Other·September 5, 2025

California Code of Regulations, Title 22, Section 72311, Nursing Service- General. (a) Nursing service shall include, but not limited to, the following: (2) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on the plan. California Code of Regulations, Title 22, Section 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. Code of Federal Regulations, Title 42, 483.25 (d) Accidents The facility must ensure that- (d) (2) Each resident received adequate supervision and assistance devices to prevent accidents. It was determined based on interview and record review, the facility failed to provide two person-assist during incontinent care (cleaning the resident while in bed after periods of urination or bowel elimination) in accordance with the plan of care, for Patient 24.  As a result of this failure, Patient 24 fell from the bed and subsequently complaint of pain and swelling in the right thigh. The patient sustained a fracture to the right thigh and was then transferred to the general acute care hospital (GACH) for further management. On July 22, 2025, a review of Patient 24’s “Admission Record,” indicated Patient 24 was admitted on January 10, 2024, with diagnoses which included bilateral osteoarthritis (a chronic joint disease characterized by the breakdown of cartilage, the protective tissue that cushions the ends of bones in joint) of knee, right knee contracture (condition where a muscle, tendon, or joint becomes permanently shortened and stiff, limiting its range of motion), muscle weakness, and difficulty in walking. A review of Patient 24’s “Care Plan,” dated June 21, 2024, indicated, “...resident has an ADL (Activities of Daily Living - fundamental self-care tasks essential for independent living, which include basic activities like bathing, dressing, eating, toileting, transferring) self-care performance deficit and needs substantial assist with mobility and ADLs...Interventions...Resident requires 2 persons assist in toileting...” A review of Patient 24’s “History and Physical,” dated February 18, 2025, indicated the patient does not have the capacity to understand and make decisions. A review of Patient 24’s “Fall Risk Assessment,” dated April 15, 2025, indicated Patient 24 was high risk for falls. A review of Patient 24’s “Minimum Data Set (MDS – an assessment tool),” dated April 16, 2025, indicated the following: a. Needed substantial/maximal assistance (helper does more than half the effort to complete the activity) with rolling left and right and personal hygiene; b. Dependent on toileting hygiene; and c. Functional impairments to bilateral upper and lower extremities (arms, hands, legs, and feet). A review of Patient 24’s “Progress Notes,” indicated the following: -July 10, 2025, at 9:57 p.m., “...According to the CNA [Certified Nursing Assistant], At 2120 (9:20 p.m.)  resident was being changed...CNA...was trying to turn resident to the side away from her while grabbing on the chux [disposable, absorbent under pads designed to protect surfaces like mattresses and furniture from fluids], when resident flip from the order (sic) side of the bed away from the CNA...resident fell using the lateral side of her body to hit on the floor. The CNA was not sure if resident landed on the floor with left or right side of the body...Primary ambulance [first ambulance dispatched to an emergency call to initiate patient care and transportation] called...” -July 11, 2025, at 8:46 a.m., “...Resident returned back from hospital @ (at) 0800 (8 a.m.)...no pain upon arrival to the facility...”; -July 12, 2025, at 5:39 p.m., “...Right lower extremity contracted [ a condition where the tissues surrounding the joints and muscles in your right leg become stiff, tightened, or shortened, leading to restricted movement and potentially deformity] from hip and knee bent toward the left side...patient c/o [complaint of] right hip and knee pain...PCP [Primary Care Physician]....gave order to have x-ray [a photographic or digital image of the internal composition of something, especially a part of the body]...” -July 13, 2025, at 10:41 a.m., “...received abnormal X ray result and noted with distal [refers to a part of the body that is farther away from the center of the body than another part] femur  fracture [a break in the femur, also known as the thighbone, which is the longest and strongest bone in the human body]...new order to transfer patient to (name of hospital)...”; and -July 13, 2025, at 6:59 p.m., “...Resident came back from the ER [Emergency Room]...@ 1700 (5 p.m.)...resident came back with right leg wrapped with bandage...” A review of Patient 24’s GACH records titled, “ED [Emergency Department] Provider Note,” dated July 13, 2025, indicated the following: - “...Pt (patient) had fall (sic) approx. (approximately) 2 [two] days ago...Facility noticed pt had right thigh area swelling and had CT [Computer Tomography - a medical imaging technique that uses X-rays to create detailed cross-sectional images of the body's internal structures, such as organs, bones, and blood vessels] done today. Pt found to have distal femur fracture from CT scan today...”; - “...When asked, pt admits to some right knee pain...”; - “...XR [x-ray] Right Femur [thigh]...There is a displaced fracture [a type of bone fracture where the broken bone fragments are no longer aligned with each other] of the distal femur...”; and - “...Per Orthopedics [the branch of medicine dealing with the correction of deformities of bones or muscles], conservative treatment is the best recommendation given patient’s condition...Acute fall [a sudden, unintentional descent resulting in a person coming to rest on the ground or another lower surface, whether assisted or unassisted, and with or without injury]with right distal femur fracture...Ace wrap [a long strip of stretchable cloth that you can wrap around to provide support and comfort to an injured area] for comfort...Pain regimen...” On July 22, 2025, at 10:55 a.m., during an interview with CNA 1, CNA 1 stated the following: -The patient (Patient 24) is dependent on staff for all ADLs; -She was informed the patient (Patient 24) required two-person assist for brief changes after the fall incident on July 10, 2025; -The patient was on a low air loss mattress (special mattress designed to relieve pressure from bony prominences) with no bed rails (bars attached to a bed that serve as a barrier to prevent patients from falling out or to aid in movement and positioning); and -While standing on the left side of the bed, she was changing the patient’s brief. As she pulled the patient’s sheet towards her (left side) and tried to pull the patient’s brief from under Patient 24 towards the right side, the patient slipped and fell out of the bed on the left side. On July 22, 2025, at 11:07 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, she stated Patient 24 was bed bound and at risk of falling due to weakness. LVN 1 stated the patient rolled on the left side of the bed while the CNA (CNA 1) was changing the patient’s brief alone. LVN 1 found the patient on the floor on the left side of the bed, holding onto the roommate’s bed rail. On July 22, 2025, at 2 p.m., during an interview with Registered Nurse (RN) 1, RN 1 stated Patient 24 was immobile (not able to move independently) in bed and required total assistance for care. RN 1 further stated the patient required two-person assist for brief changes. RN 1 stated CNA 1 should have had a second staff member present while providing care to Patient 24. On July 23, 2025, at 9 a.m., during an interview with the Director of Nursing (DON), the DON stated Patient 24 needed substantial/maximal assist for rolling from left to right, which meant the patient required two persons assistance. The DON stated the fall was caused by mechanical issues due to the air fluctuating in the low air mattress along with the mattress’ slippery surface and the CNA failing to call for help. The DON stated the fracture resulted from the fall. On July 23, 2025, at 4:06 p.m., during a follow up interview with CNA 1, CNA 1 stated she was not aware the patient required two-person assist for bed mobility, including brief changes, prior to the fall incident. CNA 1 further stated she should have called a second person for assistance when providing care for the patient. A review of the facility’s policy and procedure titled, “Falls and Fall Risk, Managing,” dated March 2018, indicated, “...staff will identify interventions related to the resident’s specific risks and causes to try to prevent the resident from falling...will identify and implement relevant interventions...to try to minimize serious consequences of falling...” A review of the facility’s policy and procedure titled, “Activities of Daily Living (ADLs), Supporting,” dated March 2018, indicated, “...Residents who are unable to carry out activities of daily living independently will receive the services necessary...including appropriate support and assistance with...Mobility...Elimination (the removal of substances through bodily fluids such as urine, sweat, and feces)...” Based on interview and record review, the facility failed to provide two-person assist during incontinent care in accordance with the plan of care, for Patient 24.  As a result of this failure, Patient 24 fell from the bed and subsequently complaint of pain and swelling in the right thigh. The patient sustained a fracture to the right thigh and was then transferred to the GACH for further management. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Patient 24.