Other·June 15, 2021

T22 C 830 72311(a)(1)(A) The facility failed to identify the care needs of Resident 1 and to revise and implement the plan of care to prevent recurrent falls. This failure resulted in Resident 1 sustaining a second fall within ten hours of her first fall. The first fall, on 3/03/15 at 6:30 p.m., resulted in bruises and pain. The second fall, on 3/4/15 at 3:15 a.m., resulted in a fracture of the C2 vertebra (cervical vertebra which allows a person to turn the head: Neck bone), a subdural hematoma, (bleeding between the brain and the skull), which can cause pressure on the brain resulting in potential severe outcome (including death), extreme pain, and hospitalization in intensive care. On 3/14/16 at 9:35 a.m., the California Department of Public Health was notified that Resident 1 had been treated in an acute care hospital Emergency Room twice in ten hours, due to two falls at the Skilled Nursing Facility. The Complainant reported the second fall resulted in Resident 1 sustaining head trauma and placement for comfort care in the Intensive Care Unit, in the acute care hospital. Resident 1 was an 88 year-old female with diagnoses including pain, muscle weakness, difficulty in walking, and dementia (Dementia describes a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily functioning). The Admission Record, submitted by the facility, indicated Resident 1 was admitted to the Skilled Nursing Facility on 6/27/15. Resident 1's care plan, dated 6/27/15, revealed she was at, "risk for falls r/t (related to) unaware of safety needs," impulsive and frequent attempts to self transfer. The goal was that Resident 1 would be free of falls. Care plan interventions, dated 2/14/16, included: Anticipate and meet the resident's needs. No specific needs were identified. Other interventions included: Bed alarm in place while in bed, and frequent visual checks. The frequency of the visual checks was not defined. A document titled, "FSI - Fall Scene Investigation Report," dated 3/4/16, revealed Resident 1 was, "found on the floor." The document indicated: Resident 1 had a history of impulsive behavior and a diagnosis of dementia as the cause for the fall. The document noted staff responded to the bed alarm. The use of the alarm was not effective to prevent the first fall, but remained as a plan without revision or new interventions, after the fall. A facility document titled, "Fall Risk Assessment," dated 3/03/16 at 11:19 p.m., revealed Resident I was categorized as, "High Risk," for falls. A document titled, "eInteract Change in Condition Evaluation V4.1," effective date: 3/03/16 at 11:29 p.m., (after the first fall) revealed, "Apparently minor recent wound now developing redness, swelling, or pain." The document revealed the description of the wound as, left temple. Noted bump. Resident 1 was sent to an Emergency Room for evaluation. An Emergency Department Note, from the Acute Care Facility, dated 3/03/16 at 9:26 p.m., revealed Resident 1 would be discharged back to the facility with report to closely observe the patient and watch for mental status change. This instruction, for, "closely observing," was not transcribed to Resident 1's care plan. The Care Plan, entry of 2/14/16, indicated the use of an alarm when Resident 1 was in bed. A facility document titled, "FSI-Fall Scene Investigation Report2 V-3," dated 3/04/16 at 9:07 a.m., revealed a second unwitnessed fall. The document revealed, Resident 1 was sent back from the acute care hospital around 12:40 a.m., on 3/04/16, following an unwitnessed fall on 3/03/16, evening shift. The document revealed Resident 1 was found on the floor, face down, prone, lying at bedside around 3:15 a.m. on 3/04/16. The document indicated Resident 1 was, "alone and unattended." Question #13 addressed whether an alarm had been in use at the time of the fall and was answered as, "No." During a phone interview, on 5/13/16 at 11:50 a.m., Licensed Staff C stated Resident 1 had gotten up from bed by herself and fallen, "one to two hours," after a Certified Nursing Assistant (CNA) had helped toilet Resident 1. Staff C stated she had heard Resident 1 yelling, "Mama, Mama," and found her on the floor when doing her rounds, but did not state she heard the alarm. An acute care document titled, "Emergency Department Visit," dated 3/04/16 at 3:52 a.m., revealed Resident 1 appeared uncomfortable and screaming in pain. An Acute Care document titled, "Discharge Summary," dated 3/05/16, revealed Resident 1 had been brought to the Emergency Room, for the second time in a row because of falling. The document indicated Resident 1 fell out of bed at the facility with a bruise to the left forehead (a closed head injury), left hip and left forearm, on 3/03/16, and was discharged back to the facility. Resident 1 was transferred back to the Emergency Room, again on 3/04/16, with another fall. A Computed Tomography or Computed Axial Tomography (CAT Scan - uses a series of x-rays of the head taken from many different directions) showed Resident 1 had a 3 mm (millimeter) maximum thickness left frontotemporal (front and side of head) subdural hematoma (affecting the layers of tissue that surround the brain). The CAT of the C-spine (cervical spine) showed that she had a nondisplaced fracture of C2 (broken neck bone). A CAT Scan of the left lower extremity showed that she also had a moderate to large subcutaneous (under the skin) hematoma in the left thigh." Random Confidential interviews with six facility staff included statements that there was, "not enough help and it was the residents who suffered.....Staff tried to monitor residents by walking around the facility, peeking quickly into the rooms and moving on throughout the facility" to check on everyone, and residents were, "not getting the care they deserved," resulting in falls. The above violations had a direct or immediate relationship to the health, safety, or security of the patient.