Health inspection·October 4, 2023

The following reflects the findings of the California Department of Public Health during the investigation of ERI CA00834854. Class B Citation 42 CFR 483.25 (d) (1) (2) at F689 The facility must ensure that a (1) The resident environment remains as free from accident hazards as is possible, and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22CCR 72315 (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. On 2/27/2023, an unannounced visit was conducted at the facility to investigate a complaint regarding a resident fall with injury. The facility failed to provide adequate supervision to Resident 3 when there was no nursing care plan initiated to prevent an accidental fall or new intervention in place following Resident 3?s fall. Resident 3 was a 77-year-old male admitted to the facility on 6/21/2016, with a history of falls, muscle weakness, Wernicke?s Encephalopathy (a neurological disorder caused by thiamine deficiency, marked by mental confusion, unsteady gait, cognitive communication deficit, and difficulty walking. Resident 3 was readmitted to the facility on 3/27/2023 after a 7 day stay in the General Acute Care Hospital with diagnosis which included Intracranial Injury with Loss of Consciousness, Traumatic Subdural Hemorrhage, and multiple skin tears. The facility failed to follow their Policy and Procedures for Falls and for Nursing Care Plans for implementing measurable and time limited goals to safeguard the resident from future falls. During a review of Resident 3's Progress Note dated 3/20/2023 at 12:35 a.m., (fall event number one). The Progress Note indicated the Registered Nurse (RN) was called to resident's room approximately 12:30 a.m. and on entering room, resident was found lying on the floor on the right side of his bed on his back. Upon assessment [Resident 3] was noted to be bleeding from the back of his head and his left eyebrow where he sustained a laceration, no loss of consciousness noted, alert with confusion, pressure applied to bleeding laceration, 911 was called and pt [patient] was taken to the Emergency Department (ED) at a [local General Acute Care Hospital-GACH]. During a review of Resident 3's Progress Note dated 3/20/2023 2:45 a.m. (fall event number two) the Progress Note indicated Pt (patient-Resident 3) had an unwitnessed fall at 1:00 a.m. Resident 3 was yelling help from his room. Two Certified Nursing Assistants (CNAs) responded to his room and found him lying face down with blood on the floor. Resident 3 was lying on the floor on the right side of the bed, with a chair between the window and the bed. Two nurses responded and found Resident 3 on his back, with large amounts of blood on floor surrounding the resident. Resident 3 had a laceration to the left elbow, under L (left) eye, L eyebrow and back of head. Resident 3 was unable to state how he fell or what caused him to fall. Pt was lifted by four CNA's and the paramedics onto a gurney and taken to the acute care hospital by ambulance. During a review on 4/13/2023 of Resident 3's Face Sheet (FS) dated 4/13/2023, the FS indicated, Resident 3 is a ?77-year-old and was initially admitted to the facility on 6/21/2016, with a history of falls ...muscle weakness ...Wernicke's Encephalopathy (a neurological disorder caused by thiamine (a nutrient in the vitamin B complex that the body needs in small amounts to function and stay healthy) deficiency.??...cognitive communication deficit (difficulty with thinking and how someone uses language) ......difficulty walking ..." Resident 3 was re-admitted to the facility on 3/27/2023, (after a hospital stay from 3/20/2023 to 3/27/2023 of seven days), with diagnoses which included " ...Intracranial Injury (injury to the skull following a head strike) with Loss of Consciousness (fainting) ...Traumatic Subdural hemorrhage (bleeding in the area between the brain and the skull) with loss of consciousness ...fall ...Fracture ...cervical vertebra [bone] ...base of skull...orbit, ... Laceration (cut) of head ...? During a concurrent interview and record review on 4/14/2023 at 9:15 a.m., with Minimum Data Set Coordinator (MDSC) 1 of Resident 3's "Risk History report (history of reported events (such as falls, injury or behavioral)) dated 4/14/2023," MDSC 1 stated Resident 3 had a long history of both witnessed and unwitnessed falls. MDSC 1 stated the last reported fall (unwitnessed) was on 12/2/2022. The Risk History report indicated Resident 3 had an unwitnessed fall on 12/2/2022, 1/15/2022, 12/6/2021, 6/15/2021, 6/7/2021, 1/30/2021, 1/29/2021, 1/28/2021, 1/27/2021, 9/2/2017, 4/21/2017. The report indicated Resident 3 had a witnessed fall on 10/30/2021- with head injury, 1/27/2021, 11/23/2019- with head injury, 9/25/2017- with head injury. During a concurrent interview and record review on 4/14/2023 at 9:15 a.m., with MDSC 1, of Resident 3's MDS assessment dated 1/1/2023, MDSC 1 stated Resident 3's MDS Section C- Brief Interview of Mental Status (BIMS) scored 6 of 15 points (indicating severe cognitive impairment in decision making ...). The MDS Section G indicated Resident 3 needed a one-person physical assistance for all Activities of Daily Living (ADLs). MDSC 1 stated the care planning expectation was to have nurses develop, review, and update the care plan daily and as needed. The care plans for resident records reviewed were not comprehensive or resident-centered for residents. The interventions were generic and not specific to the needs of the resident. The care plans were too broad, needed measurable outcomes and goals like instead of frequent rounding the nurses should state every 30 minute or hourly rounding to prevent accidents. The nurses should anticipate the needs of the resident and state how staff were to accomplish this and currently this was not done. During an observation on 4/14/2023, at 10:20 a.m., in Resident 3's room, Resident 3 was lying in bed, on his back. Resident 3 had eyes open, responded to name, nodded, and smiled, but did not speak. Resident 3 held a brown ball, about the size of a golf ball, in his right hand. This ball was presumed to be feces as there was a strong odor in the room and brown substance smeared on Resident 3's hands, clothing, and sheets. During a review of Resident 3's [facility name] Facility Risk Evaluation (FRE)," dated 12/2/2022 the FRE indicated Resident 3 was a "low risk for falls. The document indicated, ? ...resident had an unwitnessed fall while attempting to transfer self to the restroom without assistance. Resident was in wheelchair and did not lock the breaks when transferring resulting in a head injury to the right side of head, x-ray has been ordered. Resident also has skin tear on the right elbow. Resident also has complained of pain to the left knee no skin tear noted ..." During a review of Resident 3's FRE, dated 3/27/2023, indicated Resident 3 was a moderate to high risk for falls. During a concurrent interview and record review on 4/14/2023 at 9:15 a.m., with MDSC 1 of Resident 3's "Care Plan (CP)," dated 3/27/2023, the CP indicated, " ...Resident had an unwitnessed fall with injury 3/20/2023 ..." " ...Date initiated: 3/20/2023 ...Goal [Resident 3] will have no further complications r/t [related to] fall until next review date ... Date Initiated: 3/20/2023 ...Target Date: 4/11/2023 ...Interventions ...frequent room check for safety ... prompt response to call light for assistance ..." MDSC 1 stated the problem with these interventions was they were not specific enough. MDSC 1 stated that as written, the current care plan interventions indicating "frequent," and "prompt" left the timing open to individual interpretation versus clear instruction for how often the staff should be checking for safety. The MDSC 1 stated that what frequent or prompt means to one person may not be the same to another. The MDSC 1 stated that Resident 3's history and risk of falls in the facility both witnessed and unwitnessed, was known to licensed nurses. The MDSC 1 stated Resident 3's CP did not address this history and risk for falls before the 3/20/2023 fall with injury. MDSC 1 provided an electronic version of Resident 3's CP for Focus ...Long Term/Custodial Placement, initiated 1/13/2022, which indicated history of falls with fracture to right hip but did not address fall prevention/safety interventions. The facility was not able to provide any documentation of care planned fall prevention interventions prior to 3/20/2023. Review of ?Care Plans, Comprehensive Person-Centered? Policy indicated: 7. The comprehensive, person-centered care plan: a. includes measurable objectives and time frames.? During a record review of Resident 3's Progress Notes dated 4/27/2023, the Progress Note indicated the resident had an unwitnessed fall on 4/27/2023 at 2:00 a.m. while attempting to self-transfer to a wheelchair. The physician ordered Resident 3 to be sent to the Emergency Room (ER) after he sustained an unwitnessed fall resulting in multiple skin tears to the right arm. The progress note indicated staff said the resident had a change in baseline mentation after a fall in which the resident stated he was trying to get to his wheelchair. During an observation on 4/28/2023 at 10:41 a.m., Resident 3 was lying in bed with a neck brace on his neck. During a concurrent interview and record review with MDSC 1 of Resident 3?s care plan indicated Resident 3 was independent in bed mobility, had not been updated since 2020. MDSC 1 stated not having a correct and updated care plan placed the resident at a greater risk for falls with injury. The MDSC stated Resident 3 had two falls ?this week? even though there was only one documented fall in the record. The MDSC stated on 4/27/2023 Resident 3 had an unwitnessed fall trying to get to his wheelchair. He had another fall that same day which was not documented. During an interview on 5/25/2023 at 11:37 a.m. with CNA 1, CNA 1 stated Resident 3 had two falls on 4/27/23 and was taken to the General Acute Care Hospital (GACH) for evaluation. CNA 1 stated Resident 3 was readmitted later that day with a neck brace. CNA 1 stated Resident 3 had been at the facility for approximately six years and had recently had a decline in status. CNA 1 stated he was able to walk but now he kept falling. During a concurrent observation and interview on 5/25/2023 at 11:58 a.m., with Resident 3 in Resident 3's room, Resident 3 was lying on his back in his bed with a brace on his neck. The privacy curtain was pulled around Resident 3 blocking him from view to staff at the Nurse's Station and from the hall. When asked Resident 3 was asked if he remembered falling, he pointed to the floor. Resident 3 did not speak. Review of Resident 3?s GACH Trauma Admission record, dated 3/20/23 at 3:22 a.m., report indicated, ??Patient presents as a victim of falling from the ground?Patient initially had complaints of facial pain, headache, neck pain?Pertinent History of Current Problem, traumatic brain injury 3/20/23?orbital fracture?Cervical stress fracture 3/20/23?Change in Status/Orders?ORIF (Open Reduction Internal Fixation-surgical procedure) repair of left eyebrow laceration?Increased oxygen requirement overnight?? During an interview and record review on 5/25/2023 at 12:53 p.m., with MDSC 1, the "Fall Check List was reviewed." The Fall Check List indicated; the steps required after each resident fall. The document indicated, "Risk Management Entry ... Fall Evaluation ...: Care Plan with Immediate Fall Intervention ..." MDSC 1 stated the facility was not following the facility's Fall Policy and Procedures (P&P) or the Care Plan P&P. MDSC 1 stated there were no new planned interventions put into place for Resident 3 following Resident 3?s falls on 4/27/2023. As a result of the facility?s failure to follow their P&Ps for Care Planning and Falls Resident 3 fell and sustained Traumatic Subdural hemorrhage (bleeding in the area between the brain and the skull) with loss of consciousness ...fall ...Fracture ...cervical vertebra [bone] ...base of skull...orbit... Laceration (cut) of head ...? This violation had a direct or immediate relationship to the health, safety, or security of Resident 3.