Other·December 13, 2021

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident number 750801. 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 9/1/21 at 9:30 AM, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Resident 1's unwitnessed fall and injury. Resident 1 was 63 years old, and wheelchair bound, admitted with diagnoses including Congestive Heart Failure (heart cannot pump blood efficiently), Atherosclerotic heart disease (hardening of the blood vessels), myocardial infarction (heart attack), cardiac pacemaker, non-ST elevation disease (partial blockage of heart blood vessel), long-term use of antithrombotics/antiplatelets (blood thinners), hypertension (high blood pressure), hypotension (low blood pressure), and malnutrition. Resident 1 had dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life) and was impaired in decision making skills and memory. Resident 1 was also diagnosed with psychosis (mental disorder), major depressive disorder (mental disorder), and anxiety disorder. Based on observation, interview, and record review, the facility failed to implement their policy and procedure to provide supervision for one of two sampled residents (Resident 1) with dementia, while outside of station 4's patio. This failure resulted in Resident 1 falling from his wheelchair, sustaining a closed head injury (head injury without breaking the skull) and facial trauma (injury). During an interview on 9/1/21, at 10 AM, with Assistant Director of Nurses (ADON), ADON stated, on 8/31/21, around 8:10 AM, staff told her that Resident 1 was found outside at station 4's patio his wheelchair tipped over and Resident 1 was on the ground. During a concurrent observation and interview on 9/1/21, at 10:35 AM, with ADON, in Resident 1's room, Resident 1 was lying in bed with his eyes closed. Resident 1 had a bluish-dark color under both eyes. The right side of Resident 1's face had black and red colored areas extending down to his cheekbone area. The left side of Resident 1's face had scattered black and red colored areas below his eye and cheekbone. ADON stated, Resident 1's facial bruising resulted from his fall on 8/31/21. During an interview on 9/1/21, at 10:47 AM, with Patio Aide, Patio Aide stated, after getting a report from staff on 8/31/21 at approximately 8:05 AM, he went outside to station 4's patio to set up activities when he saw Resident 1 on the ground by himself. Patio Aide stated, "I turned the corner and saw [Resident 1] on the ground, his wheelchair was tilted, his feet dangling in the air." Patio Aide stated, Resident 1 had a diagnosis of dementia and was not allowed to be outside the patio without supervision. During a concurrent interview and record review on 9/1/21, at 11:50 AM, with ADON, Resident 1's current "Face Sheet" was reviewed. ADON confirmed Resident 1 had a diagnosis of dementia and stated, he had a history of falls. ADON stated, residents in station 4 were allowed to be outside on the patio when Patio Aide was out there to supervise. ADON stated, on 8/31/21, Resident 1 was not supervised when he fell outside on station 4's patio. During an interview on 9/1/21, at 12:12 PM, with Administrator, Administrator stated, it was Patio Aide's job duty to be outside on station 4's patio "to keep them [residents] safe." Administrator stated, on 8/31/21, Patio Aide was not outside on station 4's patio when Resident 1 fell. During an interview on 9/17/21, at 8:07 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 was not allowed to go outside unless the Patio Aide was outside providing supervision. During an interview on 9/17/21, at 8:24 AM, with LVN 2, LVN 2 stated, on 8/31/21, Resident had propelled himself outside to station 4's patio right after he had taken his ordered morning medications. LVN 2 stated, she assumed Patio Aide was outside at the patio and allowed Resident 1 to go outside. LVN 2 stated, "I thought he [Patio Aide] was out there." During an interview on 9/17/21, at 8:33 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, on the morning of 8/31/21, she observed Resident 1 up in his wheelchair, going in and out (the door) leading to station 4's patio. At approximately 8 AM, she left to pass breakfast trays. CNA 1 stated, Resident 1 was allowed to go outside "as long as we [staff] have eyes on them." CNA 1 stated, she assumed Patio Aide was outside on station 4 patio. During an interview on 9/17/21, at 8:45 AM, with CNA 2, CNA 2 stated, "He [Resident 1] was lying down on the grassy area, face up in his wheelchair, blood on his nose, his face looked like he got kicked." CNA 2 stated, the incident could have been prevented if he [Resident 1] was outside with supervision. During a review of Resident 1's hospital "Discharge Instructions," dated 8/31/21, the Discharge Instructions indicated, Resident 1 was diagnosed with "closed head injury, facial trauma, fall at home." During a review of the facility's policy and procedure (P&P) titled, "Safety and Supervision of Residents," dated 1/2011, the P&P indicated, "2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment." In violation of the above cited standards, the facility failed to supervise Resident 1, requiring staff to supervise while out on the patio, subsequently falling and acquiring a closed head injury and facial trauma. The facility failed to implement their policy and procedure to provide supervision for Resident 1, with dementia, while outside station 4's patio. This failure resulted in Resident 1 falling from his wheelchair, sustaining a closed head injury and facial trauma. 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 violation.