Other·December 20, 2023

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident number 851896 and 852696. The inspection was limited to the specific complaint investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the Department: 34401, HFEN A deficiency was written for FRI # 851896 and 852696 at F-tag 656/G. F 656 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; On 7/24/23, an unannounced visit was conducted at the facility to investigate two facility reported incident regarding two unwitnessed falls. Based on observation, interview, and record review, the facility failed to implement a "Comprehensive Care Plan (a written plan developed by an interdisciplinary team [attending physician, registered nurse, dietician, etc. . .] and the resident, to help attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being)" for one of three sampled residents (Resident 1) to prevent a fall incident when Resident 1 was left in the dining room without staff supervision. This failure resulted in Resident 1 falling and sustaining a right inferior orbital wall fracture (a break in the inner wall of the eye socket), requiring a transfer to an acute hospital. Resident 1 was an 84-year-old female, admitted on 8/5/22, with diagnoses included Alzheimer's disease (type of dementia that damages the brain and affects memory, thinking, and behavior) and Dementia (condition that affect the brain's ability to think, remember and function normally). Resident 1's quarterly Minimum Data Set (MDS - a standardized, comprehensive assessment tool) dated 5/12/23, the MDS indicated, Resident 1 had a BIMS (Brief Interview for Mental Status - which evaluates cognition, the ability to remember and think clearly) score of 0 (score range from 0 - 7 severe impairment). The MDS Section G 300 "Balance During Transitions and Walking" indicated, Resident 1 was "Not steady, only able to stabilize with staff assistance "when moving from seated to standing position and walking (with assistive device). During a review of the facility "Investigation Report (IR), " dated 7/26/23, the "IR " indicated, "On July 22, 2023, at approximately 1630 [4:30 p.m.] hours, [Resident 1] was on a 2 to 1 [two residents to one staff direct supervision at all times] with a staff member [Certified Nursing Assistant 1] and stated she [CNA 1] was in the dining room with both residents [Resident 1 and Resident 2] when the other resident [Resident 2] needed to use the restroom; therefore, she [CNA 1] reported to a different CNA [CNA 3] who was also in the dining room that she was leaving to take the other resident [Resident 2] to the restroom. Minutes later [Resident 1] was found on the ground in the dining room. . . Later in the evening during rounds. . . [Resident 1] had bruising [discoloration] to the right cheek area and swelling. . . send [Resident 1] to the ER [Emergency Room] for evaluation [7/22/23] . . . [Resident 1] returned [7/23/23] from the ER with diagnosis. . . non-displaced [bone cracks or breaks but retains its proper alignment] fracture of the right inferior orbital wall. " During a review of Resident 1's "Computed Tomography (CT - imaging technique used to obtain detailed internal images of the body)" scan dated 7/23/23, the CT result indicated, "fracture of the right inferior orbital wall. " During an interview on 8/2/23, at 9:30 a.m. with Director of Nurses (DON), DON stated on 7/22/23 (at approximately 4:30 p.m.), Resident 1 and Resident 2 were in the dining room with their assigned 2 to 1 sitter (CNA 1), when Resident 2 "wanted to get up." DON stated CNA 1 told another staff (CNA 3) who was in the dining room to keep an eye on Resident 1 while CNA 1 took Resident 2 for a walk. DON stated CNA 1 returned (no time given) in the dining room and found Resident 1 on the floor. DON stated Resident 1 was transferred to an acute hospital and sustained a right inferior orbital wall fracture. During an interview on 8/2/23, at 10 a.m. with CNA 1, CNA 1 stated on 7/22/23, she was assigned as 2 to 1 sitter for Resident 1 and Resident 2 during her p.m. (2 pm-10 pm) shift. CNA 1 stated at approximately 4 p.m. (7/22/23), she was in the dining room with Resident 1 and Resident 2 when Resident 2 needed to use the bathroom. CNA 1 stated before leaving the dining room, she told CNA 3 who was in the dining room passing out snacks, to keep an eye on Resident 1. CNA 1 stated she was not in the dining room when Resident 1 fell on the floor. CNA 1 stated Resident 1 was a fall risk and always requiring "2 to 1 sitter "to prevent Resident 1 from falling. CNA 1 stated Resident 1's fall incident could have been prevented if "someone was watching her [Resident 1]. " During a concurrent observation and interview on 8/2/23, at 11:06 a.m. in Resident 1's room, Resident 1 was in bed. Resident 1 was observed spitting on the left side of the bed, she did not make an eye contact or respond when spoken to. During an interview on 8/2/23, at 6:53 p.m. with Licensed Vocational Nurse (LVN), LVN stated on 7/22/23, at approximately 4:30 p.m., CNA 2 found Resident 1 on the floor in the dining room, "without staff present." LVN stated a few hours after the fall incident at approximately 8 p.m. Resident 1 started showing a bruise to her "face area" and was transferred to an acute hospital. LVN stated Resident 1 sustained a right inferior orbital wall fracture. LVN stated Resident 1 was a "high risk for fall and was assigned a 2 to 1 sitter to prevent her [Resident 1] from falling." LVN stated the fall could have been prevented if the "2 to 1 sitter was there with her [Resident 1]." During an interview on 8/7/23, at 12:51 p.m. with CNA 3, CNA 3 stated on 7/22/23, she was in the dining room obtaining weights for the residents scheduled to be weigh and she was never asked by CNA 1 to keep an eye on Resident 1. CNA 3 stated there were approximately 15 residents in the dining room doing activities with the Activity Assistant (AS) including Resident 1. CNA 3 stated she was not in the dining room when Resident 1 fell on the floor. CNA 3 stated Resident 1's fall incident could have been prevented if the assigned 2 to 1 sitter was present. During an interview on 8/9/23, at 2:54 p.m. with AS, AS stated on 7/22/23, at approximately 4:15 p.m., she was in the dining room providing activities for approximately 15 residents including Resident 1. AS stated, she noticed Resident 1 sitting in her wheelchair, "before leaving the dining room for about 10 minutes for a bathroom break." AS stated, nobody had asked her to keep an eye on Resident 1. AS stated, she was not in the dining room when Resident 1 fell on the floor. During an interview on 8/10/23, at 9:30 a.m. with CNA 2, CNA 2 stated on 7/22/23, at approximately 4:30 p.m., she was in the hallway when she heard yelling coming from the dining room. CNA 2 stated she arrived in the dining room and found Resident 1 on the floor next to her wheelchair. CNA 2 stated "No other staff were present, no sitter, no activity staff, no CNA's, no RNA's [Restorative Nursing Assistant], there was nobody." CNA 2 stated Resident 1 "Had a history of falling and was assigned a 2 to 1 sitter" to prevent Resident 1 from falling. CNA 2 stated Resident 1 "should not have been left alone, she was screaming pretty loud. " During a concurrent interview and record review on 8/15/23, at 10:52 a.m. with DON, Resident 1's "Fall Risk Evaluation (FRE)," dated 7/14/23, was reviewed. The FRE indicated, Resident 1 had a score of 11 (if the total score is 10 or greater, the resident should be considered HIGH RISK for potential falls). DON stated "[Resident 1] was high risk for fall, was impulsive [tendency to act without thinking], had poor safety awareness and required 2 to 1 sitter." During a concurrent interview and record review on 8/18/23, at 11:39 a.m. with DON, the facility's daily staff assignment, dated 7/22/23, was reviewed. The daily staff assignment for p.m. shift (2 pm-10 pm) indicated, CNA 1 was assigned as 2 to 1 sitter for Resident 1 and Resident 2. DON stated, "[Resident 1] should not have been in the dining room without her assigned 2 to 1 sitter." During a concurrent interview and record review on 9/6/23, at 12 p.m. with DON, DON stated Resident 1 had fall incidents on 5/27/23 and on 7/14/23. Resident 1's "Care Plan (CP)," dated 5/30/23, was reviewed. The CP indicated, Resident 1 was "At risk for unavoidable falls related to: Poor safety awareness, Unaware of physical limitations, Impulsiveness, Wanders into other residents' room, at times unbalanced on feet." Intervention indicated, Resident 1 "to have a 2 to 1 staff at all times." DON stated Resident 1's care plan dated 5/30/23, was not implemented. During a review of the facility's policy and procedure (P&P) titled, "Comprehensive Care Plans," dated 6/1/2022, the P&P indicated, "It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment." During a review of the facility's "Job Description for (Sitter), "undated, the Job Description for sitter indicated, "The primary purpose of your job position is to provide close observation of the resident you are assigned to. . . It is your responsibility to monitor the resident for safety issues and are to keep the resident within arm's length on your entire shift." During a review of the facility's P&P titled, "Accidents and Supervision, "dated 2022, the P&P indicated, "3. Implementation of Intervention-using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: . . . e. Ensuring that the interventions are put into action. . . 5. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. . . " In violation of the Code of Federal Regulations §483.21(b), the facility failed to implement Resident 1's person centered comprehensive fall care plan. This resulted in Resident 1 falling and sustaining a right inferior orbital wall fracture, requiring a transfer to an acute hospital. This violation presented either imminent danger that death or serious harm would result or a substantial probability of death or serious physical harm to Resident 1 and constitutes to "A" citation.