Health inspection·May 9, 2023

The following reflects the findings of the California Department of Public Health during the investigation of a Facility Reported Incident. Representing the Department: Health Facilities Evaluator Supervisor 21052 State Citation B was written. § 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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. On 2/10/23 at 8:34 A.M., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Resident 1's fall and sustained a sacral fracture (a break on the large, triangle-shape bone in the lower spine that forms part of hip). The facility failed to accurately assess Resident 1's risk for fall upon admission. In addition, the facility failed to develop a care plan that addressed Resident 1's fall risk and initiate fall preventative intervention to prevent Resident 1 from falling. As a result, Resident 1 fell and sustained a sacral fracture that caused the resident to experience severe pain. A review of Resident 1's undated Admission Record indicated Resident 1 was admitted to the facility on 1/20/23 with diagnoses that included history of falling. A review of Resident 1's History and Physical, dated 1/20/23, indicated that Resident 1 had generalized weakness and a history of fall. A review of Resident 1's nursing progress notes, dated 2/2/23, indicated that on 2/1/23 at "approximately midnight to 1 am", Resident 1 walked to the bathroom without calling for assistance and fell. According to the same record, Resident 1 was sent to the hospital on 2/1/23. An interview and joint record review of Resident 1's Fall Risk Assessment was conducted with licensed nurse (LN) 1 on 2/10/23 at 1:53 P.M. LN 1 remembered Resident 1 and confirmed that she conducted and completed Resident 1's Fall Risk Assessment on 1/20/23. LN 1 stated, prior to Resident 1's admission to the facility, Resident 1 was treated at the hospital due to a fall that Resident 1 experienced at home. LN 1 stated she had access to Resident 1's hospital medical record and that she (LN 1) knew about Resident 1's history of fall. LN 1 reviewed Resident 1's Fall Risk Assessment completed on 1/20/23. LN 1 stated that Resident 1 scored "8", which according to the Fall Risk Assessment document, dated 1/20/23, a score of 0-8 meant low risk. Further review of the document indicated that Resident 1 did not take any medications, such as antihypertensives (medications use to treat high blood pressure), anticonvulsants (medications for uncontrolled body movement), and psychotropics (medications that affect mental function and behavior) that could be considered contributors to falls. However, a review of Resident 1's hospital visit summary, dated 1/20/23, indicated that Resident 1 took antihypertensive, anticonvulsant, and psychotropic medications while at the hospital, prior to being admitted to the facility. LN 1 stated the Fall Risk Assessment, completed on 1/20/23, was inaccurate. LN 1 acknowledged that if she marked the three medications that Resident 1 took at the hospital, Resident 1 would have been assessed as "moderate risk for fall". An interview and joint record review of Resident 1's care plan was conducted with LN 1 on 2/10/23 at 2:05 P.M. LN 1 reviewed Resident 1's care plan but could not locate a care plan related to Resident 1's risk for fall. LN 1 could not locate documentation of fall preventative measures initiated prior to Resident 1's fall incident on 2/1/23. LN 1 stated fall preventative interventions should have been initiated for Resident 1 on admission to help prevent fall incidents. A review of Resident 1's Emergency Department Note, dated 2/1/23, indicated that Resident 1 was taken to the emergency department with a complaint of "severe buttock pain" after an "unwitnessed fall". A review of Resident 1's CT (a medical imaging technique used to obtain detailed internal images of the body) of the Pelvis, completed at the hospital on 2/1/23, indicated, "acute transverse fractures involving the S4 and S5 vertebra (two bones on the tailbone broke horizontally to its length)". An interview with Assistant Director of Nursing (ADON) 1 was conducted on 3/13/23 at 8:55 A.M. ADON 1 stated that Resident 1's Fall Risk Assessment, completed by LN 1 on 1/20/23, was inaccurate. The ADON stated Resident 1 should have been placed at a high risk for fall on admission due to the resident's fall incident at home, prior to going to the hospital. ADON 1 stated fall preventative measures should have been started for Resident 1 immediately on admission to help prevent fall incidents. ADON 1 stated it was important for residents to have accurate fall assessments so staff could initiate appropriate fall preventative measures. ADON 1 also stated that initiating fall preventative measures timely was important to help prevent fall incidents. A review of the facility's policy and procedure titled Fall Risk Assessment, revised March 2018, was conducted. The policy indicated, " ...1. Upon admission, the nursing staff and the physician will review a resident's record for history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling overtime. 2. The nursing staff will ask the resident and/or his/her family about any history of the resident falling. ..." A review of the facility's policy and procedure titled Managing Falls and Fall Risk, revised March 2018, was conducted. The policy indicated, "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling." The policy also indicated, " ...1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls." These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.