Health inspection·March 12, 2025

The following reflects the findings of the California Department of Public Health during the investigation of a facility reported incident number 925239. The inspection was limited to the specific facility reported incident investigated during an investigation of a facility reported incident and does not represent the findings of a full inspection of the facility. A deficiency was issued for facility reported incident number 925239 at F tag 689/G. 42 Code of Federal Regulations part 483.25 Quality of care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (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: (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. California Code of Regulations, Title 22, section 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. California Code of Regulations, Title 22, section 72543. Patients' Health Records. (f) Patients' health records shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each patient. Based on interview and record review, The facility failed to implement policies and procedures (P&P) titled, "Fall Management Program," for one of three sampled resident (Resident 2) when the facility failed to: 1. Complete the Post Fall Evaluation (PFE- document to help identify possible causes of a fall and prevent future falls). 2. Develop a care plan (a person-centered plan of care outlining a person's needs and how they will be addressed) to prevent future falls for Resident 2. These failures resulted in Resident 2 sustaining at least five ground-level falls in a five-month period, and Resident 2 sustaining a left intertrochanteric (between greater and lesser trochanter regions) femoral (thigh bone) fracture (broken bone) requiring surgical intervention. Findings: On 10/22/24, at 10:45 a.m. an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Resident 1's fall with fracture. 1. During a review of Resident 2's "Admission Record," (AR) the AR indicated, Resident 2 was an 87 year old male, admitted on 10/31/23, with diagnoses including Dementia (a decline in mental ability that affects a person's daily life; characterized by a loss of cognitive functioning such as thinking, remembering, and reasoning, that worsens over time) and Bipolar disorder (a serious mental illness that causes extreme shifts in mood, energy, thinking, behavior, and sleep). During a review of Resident 2's annual "Minimum Data Set," (MDS - an assessment tool) dated 7/30/24, the MDS indicated, Resident 2's BIMS (Brief Interview for Mental Status with a range of scores from 0-15)) score was 3 (a score of 0-7 suggests the resident has severely impaired cognition). The MDS indicated Resident 2 needs supervision or touch assistance (helper provides verbal cues and/or touching/steading and/or contact guard (staff provides a light touch to help a resident with balance while resident perform a task) assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) chair/bed-to-chair transfer (the ability to get to and from a bed to a chair (or wheelchair), and walk 50 feet (once standing the ability to walk at least 50 feet and make two turns). During a review of Resident 2's "Change of Condition," (COC) dated 6/20/24, the COC indicated Resident 2 had an unwitnessed fall (fall not observed by staff) in his room. Resident 2's "Post Fall Evaluation," (PFE) dated 6/20/24, was reviewed. The PFE under the Care Planning and Clinical Suggestions section were not completed (blank). During a review of Resident 2's "COC," dated 7/25/24, the COC indicated Resident 2 had an unwitnessed fall. The COC indicated, "Received report from PM staff (Resident 2) sustained a fall. Upon walking into room resident lying in bed resting. Upon assessing (Resident 2), noticed small amount of blood to back of the head. Small laceration (cut or tear in the skin) noted. . .Recommendation of Primary Clinicians . . . Send to ER (emergency room) for further Eval (evaluation)". Resident 2's PFE dated 7/25/24, was reviewed. The PFE under Fall Details, Contributing Factors, Medication Changes, Physical Findings, MDS, Care Planning, and Clinical Suggestions sections were not completed (blank). During a review of Resident 2's "COC," dated 9/1/24, the COC indicated Resident 2 had an unwitnessed fall exiting the restroom. The COC indicated, "(Resident 2) was observed with blood on face and floor, . . . Ambulance called and sent to (acute hospital) for further evaluation." Resident 2's PFE dated 9/1/24, was reviewed. The PFE under Fall Details was noted as incomplete. The PFE under Contributing Factors, Medication Changes, Physical Findings, MDS, Care Planning, and Clinical Suggestions sections were not completed (blank). During a review of Resident 2's "COC," dated 9/16/24, the COC indicated Resident 2 had an unwitnessed fall on the right side of Resident 2's bed. Resident 2's PFE dated 9/16/24, was reviewed. The PFE under Fall Details, Contributing Factors, Medication Changes, and Physical Findings were noted as incomplete. The PFE under Care Planning, and Clinical Suggestions sections were not completed (blank). During a review of Resident 2's "COC," dated 10/13/24, the COC indicated Resident 2 had an unwitnessed fall in the facility hallway. Resident 2's "Change of Condition Follow-Up Note," (COCFUN) dated 10/13/24, indicated, "(Resident 2) had complaints of pain (pain scale not indicated) to left leg. . . (Resident 2) was transferred to (acute hospital) for further evaluation and treatment." Resident 2's PFE dated 10/13/24, was reviewed. The PFE under Fall Details were noted as incomplete. The PFE under Contributing Factors, Medication Changes, Physical Findings, MDS, Care Planning, and Clinical Suggestions sections were not completed (blank). During a review of Resident 2's hospital record, dated 10/13/24, the record indicated Resident 2 sustained an acute (sudden in onset) mildly displaced (out of alignment) left intertrochanteric femoral fracture. The record indicated Resident 2 had surgical repair of left intertrochanteric femoral fracture on 10/14/24. During an interview on 10/22/24 at 1:44 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated "Post evaluations (PFE) are completed to find the reason for fall, so the resident's care plan can be updated to prevent future falls." During a concurrent interview and record review on 11/19/24 at 12:19 p.m. with Director of Nursing (DON), Resident 2's PFE dated 6/20/24, 7/25/24, 9/1/24, 9/16/24, and 10/13/24, were reviewed. DON confirmed the post falls evaluations (PFE) were not completed for the above fall incidents. DON stated, "Post fall evaluations (PFE) information was used to develop care plans to prevent future falls." 2. During a concurrent interview and record review on 11/19/24 at 12:19 p.m. with DON, Resident 2's "COC," dated 6/20/24, 7/25/24, 9/1/24, 9/16/24, and 10/13/24 were reviewed. DON stated Resident 2 had multiple falls. Resident 2's care plan with the focus on "(Resident 2) is at high risk for falls related to Dementia, Gait instability (an abnormal, uncoordinated, or unsteady walking pattern) and history of recurrent falls," date initiated 10/31/23 was reviewed. There was no care plans developed for the fall incidents on 6/20/24, 7/25/24 and 9/1/24. DON confirmed care plans were not developed after Resident 2's fall incidents on 6/20/24, 7/25/24, and 9/1/24. During a review of the facility's P&P titled, "Fall Management Program," revised 3/13/21, the P&P indicated, "To provide residents a safe environment that minimizes complications associated with falls . . . Post-Fall Response A. following every resident fall, the licensed nurse will perform a post fall evaluation and update, initiate, or revise the Resident's care plan as necessary . . .D. Once the Post-Fall Huddle is completed the licensed nurse will immediately update the care plan with recommendations E. The Post-Fall Huddle form and documentation of the post-fall investigation will go to the IDT (Interdisciplinary Team - group of professionals who assess, coordinate, and manage each resident's comprehensive needs) meeting for review Fall investigation, Reporting and Documentation A. Following a resident fall, the licensed nurse with the most knowledge of the incident will complete an incident and Accident Report . . . C. The IDT will investigate the fall including a review of the Resident's medical record, post-fall huddle and review of the incident and Accident Reports D. The IDT will review the circumstances surrounding the fall them summarize their conclusions on an IDT note . . . prevent more falls, the IDT will review and revised the care plan as necessary". In violation of the above cited standards, the facility failed to investigate the cause of Resident 2's repeated falls and develop and implement Resident 2's person centered comprehensive fall risk care plan. This resulted in Resident 2's repeated falls and Resident 2 sustaining a fracture of the left intertrochanteric femoral fracture requiring surgical repair and, unnecessary hospitalization, and pain. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm to Resident 2 would result and constitutes to a Class A citation.