Other·April 4, 2022

Provider Number 555658 Bakersfield District Office Zeny Isla, HFEN Marika Walker, HFES Event ID: XG2C11 Complaint Number: 764364 The following reflects the findings of the California Department of Public Health during the investigation of Facility Reported Incident 764364. F580 Notification of Changes. 42 CFR 483.10(g)(14) (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is - (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is - (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). On 12/22/21, at 10 AM, the California Department of Public Health conducted an unannounced visit at the facility to investigate a facility reported incident regarding a fracture of unknown origin for Resident 1. Resident 1 was a 79-year-old male, admitted to the facility on 12/23/20 with diagnoses of osteo- arthritis, epilepsy (seizures), hemiplegia (paralysis) affecting left side, dementia (impaired decision making and memory), and schizophrenia (mental health condition). Resident 1 is cognitively impaired, and requires staff assistance with all activities of daily living (ADLs, includes bathing, grooming, eating, etc.) Based on observation, interview, and record review, the facility failed to immediately assess and notify the Attending Physician (AP) for one of two sampled residents (Resident 1) after an unwitnessed fall. This resulted in a delay in the treatment of a right hip fracture and pain. During an interview on 12/22/21, at 10:05 AM, with Administrator and Director of Nursing (DON), Administrator stated on 12/12/21 Resident 1 complained of right leg pain. Staff notified Resident 1's AP, who ordered an x-ray for Resident 1. Administrator stated the x-ray results indicated a right hip fracture. Administrator stated he did not know how Resident 1 had sustained a right hip fracture until after the facility investigation. Administrator stated on 12/10/21, Restorative Nursing Assistant (RNA) found Resident 1 on the floor lying on his floor mat. RNA called for assistance and when Certified Nursing Assistant (CNA) responded; and saw Resident 1 on the floor, CNA thought Resident 1 was sleeping so CNA, picked Resident 1 up and placed him in bed. Administrator stated RNA and CNA did not report the fall to the on-duty Licensed Vocational Nurse (LVN). The LVN did not conduct a body assessment of Resident 1 on 12/10/21 after the fall. During an interview on 12/22/21, at 11:15 AM, with Director of Staff Development (DSD), DSD stated it was the facility's practice for staff to notify the LVN of all falls. DSD stated, "They [staff] need to tell right away, they should never move them [resident], they need to wait for LVN to assess, and then help get them on the bed only if the LVN says so." During a concurrent observation and interview, on 12/22/21, at 11:34 AM, with LVN 1, in Resident 1's room, Resident 1 was observed lying in bed with eyes closed. LVN 1 stated Resident 1 was re-admitted from the hospital after having a right hip surgery. LVN 1 stated on 12/12/21, Resident 1 had refused care, and kept saying "No it hurts." LVN 1 stated Resident 1 was "very confused" and it was hard to determine the location of his pain but he "kept guarding his knee." LVN 1 stated staff found Resident 1 on the floor on 12/10/21, but the fall was never reported and LVN 1 believes Resident 1's right hip fracture was from the fall. LVN 1 stated "anytime a resident is found on the floor, we [LVN] need to go do a body assessment, do COC [change of condition], and notify MD [medical doctor]." During a concurrent interview and record review, on 12/22/2021, at 11:34 AM, with LVN 1, after reviewing the clinical record of Resident 1 LVN 1 validated that on the day of the incident (12/10/21) there was no documented evidence a physical assessment of Resident 1 was completed and validated that the LVN assigned did not notify the AP on 12/10/21 of the fall. During an interview on 12/22/21, at 12 PM, with RNA, RNA stated on 12/10/21 at approximately 2:45 PM, she was passing out the afternoon snacks when she saw Resident 1 lying on his right side on the floor next to his bed, his face was towards the closet. RNA stated CNA responded to her call for help and moved on to passing the rest of the afternoon snacks to other residents when CNA stated, "yeah I got this." RNA stated she assumed CNA had notified the LVN of Resident 1's fall. RNA stated, "For any fall, we always let the nurse know. Nurse must assess first before we can do anything. We don't move the resident at all unless the nurse says it's ok." During an interview on 12/22/21, at 12:09 PM, with DON, DON stated CNA "should have reported the fall right away." During an interview on 12/23/21, at 10:40 PM, with LVN 2, LVN 2 stated it was the facility practice for LVNs to be notified of any fall. LVN 2 stated after a fall, the resident is assessed, MD is notified, an order for an x-ray is obtained if the fall is unwitnessed, and the resident is monitored for any changes. LVN 2 stated, "LVN is always made aware. Assessment is to be done right away." During an interview on 12/23/21, at 10:55 PM, with CNA, CNA stated, he had arrived to work on 12/10/21 for PM shift, when he heard RNA calling for assistance in Resident 1's room. CNA stated, "When I got to his [Resident 1] room, he was lying on his right side, on the floor, curled up like he was sleeping." CNA stated he called Resident 1 by his name and asked for Resident 1 to stand up. CNA stated Resident 1 stood up and CAN helped Resident 1 back into bed. CNA stated, "I totally spaced out when it (fall) happened, and I didn't tell the nurse. . . I should have told the nurse right away." During a review of Resident 1's right hip x-ray dated 12/12/21, the result indicated a right hip fracture. During a review of Resident 1's "Interdisciplinary Team (IDT)" note dated 12/14/21, at 11:50 AM, the IDT indicated, "An investigation was completed and it was identified through staff interviews that on 12/10/21 @ [at] apx.[approximately] 2:45 p.m. a CNA observed [Resident 1] on the floor in his room. She immediately notified another CNA who stated that he would take care of it. The CNA stated that he saw [Resident 1] sleeping on the floor by his bed, assisted him up and back in to [sic] bed. He further stated that he did not notify the nurse of the fall." During a review of the hospital's "Operative Report", dated 12/15/21, the report indicated, Resident 1 had sustained a displaced fracture (misaligned broken bone) of the right hip which required an "open reduction internal fixation with trochanteric fixation nail Synthes implant (surgery which places screws to fix the broken bone)." During a review of the facility's policy and procedure (P&P) titled, "Falls-Clinical Protocol," dated 3/18, the P&P indicated, "Assessment and Recognition 2. In addition, the nurse shall assess and document/report the following: a. Vital signs; b. Recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for changes in normal range of motion, weight bearing, etc,. . . 5. The staff will evaluate and document falls that occur while the individual is in the facility: for example, when and where they happen, any observations of the events, etc." During a review of the facility's P&P titled, "Change in a Resident's Condition or Status," dated 5/17, the P&P indicated, "1. The nurse will notify the resident's Attending Physician or Physician on call when there has been a(an): a. accident or incident involving the resident; d. significant change in the resident's physical/emotional/mental condition. . ." In violation of the above cited, the facility failed to assess and notify AP after Resident 1 experienced an unwitnessed fall on 12/10/21. This resulted in a delay in treatment of the right hip fracture, 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 would result to Resident 1 and is a Class A citation.