Health inspection·August 30, 2024

Sunnyvale Gardens Post Acute F 689 The following reflects the findings of the California Department of Public Health during an abbreviated survey. Event ID: C5IQ11 Representing the Department, HFEN # 46552 State Citation B was written §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. On 8/15/2024 an unannounced visit was conducted at the facility for an abbreviated survey. The facility failed to provide required supervision and assistance and failed to implement a resident's minimum data set (MDS: clinical and functional assessment tool) assessment for assistance for bed mobility, transfers, toileting, ambulation, and risk for falls care plan for transfer and ambulation assistance, to prevent a fall on 2/3/2024 for one of 2 sampled residents (Resident 1). These failures resulted in Resident 1's fall and subsequent transfer to acute hospital (AH: where residents receive short term treatment for an urgent medical condition or severe illness) where Resident 1 was diagnosed with left wrist fracture (broken wrist bones). Findings: Review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the facility on 1/14/2024 and transferred to AH on 2/3/2024 following an episode of fall. Resident 1's FS indicated Resident 1 was admitted to the facility with diagnoses including wedge compression fracture of fifth lumbar vertebra (series of small back bones broken), unsteadiness on feet (pattern of walking that is unstable), muscle wasting and atrophy (decrease in size of muscle tissue), osteoporosis (a condition in which bones become weak and brittle), arthritis (swelling and tenderness in one or more joints), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities of daily living), and malignant neoplasm of bladder (bladder [body organ that stores urine] cancer). Resident 1 had an assigned significant family member as resident representative (RP: a person authorized to act as a resident's agent). Review of Resident 1's admission/readmission evaluation document dated 1/14/2024 indicated Resident 1 was at risk for falls due to history of falls, impaired vision, and medical problems. Review of Resident 1's MDS assessment dated 1/18/2024 for Resident 1's brief interview for mental status (BIMS, an assessment to test a person's cognition level) indicated score 13 of 15 (score of 0-7: severe impaired cognition, 8-12: moderately impaired cognition, 13-15: intact cognition). Review of mobility device Resident 1 used indicated walker (a device that gives support to maintain balance and stability while walking). Review of toileting hygiene indicated Resident 1 required partial/moderate assistance [helper does less than half the effort. Helper lifts or holds trunk (body apart from hands and legs) or limbs (hands and legs) but provides less than half the effort]. Review of lower body dressing for Resident 1 indicated dependent (helper does all the effort). Review of lying to sitting on side of the bed and sit to lying on side of the bed for Resident 1 indicated dependent. Review of sit to stand and transfer from bed Resident 1 required partial/moderate assistance from care giver staff. Review of Resident 1's care plan for risk for falls dated 1/15/2024 indicated, "Provide assist to transfer and ambulate as needed." Review of Resident 1's medical doctor (MD)'s progress notes, dated 1/15/2024, 1/17/2024, 1/24/2024, 1/25/2024, and 1/29/2024, for fall risk assessment indicated, "High fall risk" and for plan indicated, "Strict fall precautions." Review of Resident 1's physical therapy treatment (a branch of health care that helps with exercise, massages and various other treatments based on physical stimuli) encounter notes dated 2/2/2024 indicated, spinal precautions (prevent movement of the backbone). Review of functional status for bed mobility transfers indicated Resident 1 required supervision (assistance may be provided throughout the activity or intermittently), and for gait (walking pattern) Resident 1 needed stand by (to be there, just in case need to help) assist with walker. Review of Resident 1's occupational (a branch of health care that helps with physical sensory, and cognitive problems) encounter notes dated 2/1/2024 indicated fall precautions. Review of functional status for lower body dressing and toileting, Resident 1 needed moderate assistance, and toilet/commode transfers, Resident 1 required contact guard assist (one or two hands on assistance by the staff). Review of occupational treatment encounter notes dated 2/2/2024 indicated fall precautions. Review of functional status for lower body dressing needed minimum assistance (some assistance from staff is needed), and for toileting and transfers, Resident 1 required supervision. Review of Resident 1's ADL (activities of daily living) worksheet for February 2024 indicated, Resident 1 received supervision with one-person physical assist for bed mobility, transfers, and toileting during night shift (11:00 pm to 7:00 am) on 2/1/2024 and 2/2/2024. Review of Resident 1's nurse progress notes dated 2/3/2024 at 4:00 a.m., indicated Resident 1 was found sitting on floor leaning against the closet in room with hands on the lap at 1:00 a.m. Further review of these notes indicated Resident 1 stated, "I heard voices talking while going back to bed from the bathroom, and I don't know what happened I just fall." Resident 1 denied pain upon nursing assessment. Review of continuation of nurses note at 6:00 a.m., indicated Resident 1 complained of left wrist and forearm pain and requested to go to AH. Nursing noted minimal swelling on Resident 1's left wrist and forearm area. Resident 1 was sent to AH via 911 (emergency medical personnel assess and transport resident to appropriate emergency department for clinical care) around 7:23 a.m. Review of nurse progress notes dated 2/1/2024 at 11:50 a.m., and 2/2/2024 at 4:25 p.m., indicated Resident 1 ambulated with walker with supervision both times. Review of emergency department at AH MD notes dated 2/3/2024 at 8:14 a.m., indicated, left wrist x-ray (painless test that takes pictures of inside the body) with distal radius fracture (broken one of two long bones in the forearm) as well as ulnar styloid process fracture (broken wrist bone) for Resident 1. Review of case manager at AH discharge planning notes dated 2/3/2024 at 12:03 pm., indicated, "Daughter said that pt (patient) fell this morning while going to the restroom. Also, pt mentioned that she was calling to go to the restroom as she is supposed to have walk with walker and assistance, but no one came to help her." Review of MD consult note from AH dated 2/3/2024 at 7:29 p.m., indicated, "This morning around 1 am, while patient tried to use the restroom on her own, she developed a fall. Wrist X-ray showed fracture of the distal left radius and mildly displaced fracture of the ulnar styloid process." During an interview over the telephone with Resident 1's RP on 6/7/2024 at 11:36 a.m., RP stated, "mom told me she fell after walking back from bathroom by herself, mom needed help to use the bathroom." RP also stated, "Mom called for help several times, staff did not come to help her, facility staff neglected my mom's care, she had a wrist fracture from this fall." During a concurrent review of Resident 1's nurse progress notes dated 2/3/2024 at 4:00 a.m., and interview with facility's director of nursing (DON) on 6/7/2024 at 3:35 p.m., DON acknowledged Resident 1 did not receive supervision or assistance as needed for transfer, toileting, and ambulation. DON stated nursing staff did not implement risk for falls care plan to assist with transfer and ambulation as needed for Resident 1. DON also stated nursing staff should have provided supervision and assistance as needed for Resident 1 to prevent the fall on 2/3/2024. During a concurrent record review of Resident 1's ADL work sheet for February 2024 and interview over the telephone on 8/7/2024 at 2:06 p.m., with certified nursing assistance A (CNA A), assigned for Resident 1 on 2/3/2024 during night shift, when Resident had the fall, CNA A confirmed Resident 1 required supervision with set-up help from staff for bed mobility, transfers, and toileting. CNA A stated supervision with set up help means staff person required to stay in-person with Resident 1 for bed mobility, transfers, and toileting to supervise and assist as needed for Resident 1. CNA A also stated she did not recall how the fall happened for Resident 1 since it happened months ago. During an interview with facility's director of rehabilitation (DOR) on 8/8/2024 at 11:40 a.m., DOR confirmed Resident 1 required staff's supervision for bed mobility, transfers, and toileting. DOR stated supervision means staff person needed to be present with residents to assist in case if residents needed help with above tasks. DOR also stated staff should have helped as needed for Resident 1. During a review of the facility's policy and procedure (P&P) titled, "Assisting Activities of Daily Living (ADL); Supervision," dated 2001, the P&P indicated, "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: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting)." This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.