Other·March 11, 2022

Provider: 056261 Bakersfield District Office Zeny Isla, HFEN Marika Walker, HFES Event ID: IHGT11 The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident number 760712 Free of Accident Hazards/Supervision/Devices §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, title 22 §72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure the patient related goals and facilities objectives are achieved. On 11/17/21, at 10 AM, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Resident 1's right leg fracture. Resident 1 is an 80-year-old male who was admitted to the facility on 4/12/19 with diagnoses of dementia (a group of conditions which cause damage to the brain resulting in difficulty making decisions, memory loss, impaired judgment, and interferes with daily functioning), depression (mental disorder), schizophrenia (serious mental disorder), and joint pain. Resident 1 has a history of falls, has had a decreased in mobility during his stay in the facility, requires extensive assistance in Activities of Daily Living including assistance in toileting. Based on observation, interview, and record review the facility failed to provide supervision for one of three sampled residents (Resident 1). This resulted in Resident 1 sustaining a right hip fracture from an unwitnessed fall in the bathroom. During an interview on 11/17/21, at 10:15 AM, with Administrator and Director of Nurses (DON), Administrator stated Resident 1 had an unwitnessed fall on 11/8/21. X-ray to right knee and hip was obtained due to complaint of pain. X-ray to right knee and hip indicated no fracture. On 11/10/21, Resident 1 was transferred to the acute hospital due to uncontrolled pain. Administrator stated hospital Computed Tomography (CT) scan report indicated a fracture to Resident 1's right hip. During an interview on 11/17/21, at 10:47 AM, with Registered Nurse (RN), RN stated on 10/8/21 at approximately 4:30 PM, he was at the nurse station when he was alerted by Sitter (non-licensed staff), that Resident 1 had an unwitnessed fall in the bathroom. RN stated he was told by the Sitter (individual assigned to another resident), Resident 1 was left in the bathroom without supervision. During an interview on 11/17/21, at 3:20 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 10/8/21, she assisted Resident 1 to the bathroom, placed him on the toilet, and left Resident 1 on the toilet while she continued to pick-up the evening meal trays from other rooms. CNA 1 stated, "He [Resident 1] said he needed to go number two [bowel movement], so I left him to give him privacy." CNA 1 stated Resident 1 was already on the bathroom floor being assessed by RN when she returned to check on Resident 1. CNA 1 stated "I was told not to leave him [Resident 1] alone. He's a high fall risk." During a concurrent observation and interview on 12/1/21, at 9:58 AM, Resident 1 was in his room lying down with eyes closed. CNA 2 was at Resident 1's bedside. CNA 2 stated Resident 1 required assistance in transferring and walking, "he's wobbly when walking or getting up." CNA 2 stated Resident 1 should never be left unsupervised when in the bathroom. During an interview on 12/1/21, at 10:03 AM, with CNA 3, CNA 3 stated Resident 1 didn't have a good balance and required assistance going to the bathroom. CNA 3 stated Resident 1 should not be left alone in the bathroom "because he [Resident 1] tries getting up and he's unsteady he can fall. He's a high risk for fall." During an interview on 12/1/21, at 10:10 AM, with Director of Staff Development (DSD), DSD stated Resident 1 was a high risk for fall and should not have been left in the bathroom by himself. DSD stated, "Staff are supposed to stay in the room with the bathroom door a little open just in case he gets up. His unsteady." During an interview on 12/1/21, at 12:05 PM, with Sitter, Sitter stated, he was assigned 1:1 (staff to resident direct observation) with Resident 2 when CNA 1 assisted Resident 1 to the bathroom and left the room with Resident 1 still in the bathroom. Sitter stated, "She [CNA 1] didn't say anything to me she just left the room." Sitter stated approximately five minutes after CNA 1 left the room, he heard Resident 1 fall in the bathroom. Sitter stated Resident 1's fall could have been prevented if CNA 1 "just stayed. . . [Resident 1] is unsteady, he will try to get up on his own, but he needs help." During a review of Resident 1's "Minimum Data Set" (MDS), dated 8/16/21, the MDS, Section C (Cognitive Patterns) BIMS score (Brief Interview for Mental Status-assessment score of cognitive functioning, score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired and 0-7 indicates severe cognitive impairment) for Resident 1 was3 which indicated Resident 1 was cognitively impaired. During a review of Resident 1's MDS, the MDS, Section G (Functional Status) indicated Resident 1 required extensive assistance in toileting, was "not steady, only able to stabilized with staff assistance" when moving on and off toilet. During a review of Resident 1's "Care Plan" (CP), date initiated on 9/1/20, the CP indicated Resident 1 had a decreased in mobility. Intervention included Resident 1 requiring "extensive assist with ADL [Activities of Daily Living] care . . . " During a review of Resident 1's CT scan, dated 11/11/21, the CT indicated Resident 1 had sustain a "Basicervical fracture of the right femoral neck [right hip fracture]." During a review of the facility's policy and procedure (P&P) titled, "Activities of Daily Living (ADL), Supporting," dated 2018, the P&P indicated, "2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: . . . c. Elimination (toileting)." During a review of the facility's policy and procedure (P&P) titled, "Safety and Supervision of Residents," dated 2017, the P&P indicated, "Individualized, Resident-Centered Approach to Safety . . .4. Implementing interventions to reduce accident risks and hazards shall include the following: . . . d. Ensuring that interventions are implemented; . . .5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently." In violation of the above cited standards, the facility failed to implement their policy and procedure to provide a safe environment when Resident 1 was left unsupervised while on the toilet, subsequently resulting in Resident 1 falling and acquiring a right hip fracture. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and is a class A citation.