Other·November 15, 2023

The following reflects the findings of the California Department of Public Health during the investigation of complaint CA00861244. Representing the Department, HFEN 39111. State Citation B was written. 42 CFR §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. 22 CCR § 72311. Nursing Service--General. (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. 22 CCR § 72523. Patient Care Policies and Procedures (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 9/26/23 at 8:40 A.M., the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct an investigation for a complaint that alleged Resident 1 had fallen while unsupervised and sustained a head injury. The facility failed to: 1. Supervise Resident 1 when certified nursing assistant (CNA) 2 placed the resident in a wheelchair, when the resident was agitated, and left the resident alone and unattended in the hallway around 2 A.M. 2. Implement Resident 1's Activities of Daily Living (ADL, self-care activities) care plan related to locomotion (how the resident moves between locations including self-sufficiency in a wheelchair) when the task was required to be provided by at least one staff. 3. Implement policies and procedures, including but not limited to facility policies titled: "Safety and Supervision of Residents" and "Dementia- Clinical Protocol." As a result, Resident 1 while unsupervised and performing locomotion, fell out of the wheelchair and hit her head on the floor. Resident 1 sustained a laceration (open wound) to her left forehead that required evaluation at the hospital and sutures (stitches holding the edges of a wound together) to close the laceration. A review Resident 1's facility Admission Record dated 9/26/23, indicated the resident was admitted on 2/10/18 and readmitted on 4/3/23 with diagnoses to include Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 1's facility nursing progress notes indicated the resident had a history of multiple falls: * 3/8/22, Resident 1 was found lying on her right side in the southeast hallway. * 8/29/22, Resident 1 had an unwitnessed fall around 3:10 P.M. in the dining hallway. Resident 1 was found sitting on the floor by maintenance staff and a restorative nursing assistant (provides rehabilitative care to individuals recovering from illnesses or injuries). * 8/29/22, Resident 1 had a witnessed fall around 5:15 P.M. in the hallway in front of the resident's room. Resident 1 hit the left side of her head. * 9/21/22, Resident 1 fell while in the shower room. "...Resident unable to give full description of incident d/t [due to] current mentation...[Resident 1 was] being physically aggressive toward staff, yelling out and scratching staff... resident kept pushing herself backwards... and slid off shower chair... landed on her buttocks...." A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment) dated 6/3/23, indicated the resident scored 02 on the brief interview of mental status (a score of 02 meant the resident had severe cognitive impairment). The same MDS assessment indicated the resident required extensive assistance (staff had to provide weight bearing support) and one-person physical assistance for locomotion in the wheelchair. A review of Resident 1's activity of daily living (ADL, self-care activities like locomotion and getting dressed) care plan dated 1/11/21 and revised 6/8/23, indicated the resident required extensive assistance provided by one staff while the resident did locomotion in her wheelchair. A review of Resident 1's change of condition progress note dated 8/17/23 and documented at 4:33 A.M., indicated, "... [Resident 1] found on the floor by staff after unwitnessed fall from wheelchair to floor, with approx [approximate] 2 cm [centimeter] laceration to L [left] eyebrow area. Wound presents with profuse [excessive] bleeding. [Resident 1] currently agitated/confused, and combative [aggressive]with staff... [Resident 1] sent out via ambulance for stitches and follow up...." A review of Resident 1's nursing progress note dated 8/17/23 and documented at 12:12 P.M., indicated the resident returned to the facility after being treated at the emergency room. Resident 1 was observed to have sutures on the left eyebrow area. A review of Resident 1's physician progress note dated 8/17/23 and documented at 3:19 P.M., indicated the resident was evaluated by the physician due to a fall that occurred at 2 A.M. "...Patient sustained laceration to left forehead which was sutured in the ER [emergency room]... Per son at bedside, nursing and roommate patient has been experiencing difficulties with sleeping, at most able to sleep two hours at a time, she has uncontrollable impulsive [tendency to act without thinking] behavior attempting to get OOB [out of bed] unassisted...." The physician's note further indicated Resident 1 had bruising to the eye area and left side of the head, and that the resident was, "...confused, frail, [foreign language] speaking," and had generalized weakness. On 9/26/23 at 9:03 A.M., an interview was conducted with Resident 2 (roommate of Resident 1) inside the resident's room. Resident 2 stated Resident 1 was her friend. Resident 2 stated Resident 1 had dementia (cognitive impairment and memory loss) and needed a lot of supervision. Resident 2 stated Resident 1 would go around in her wheelchair, touching everything and put objects into her mouth. Resident 2 stated while inside of their shared room a few months ago, Resident 1 got a hold of some paper and started eating it. Resident 2 stated Resident 1 had become physically weaker lately. Resident 2 stated on the night Resident 1 fell, Resident 1 had been restless and was trying to get out of bed which had woke Resident 2. Resident 2 stated she used her call light to summon help for Resident 1. Resident 2 stated a CNA (did not identify their name) came and put Resident 1 into her wheelchair and brought the resident into the hallway. Resident 2 stated sometime later, staff brought Resident 1 back into the room and Resident 1 was bleeding from her head. On 9/26/23 at 11:06 A.M., an interview was conducted with the director of staff development (DSD). The DSD stated she had investigated Resident 1's fall incident that occurred on 8/17/23. The DSD stated CNA 2 had placed Resident 1 in her wheelchair when she was in a state of agitation and left the resident unsupervised in the hallway. The DSD stated CNA 2 had been familiar with Resident 1 and "knew better." The DSD stated Resident 1 was confused and should not have been left alone in her wheelchair in the middle of the night. The DSD stated CNA 2 quit and no longer worked at the facility. A review of Resident 1's progress note dated 8/17/23 and authored by the DSD indicated, "Met and spoke with the resident's son regarding the incident last night... Writer reeducated the CNA about how to handle residents with special needs and how to communicate properly with the licensed nurse and other CNAs...." On 9/26/23 at 2:25 P.M., an interview was conducted with CNA 3. CNA 3 stated Resident 1 was, "Very confused even when speaking [foreign language]." CNA 3 stated Resident 1 required frequent checks because the resident would eat things like paper. CNA 3 stated Resident 1 would become agitated and sometimes scratch staff during care because Resident 1 was confused. CNA 3 stated she would not put Resident 1 into the wheelchair and let the resident do locomotion by herself even in the daytime, because of the resident's behavior. CNA 3 stated when unattended, Resident 1 would try and go out different doors and pulled objects off surfaces. CNA 3 stated Resident 1 "leans dangerously forward" in the wheelchair and required staff to pull the resident up often while sitting in the wheelchair. CNA 3 stated there was a good chance Resident 1 would fall forward when sitting in the wheelchair. CNA 3 stated Resident 1 required more supervision when agitated and should not be left alone. On 9/27/23 at 7:05 A.M., a telephone interview was conducted with CNA 4. CNA 4 stated she was working on 8/17/23 with CNA 2, but it was CNA 2 who was assigned to provide care to Resident 1. CNA 4 stated Resident 1 was "always confused" and required "extensive supervision" due to the resident wandering into other rooms and putting things into her mouth. CNA 4 stated that night had been busy and she had been providing care to another resident when CNA 2 came and told her that she was going to put Resident 1 into her wheelchair. CNA 4 stated, "I told [CNA 2] not to do that because I couldn't watch [Resident 1]." CNA 4 stated Resident 1 often put her legs over the bed but was too weak to get out of bed on her own. CNA 4 stated, "[Resident 1] was safer in bed until someone could watch her." CNA 4 stated, "The next thing I know [CNA 2] tells me, 'Oh hey, I got [Resident 1] up and I'm going on my lunch break.'" CNA 4 stated she was still with her resident providing care and again told CNA 2 not to do that. CNA 4 stated when CNA 2 came back, she then went on her own lunch break. CNA 4 stated she got a text message when she was on break that Resident 1 had fallen. CNA 4 stated she came back inside the building and saw Resident 1 on the floor over by Room A on the north side of the building. CNA 4 stated Resident 1 had self-propelled in the wheelchair, "Pretty far from her room." CNA 4 stated they were a "skeleton crew" at night and did not have as many staff present and in the hallways, as during the daytime. CNA 4 stated putting Resident 1 into the wheelchair while agitated and leaving the resident unsupervised was, "The worst idea [CNA 2] could have had." On 10/3/23 at 1:01 P.M., a telephone interview was conducted with CNA 2. CNA 2 stated she no longer worked for the facility. CNA 2 stated she had been assigned to provide care to Resident 1 on 8/17/23. CNA 2 stated CNA 4 had been her partner during that time and that CNA 4 had agreed to watch Resident 1 while she went on a lunch break. CNA 2 stated Resident 1 had fallen while she on her lunch break and under the care of CNA 4. CNA 2 stated Resident 1 was confused and would carry around stuffed toys that the resident thought were babies. CNA 2 stated Resident 1 had been agitated and was trying to get out of bed that night. CNA 2 was asked if she had reported Resident 1's agitation to the licensed nurse (LN). CNA 2 stated she, "Told [LN 5] who just said 'okay' and didn't really listen." CNA 2 stated she decided to place Resident 1 into her wheelchair and leave the resident unattended in the hallway because she had seen other staff do that on previous occasions. CNA 2 stated, "I trusted [CNA 4] to watch [Resident 1] when I went to lunch." CNA 2 then stated when she returned from lunch, she saw Resident 1 sitting in the wheelchair in the hallway. CNA 2 further stated she went into another resident's room to provide care and heard a "loud boom," and saw that Resident 1 had fallen in the hallway. CNA 2 was informed this statement was inconsistent with her previous statement. CNA 2 was asked to clarify if Resident 1 fell during her lunch break or while providing care to another resident. CNA 2 did not provide an answer and the interview was ended. On 10/4/23 at 8:58 A.M., a telephone interview was conducted with LN 5. LN 5 stated she was familiar with Resident 1 and that the resident was not confused but was alert and oriented. LN 5 was informed her statement did not match the resident's medical records that indicated Resident 1 had cognitive impairment. LN 5 was asked to clarify. LN 5 then stated Resident 1 was "very confused" and "not very alert." LN 5 was asked about Resident 1's fall incident that occurred on 8/17/23. LN 5 stated she did not recall Resident 1 having any fall during her shift and that she did not think that Resident 1 had been her assigned resident. LN 5 was informed she was on the sign-in sheet and assigned to Resident 1 on 8/17/23. LN 5 stated, "Well that's in August and I can't remember that far back." LN 5 was informed that according to Resident 1's medical record the resident had profuse bleeding from the head after the fall and first aid had been rendered. LN 5 then stated she remembered the fall incident and that Resident 1, "Wasn't really bleeding." LN 5 stated she had, "Performed an operation on [Resident 1's] eye and put stitches." LN 5 was asked to clarify that statement. LN 5 stated, "Okay, that was at the hospital." LN 5 then made some incoherent statements. LN 5 was asked if she was able to continue with the interview. LN 5 stated, "Yes." LN 5 stated CNA 2 had informed her that Resident 1 was agitated and trying to get out of bed. LN 5 was asked how she responded to CNA 2's concern. LN 5 then stated CNA 2 did not tell her anything that night. LN 5 was asked if she had provided any medications to Resident 1 that night for agitation or sleep. LN 5 stated, "I didn't give [Resident 1] anything that night not even Tylenol." LN 5 again stated she could not remember if she had worked that night. On 10/4/23 at 9:12 A.M., an interview was conducted with the director of nursing (DON) related to the telephone interview that was conducted with LN 5. The DON was informed that LN 5 made contradictory and incoherent statements during the interview and the LN was unsure if she had worked the night of 8/17/23. The DON stated LN 5 was the LN responsible for Resident 1 on 8/17/23 and had been present during the resident's fall incident. The DON stated she spoke to LN 5 about Resident 1's fall and, "[LN 5] knows about the fall." On 10/4/23 at 9:45 A.M., a continuous observation was conducted beginning in the hallway outside of Resident 1's assigned room (Resident 1 was not currently in the facility). Resident 1's room was located on the south end of the building. Room A (where CNA 4 stated the resident's fall occurred) was observed on the opposite end of the building on the north side (same hallway). In between Resident 1's assigned room to where the fall was reported to have occurred (Room A), there was the kitchen, laundry, dining hall, staff lounge, and other resident rooms. On 10/4/23 at 10:05 A.M., a joint interview and record review was conducted with LN 6. LN 6 stated Resident 1 was confused, frail, and had become weaker over the last several months. LN 6 stated Resident 1 tended to lean forward while in the wheelchair and required supervision when seated in the wheelchair. LN 6 reviewed Resident 1's medication administration record for 8/16/23 at 9 P.M. and stated the resident had received trazodone (medication that can make a person sleepy) and melatonin (a sleep aid). LN 6 stated those medications could have made Resident 1 drowsy and unable to safely sit in her wheelchair. LN 6 reviewed Resident 1's ADL care plan revised 6/8/23 and MDS assessment dated 6/3/23, and stated the resident required one staff to assist when the resident was in her wheelchair performing locomotion. LN 6 stated Resident 1's MDS assessment and ADL care plan should have been followed. LN 6 further stated Resident 1 should not have been placed in her wheelchair and left unsupervised at night. LN 6 stated Resident 1 should not have been permitted to perform locomotion in her wheelchair alone. On 10/4/23 at 11 A.M., a joint interview and record review was conducted with the minimum data set assessment nurse (MDSN). The MDSN stated Resident 1 had a "multiple fall history." The MDSN reviewed Resident 1's MDS assessment dated 6/3/23, and stated extensive one person assistance for locomotion meant a staff member had to be present and holding the wheelchair handles while guiding the resident in their wheelchair. The MDSN stated the required