Health inspection·April 25, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to monitor and supervise one of four residents (Resident 1) to prevent falls. Resident 1 had a history of falling with fractures (A break in a bone), and osteopenia (A condition in which there is a lower-than-normal bone mass). This deficient practice resulted in Resident 1 slipping and falling from a wheelchair (WC) and sustained a left hip fracture on 3/7/2023. Resident 1 was transferred to a General Acute Care Hospital (GACH) on 3/9/2023 for further evaluation and care. Resident I had left hip surgery on 3/14/2023. Findings: A review of Resident 1's admission Record, indicated the facility originally admitted Resident 1 on 10/26/2021 and readmitted Resident 1 on 2/27/2023 with diagnoses including Alzheimer's disease (Gradual decline in memory, thinking, behavior and social skills), dementia (Loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), impulse disorder (A condition in which a person has trouble controlling emotions or behaviors), history of falling, and fracture of distal (A part of the body that is farther away from the center of the body) phalanx (Any digital bones of the hand or foot) of left finger. A review of Resident's physician order, dated 3/24/2022, timed at 11:35 a.m., indicated, May apply bed tab alarm (A system to alert staff when a resident attempts to stand up) to alert staff of unassisted transfer/ambulation. A review of Resident 1's care plan on Resident with High Risk for Falls related to gait (manner of walking)/balance (stability) problems, initiated on 3/24/2022, indicated the goal included, The resident [Resident 1] will not sustain serious injury . The resident will be free from falls. The interventions included to, Anticipate and meet the resident's needs. Remove any potential causes . The resident needs a safe environment with even floors . A review of Resident 1's care plan on Risk for Falls, initiated on 5/4/2022, indicated Resident 1 will be free of falls. The interventions included to evaluate Resident 1 fall risk on admission and as necessary (PRN). If resident is a fall risk, initiate fall risk precautions. The interventions also included, Determine resident's [Resident 2] ability to transfer. Evaluate fall risk on admission and as necessary (PRN). If resident is a fall risk, initiate fall risk precautions. Resident will have a tab alarm on the wheelchair as ordered to alert nurses of attempts to get out of the wheelchair unassisted. A review of Resident 1's Minimum Data Set (MDS- A standardized assessment and care screening tool) Page 1 of 4 555061 555061 04/25/2023 Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated 2/1/2023, indicated Resident 1 had severely impaired cognition (Mental ability to make decisions of daily living). The MDS indicated Resident 1 required one staff physical assist with surface transfers, walking, bed mobility, locomotion [movement] on and off unit [facility], dressing and personal hygiene. The MDS indicated Resident 1 was not steady when moving from sitting to standing position, walking, turning around, surface transfer, and moving on and off the toilet. The MDS indicated Resident 1 used a wheelchair (WC) for mobility. A review of the facility's Inservice (Education) Meeting Minutes dated 2/3/2023, on Safety of a Resident, indicated, The safety of the resident is the utmost importance of our job. We have to make the environment as free from accident hazards as possible. Resident supervision is a core component of the systems approach to safety. Risk factors include: bed safety, safe lifting and movement of residents, falls . A review of Resident 1's Fall Risk Evaluation dated 2/28/2023, timed at 7:26 p.m., indicated Resident 1 score was 11 (If the total score is 10 or greater, the resident should be considered at high risk for potential falls). A review of Resident 1's care plan on Psychosocial Need (Having to do with the mental, emotional, social, and spiritual effects of a disease): Other Confusion (A decline in cognitive ability), dated 3/2/2023, indicated, Resident 1, Has episodes of confusion and disorientation (A mental state marked by confusion about time, place, or who one is) and repetitiveness R/T Alzheimer's disease. The goals included, Resident 1 will, Engage in daily routine activities safely. The interventions included, Provide . supervision. A review of Resident 1's Skilled Nursing facility Progress Note dated 3/7/2023, a physician documented Resident 1 fell in the backyard. A review of Resident 1's Radiology (X-ray) Results Report dated 3/8/2023 and timed at 1:15 p.m., indicated the reason for the study was pain in the left hip for Resident 1. The radiology results report indicated, There is a fracture (Break in a bone) involving the left greater trochanter (Hip bone) with no displacement . There is osteopenia. A review of Resident 1's General Note, dated 3/9/2023, timed at 3:21 p.m., indicated Emergency Medical Transport (EMT- Ambulance services for an emergency medical condition) was the facility but Resident 1 refused to go to GACH. A review of Resident 1's Skilled Nursing Facility (SNF)/ Nursing Facility (NF) to Hospital Transfer Form dated 3/9/2023, indicated the facility transferred Resident 1 to a hospital on 3/9/2023 at 7:10 p.m. The SNF/NF to hospital form indicated Resident 1 was a high risk for fall. A review of Resident 1's Physician Progress Notes dated 3/10/2023 timed at 10:43 a.m., indicated reason for study was pain in the left hip. The radiology Resident 1 had left greater trochanter fracture and osteopenia). A review of Resident 1's GACH history and physical (H&P) dated 3/11/2023, indicated Resident was admitted to GACH on 3/9/2023 after falling at the facility on 3/7/2023. The H&P indicated an Xray performed at the facility on 3/8/2023, confirmed Resident 1 had a fracture on the left hip and that Resident 1 had refused to go to GACH. However, the H&P further indicated Resident 1 agreed to go to GACH on 3/9/2023. 555061 Page 2 of 4 555061 04/25/2023 Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401

F 0689 Level of Harm - Minimal harm or potential for actual harm A review of Resident 1's Progress Note- Therapy. Dated 3/14/2023, timed at 9:39 a.m., indicated Resident 1 was not seen because, The plan is for operating room (OR) for hip pinning. A review of Resident 1's GACH Progress Notes-Physician, dated 3/15/2023, timed at 12;21 p.m., indicated, Resident 1 was, Status post (after) hip surgery yesterday (3/14/2023). Residents Affected - Few On 3/22/2023 at 1:42 pm., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 health has slowly deteriorated (Declined). LVN 1 stated she heard that Resident 1 had unwitnessed fall on 3/4/2023 on the 3 p.m. to 11 p.m. shift. LVN 1 stated a charge nurse working the 11 p.m. to 7 a.m., shift, reported that Resident 1 complained of left hip pain, a medical doctor (MD) was notified, and a stat (now) x-rays ordered and done. LVN 1 stated Resident 1 agreed to be transferred to a GACH for evaluation of for possible fracture. LVN 1 stated Resident 1 had left hip surgery performed while at GACH. On 3/22/2023 at 2:52 p.m., during an interview, LVN 3 stated on 3/7/2023 at around 4 p.m., Certified Nursing Assistant 5 (CNA 5) notified her [LVN 3] that Resident 1 was on the grass in the patio. LVN 3 stated she found Resident 1 laying on the left on the grass. LVN 3 stated Resident 1 told her that he [Resident 1] slid from the wheelchair. On 3/22/2023 at 3:40 p.m., during an interview, the Director of Staff Development (DSD) stated CNA 5 found Resident 1 on the grass in the patio on 3/7/2023. The DSD stated Resident 1 had unwitnessed fall, stat Xray of the left hip was ordered on 3/8/2023. On 4/14/2023 at 3:09 p.m., during an interview, CNA 5 stated Resident 1 was alert but forgetful. CNA 5 stated that on 3/7/2023 at around 3p.m. and 4 p.m., she [CNA 5} was abought to put another resident's WC outside the patio when she saw Resident 1 lying on the grass area on his side next to his [Resident 1] WC. CNA 5 stated she called the charge nurse (unable to recall the staff) who responded quickly. CNA 5 stated the charge nurse assessed Resident 1 and assist Resident 1 back into the WC. CNA 5 stated no other resident or staff were around in the patio when she [CNA 5] found Resident 1 lying on the grass. CNA 5 stated, It does not matter if a nurses endorsed to her that a resident was at risk. All residents are high risk regardless. So, it is important to check on the resident all the time. On 4/14/2023 at 3:36 p.m., during a concurrent interview and record review with the Director of Nursing (DON), Resident 1's medical chart was reviewed. The DON stated Resident 1 was a high risk for fall. A review of Resident 1's facility admission Summary note dated 3/16/2023, timed at 9:58 p.m., indicated the facility readmitted Resident 1 on 3/19/2023, at 8:30 p.m. Resident 1 was noted with 1 [one] staple (A metal fastener used to hold layers of tissue together to close an incision [cut]) on the left knee, eight staples on the left hip, and five staples on the left upper thigh. A review of the facility's policy and procedures (P&P), titled, Safety and Supervision of Residents, revised 7/2017, indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 3. Employees shall be trained on potential accident hazards . on how to identify and report accident hazards and try to prevent avoidable accidents. The P&P under System Approach to Safety 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 555061 Page 3 of 4 555061 04/25/2023 Good Shepherd Health Care Center of Santa Monica 1131 Arizona Ave. Santa Monica, CA 90401

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and identified hazards in the environment. The P&P under, Resident Risks and Environmental Hazards, indicated, . These risk factors and environmental hazards include: . c. Falls. E. Unsafe wandering. A review of the facility's policy and procedures, titled, Falls-Clinical Protocol, dated 3/2018, indicated under Assessment and Recognition 3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record. A. Examples of risk factors for falling include . cognitive impairment, weakness, environmental hazards, and confusion . A review of the facility's policy and procedures, titled, Falls and Fall risk, managing, revised 3/2018, indicated, Based on previous evaluation and current data, the facility will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications of falling . Fall Risk Factors: 1.d. obstacles in the footpath. The P&P under, General guidelines, indicated, 1. Falls are a leading cause of morbidity (The state of having an illness or medical condition) and mortality (The death rate) among elders in nursing homes. 3. Falling may be related to . environmental risk factors. A review of the facility's Falling Star Program, revised 3/1/2023, indicated under bullet point, 2. Monitoring . Monitor residents who attempt to transfer without assistance. Monitor residents who ambulate or attempt to ambulate (walk) without assistance - if resident is unable to ambulate independently. 3. Interventions: Assess resident environment and make appropriate changes . 555061 Page 4 of 4