Health inspection·November 15, 2024

California Code of Regulation Title 22 §72523 Patient Care Policies and Procedures (a) Written patient care policies procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Code of Federal Regulation Title 42 §483.25(d) Accidents - The facility must ensure that - (d)(1) The resident environment remains as free of accident hazards as is possible. It was determined that the facility failed to provide an environment free from accident hazards when the facility failed to ensure an in-ground planter (a garden bed or a space dug into the ground where plants are grown) that was approximately 3.25 to 3.5 inch deep below the ground level, was properly leveled. This failure resulted in Patient 41 to trip, fall, and hit her head on the picnic table causing Patient 41 to sustain a periorbital hematoma ("black eye"- swelling and discoloration around the eye area) and a fracture of the nasal septum (broken or cracked part inside the nose that separated the two sides). On July 24, 2024, at 9 a.m., Patient 41 was observed walking independently by the nursing station and had dark purplish discoloration on both eyes. A review of Patient 41's "ADMISSION RECORD," dated July 23, 2024, indicated, Patient 41 was admitted to the facility on November 29, 2019, with diagnoses which included dementia (loss of memory) and schizophrenia (a mental disorder). A review of Patient 41's "History and Physical," dated November 5, 2023, indicated Patient 41 did not have the capacity to make decisions. A review of Patient 41's "FALL RISK ASSESSMENT," dated June 30, 2024, indicated, "...Score: 18...a score of 18 or more is High Risk (very likely to fall)..." A review of Patient 41's "Progress Notes," indicated: - July 15, 2024, "...At around 1340 (1:40 p.m.), guard came to the nurses' station stating resident (Patient 41) was in the patio outside DON (Director of Nursing)...with a bloody nose...Upon assessment, resident (Patient 41) was sitting on the side of the planter behind DON office crying and yelling. Noted with a cut to the bridge of her nose and bleeding...Resident (Patient 41) was transferred out to (name of general acute care hospital [GACH]) for further evaluation..." - July 15, 2024, "...Resident (Patient 41) returned to facility...Resident (Patient 41) diagnosed with bilateral nasal fracture. Open wound approx. (approximately) 4x2cm (four by two centimeters) in size on the left side of the nose, with discoloration of the skin on and around the nose. Red drainage noted on left side of the nose with loose skin..." - July 16, 2024, "...resident (Patient 41) noted with left and right periorbital hematoma and scab to the bridge of nose..." A review of Patient 41's CT Maxillofacial (Computed Tomography - uses radiologic and computer technology which evaluates the bones of the face), dated July 15, 2024, indicated, "...Impression...Acute mildly displaced bilateral nasal bone fractures...Acute minimally displaced fracture of the anterior-superior (front and upper part) bony nasal septum..." On July 23, 2024, at 12:02 p.m., Licensed Vocational Nurse (LVN) 2 was interviewed. LVN 2 stated, on July 15, 2024, the facility guard came to the nurse's station to report that Patient 41 had a fall. LVN 2 stated they reviewed the video of the incident, which showed Patient 41 tripped and hit her face on the table. On July 25, 2024, at 4:04 p.m., a concurrent interview and observation of the outer patio were conducted with the DON. The in-ground planter where Patient 41 tripped was observed approximately 3.25 to 3.5 inches deep relative to the ground level. The DON stated, Patient 41 was walking in the outer patio toward the picnic table when the patient tripped in the in-ground planter and hit her face on the picnic table. The DON stated Patient 41's fall could have been avoided if the in-ground planter was fixed to prevent tripping and falling. The DON further stated the patient fell due to the unevenness of the pavement and sustained a nasal fracture from the fall on July 15, 2024, at 1:30 p.m. A review of the facility policy and procedure titled, "Promoting Safety, Reducing Falls," undated, indicated, "...By simply focusing on fall preventions, caregivers can enhance the quality of life for residents...MAJOR RISK FACTORS...Extrinsic factors. These include risk factors outside the resident's body, such as environmental hazards (...uneven floors, highly patterned floors...)" A review of facility Policy titled, "Grounds," dated May 2008, indicated, "...Areas around the buildings (i.e., sidewalks, patios, gardens, etc.) shall be maintained in a safe and orderly manner at all times..." Based on observation, interview, and record review, it was determined that the facility failed to provide an environment free from accident hazards when the facility failed to ensure an in-ground planter that was approximately 3.25 to 3.5 inch deep below the ground level, was properly leveled. This failure resulted in Patient 41 to trip, fall, and hit her head on the picnic table causing Patient 41 to sustain a periorbital hematoma and a fracture of the nasal septum. 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.