNA D said she needed to use the bathroom. LVN C stated she did not know if CNA D asked another staff member to take over as 1:1 sitter while she was in the bathroom, but confirmed she did not see any staff members with Resident 1 when she and LVN A saw the resident on the ground. During an interview with CNA D on 11/21/2020 at 10:00 a.m., she confirmed she was the assigned 1:1 sitter when Resident 1 fell on 4/4/2020. CNA D stated Resident 1 required a 1:1 sitter because at times “she would want to keep getting up.” CNA D explained that Resident 1 would briefly follow directions when staff asked her to sit down, but would try to get up again shortly after. So staff needed to keep reminding Resident 1 to sit down. CNA D explained that at the time of the fall, she had to use the bathroom, so she put Resident 1 in front of the nurse’s station in her wheelchair. CNA D stated there were other staff members in the area at that time. CNA D explained that as she was exiting the bathroom, she heard another resident say that Resident 1 fell. CNA D confirmed she did not get another staff member to take over as 1:1 sitter while she went to the bathroom. Review of the facility’s Nursing Staffing Assignment and Sign-In Sheet, dated 4/4/2020, indicated CNA D was the assigned 1:1 sitter during the shift when Resident 1 fell. Review of the facility’s Written Warning for CNA D, signed on 4/6/2020, indicated a job performance violation occurred on 4/4/2020. The Written Warning indicated the nature of CNA D’s violation was, “not endorsing to another staff person to oversee resident on 1:1. Then patient fell. She was educated to call staff if leaving a patient so that pt [patient] is not alone.” During an interview with CNA E on 11/21/2020 at 3:20 p.m., she stated she was not assigned to Resident 1, but worked on the same station when Resident 1 fell on 4/4/2020. CNA E stated Resident 1 required a 1:1 sitter because she wandered and would get up without asking for assistance. CNA E stated she did not witness Resident 1’s fall, as she was doing rounds (checking on and assisting residents) at the time. During an interview with CNA F on 11/21/2020 at 3:30 p.m., she stated she was working on the same station when Resident 1 fell on 4/4/2020. CNA F stated she did not witness the fall and was not watching Resident 1 at the time of the fall. CNA F stated nobody asked her to watch Resident 1 at that time. CNA F explained that Resident 1 needed a 1:1 sitter because she would “get up and walk away.” She also stated Resident 1 was getting weaker and did not realize how weak she was. CNA F stated she did not know where the 1:1 sitter was at the time of Resident 1’s fall. During an interview with CNA G on 11/21/2020 at 3:40 p.m., she stated she heard about Resident 1’s fall, but she did not witness it. CNA G explained she was working on Resident 1’s station at the time of the fall, but was working “on the other side.” CNA G stated Resident 1 required a 1:1 sitter because she was confused and would get up and wander into other residents’ rooms. During an interview with LVN H on 11/23/2020 at 4:37 p.m., she stated she was not Resident 1’s assigned nurse when she fell on 4/4/2020, but had worked on the other side of the same station that day. LVN H explained that at the time of the fall, she was in the nurse’s station doing her charting. LVN H stated she heard a “bump” noise and when she went out of the nurse’s station, she saw Resident 1 on the floor. LVN H stated the 1:1 sitter was not with Resident 1 when she fell. LVN H stated she asked the 1:1 sitter why she was not with Resident 1 and the 1:1 sitter said she had to use the bathroom. LVN H stated the 1:1 sitter did not inform her that she was leaving to use the bathroom. LVN H stated Resident 1 had a 1:1 sitter because she had a history of falls and had behaviors. LVN H stated the 1:1 sitter was supposed to inform another staff member that she was going to the bathroom so the other staff member could cover for her. Resident 1’s IDT Fall Review, dated 4/6/2020, indicated she had an unwitnessed fall in the hallway outside her room near the nurse’s station on 4/4/2020 at 3:20 p.m. The IDT Fall Review indicated Resident 1 was noted with a laceration (deep cut in the skin or flesh) on the occipital area with bleeding. The IDT Fall Review further indicated that Resident 1 was sent to the acute hospital for further evaluation and treatment. Resident1’s ED (emergency department) Provider Notes from the acute hospital, dated 4/4/2020, indicated Resident 1 “reportedly fell after coming to stand from her wheelchair striking the back of her head on the hard floor.” The ED Provider Notes further indicated, “EMS [emergency medical services] reports small laceration and large hematoma [abnormal collection of blood] to posterior [back] scalp.” Resident 1’s computerized tomography scan (CT scan, procedure used to view internal components of the body) report from the acute hospital, dated 4/4/2020, indicated Resident 1 had acute (sudden onset) traumatic (caused by forces from outside of the body) intraparenchymal and extra-axial hemorrhage (bleeding within the brain and in the area between the brain and the skull), subdural hemorrhage (bleedin