Health inspection·February 19, 2025

Windsor Hampton Care Center Event ID: WRDW11 1/16/25 FRI: CA00926227 at F-689 (G). A citation Regulations: Code of Federal Regulations, Title 42, Section 483.25(d) Accidents. The facility must ensure that - (d)(1) The resident environment remains as free of accident hazards as is possible; and (d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 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. (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 72523 - Patient Care Policies and Procedures (a) Written patient care and policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 1/16/25, an unannounced visit was conducted at the facility to investigate a Facility Reported Incident of a resident fall with injury. The department determined the facility failed to ensure an environment free of accidents or hazards when Resident 1 fell forward to the floor while being pushed in a wheelchair that lacked a footrest. This failure resulted in Resident 1 sustaining injuries to the left knee, left side of the forehead and a fracture (break) of her left leg. Resident 1 was admitted to the facility with diagnoses which included type 2 diabetes mellitus (a chronic condition in which the body has trouble controlling blood sugar levels), dysphagia (difficulty swallowing), and bipolar disorder (a mental health disorder which causes dramatic shifts in mood, energy, and activity levels). Resident 1 was dependent for transferring from the bed to the wheelchair and depended on staff for mobility while in the wheelchair. A review of Resident 1's "Interdisciplinary Team Progress Notes," (IDT- a team of professional staff or a care team consisting of different disciplines working together towards the goals of the residents) dated 10/15/24, indicated, "...Type of IDT Care Conference: Fall Incident...Date and Time of Fall Incident: 10/14/2024 10:49 [a.m.]...Fall Report (brief summary of the incident): Resident was being wheeled in the hallway when her left shoe gripped the floor causing her to fall forward. On initial assessment, resident sustained skin tear [a rip in the skin causing injury] to left knee and below knee including bruising to left side of forehead. Resident was sent out to ED [emergency department]. Resident returned to facility with diagnosis of left tibia [the larger of two bones between the knee and the ankle] fracture...Current functional level. Resident requires assistance with...Transfers...Ambulation [walking]...Dressing...Toilet use...Hygiene...Safety Review/Risk Factors...Other: Resident requires 1 person assist with ADLs [activities of daily living (grooming, toileting, dressing)] and transfers [moving from bed to chair]. Resident mostly stays in bed and requires maximum assistance with wheelchair mobility..." A review of Resident 1's "[Acute Care] Emergency Documentation," dated 10/14/24, indicated, "...Diagnostic Radiology [a branch of medicine that uses non-invasive imaging to locate and identify certain conditions and diseases]...Report...Procedure Date: October 14, 2024...Exam...Knee 3V [view]...LT [left]...IMPRESSION...tibial [tibia] ...fracture...joint effusion [swelling of a joint] and soft tissue swelling..." During an interview by phone on 1/3/25, at 10:37 a.m., Resident 1's Responsible Party (RP) stated that the Restorative Nursing Assistant (RNA) pushed the wheelchair too fast. The RP further stated the RNA did not put the left leg rest on the wheelchair. The RP stated that she believed Resident 1's left leg got tired, and her leg slipped down, then the wheelchair tipped (on 10/14/24). The RP further stated Resident 1 was afraid to get up on her feet because of pain but felt that [Resident 1] needed to progress with therapy so that she could return home. During an interview on 1/3/25, at 11:35 a.m., Certified Nursing Assistant (CNA) stated she heard about Resident 1's fall (on 10/14/24). CNA further stated Resident 1 got up out of bed with assistance since she fell. During an interview on 1/3/25, at 11:36 a.m., Licensed Nurse (LN) 1 stated she was in the facility on the day that Resident 1 fell (on 10/14/24) but did not witness the event. LN 1 further stated Resident 1 loved bingo but had not been to bingo very much since she fell. LN 1 stated Resident 1 also liked talking with staff at the nurses' station but had not been up to the nurses' station since she fell. During an interview on 1/3/25, at 11:40 a.m., with Resident 1 in her room, Resident 1 stated that she had not been up in a chair or to bingo for a while. Resident 1 further stated her leg went under the wheelchair then she fell forward. Resident 1 stated that (RNA 1) was pushing the wheelchair when she fell (on 10/14/24). Resident 1 stated she had not been in the wheelchair since she fell and was receiving physical therapy in her room. During an interview by phone on 1/3/25, at 12:16 p.m., RNA 1 stated that she remembered the incident when Resident 1 fell (on 10/14/24). RNA 1 further stated that she picked Resident 1 up for physical therapy in her room. RNA 1 stated Resident 1 was already up in the wheelchair dressed and ready. RNA 1 further stated that she did not check to see if the left footrest was on the wheelchair but should have checked. RNA 1 stated that she pushed the wheelchair down the hallway and Resident 1's left foot got tangled with her right foot and Resident 1 fell out of the wheelchair. RNA 1 further stated that she got an LN to help get Resident 1 off the floor. RNA 1 stated that the footrests should always be on the wheelchair. RNA 1 further stated that the incident would have been avoided if the left footrest was on the wheelchair. During an interview on 1/3/25, at 12:47 p.m., LN 2 stated the expectation was that before residents were transported by wheelchair, staff would check the arm rests, footrests, cushions if the resident needed a cushion, and checked to make sure the wheelchair was well functioning before residents were transported. LN 2 further stated that if the footrests were not on the wheelchair, the risk was that the resident's foot could get caught on the floor, and the resident could fall forward and sustain an injury. During an interview by phone on 1/3/25, at 2:22 p.m., RNA 2 stated that she remembered Resident 1. RNA 2 further stated the wheelchair should have both footrests in place before residents were transported. RNA 2 stated that the risk was the resident may fall. During an interview by phone on 1/3/25, at 3:11 p.m., Resident 1's physician (MD) stated that he remembered the incident. The MD further stated that when Resident 1 fell, it was a "shock to the system." The MD stated after a fall, residents sometimes tried to be more careful not to fall, or became less active or depressed. During an interview by phone on 1/16/25, at 9:50 a.m., the Director of Nursing (DON) stated she was made aware by staff after Resident 1's fall occurred (on 10/14/24). The DON further stated that the left footrest should have been on Resident 1's wheelchair. The DON stated that she felt that the fall interfered with Resident 1's quality of life. The DON further stated that the accident was preventable. During a concurrent interview and record review on 1/16/25, at 10:30 a.m., the Activities Director (AD) stated that she was in the facility when Resident 1 fell, but did not witness the fall. The AD further stated that she visited Resident 1 in her room after she came back from the hospital. The AD stated Resident 1 had told her that she needed to heal and receive therapy before participating in activities in the Activity Room. During a follow-up concurrent interview and record review on 1/16/25, at 11 a.m., Resident 1's "Activity Records (documentation of Resident 1's participation in facility activities)" for October, November, and December 2024 were reviewed with the AD. The AD stated Resident 1 attended activities regularly until she fell. The AD further stated that when Resident 1 returned to the facility after the fall in October 2024, Resident 1's participation in activities decreased. The AD stated that she did one-on-one visits (meeting or interaction between only two individuals regarding a specific need, concern or interest) with Resident 1 in October 2024 when she returned to the facility to encourage her to participate in activities when she saw a decrease in Resident 1's participation. A review of a facility document titled, "Restorative Nursing Assistant," revised October 2020, indicated, "...The primary purpose of these positions is to perform restorative nursing procedures [nursing interventions that promote the resident's ability to adapt and adjust to living as independently and as safely as possible] that maximize the resident's existing abilities, emphasize independence instead of dependence and minimize the negative effects of disability...Duties and Responsibilities...Personal Nursing Care Functions...Essential Functions ...Observe body alignment of all residents in bed, chairs and wheelchairs...Monitor wheelchair-bound residents to ensure proper use, positioning and fit of leg extenders and footrests...Follow appropriate safety...measures..." A review of a facility policy and procedure (P&P) titled, "Repositioning," revised May 2013, indicated, "...The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed-bound or chair-bound residents...Evaluation...Components to evaluate when a resident is in a chair...Does the resident need intervention to maintain postural alignment [refers to how the head, shoulders, spine, hips, knees, and ankles relate and line up with each other]...Does the resident need devices to maintain sitting balance [ability to maintain the seated posture without falling over. To get a balanced sitting position, choose a chair that supports your spine, adjust the chair height so that your feet rest flat on the floor, or use a footrest so that your thighs are parallel to the floor]..." The department determined the facility failed to ensure an environment free of accidents or hazards when Resident 1 fell forward to the floor while being pushed in a wheelchair that lacked a footrest. This failure resulted in Resident 1 sustaining injuries to the left knee, left side of the forehead and a fracture of her left leg. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1 and is an A citation.