Health inspection·December 27, 2024

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document on a dialysis (a communication form sent to dialysis with the resident and returned to the facility with documentation from the dialysis team) communication form, a witnessed fall prior to a dialysis treatments (an off site treatment, which removes toxins from the blood because the kidneys fail to function property) for one of three resident's reviewed for Quality of Care. Residents Affected - Few This failure had the potential for the dialysis staff to be unaware and not monitoring or evaluating for potential injuries related to the previous fall. Findings: Resident 1 was readmitted to the facility on [DATE] with diagnoses which included end stage renal disease, per the facility's admission Record. According to the physician's order, dated 3/5/24, dialysis every morning on Tuesday, Thursday, and Sunday. According to the facility's SBAR (Situation-Background-Assessment-Recommendation)-Fall note, dated 12/2/24 at 4:30 A.M., Resident 1 had a witnessed fall during a transfer, from the bed to a wheelchair, prior to dialysis treatment and complained of leg pain,. The physician was notified and the Responsible Party (RP-a person legally responsible for the resident's health and financial decisions), was notified on 12/2/24 at 5:14 A.M. According to the facility's Dialysis Communication Sheet, dated 12/2/24, there was no documented evidence the dialysis staff were informed of the fall earlier that morning. According to the care plan, titled Activities of Daily Living (ADL) Functional, dated 4/9/24, listed .Transfers as substantial to maximum assist 1-2 persons . According to the care plan, titled Fall Risk, dated 4/9/24, listed a witnessed fall on 12/2/24 with an intervention of Rehab screening for possible pick up in sensory program. According to the Minimum Data Set, (a clinical assessment tool), dated 11/11/24, Resident 1 had a cognitive score of 13, indicating cognition was intact. The Functional Abilities assessment indicated no impairment to the lower extremities and substantial to maximum assistance was required from sitting to standing position. The number of staff required was not listed. Page 1 of 2 555076 555076 12/27/2024 Stillwater Post-Acute 510 E. Washington Avenue El Cajon, CA 92020

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with the RP on 12/26/24 at 4:05 P.M. The RP stated she was informed of Resident 1 fall on the morning of 12/2/24. The RP stated she called dialysis center later to inquired how Resident 1 was doing and the dialysis nurse was unaware of the fall earlier that morning. An interview was conducted with Licensed Nurse 1 (LN 1) on 12/27/24 at 12:50 P.M. LN 1 stated if a resident fell prior to going to dialysis, the Dialysis Communication sheet should indicate a fall, so staff could be watching for any complication later occurring from the fall. LN 1 stated it was important to inform the dialysis staff for continuity of care. An interview was conducted with LN 2 on 12/27/24 at 12:57 P.M. LN 2 stated a fall or any changes in condition should be listed on the Dialysis Communication form, so the dialysis staff could be monitoring for any changes. If the dialysis staff were not aware of a fall and resident's condition deteriorated, the dialysis staff would be uninformed as to the cause. An interview was conducted with the Director of Nursing (DON) on 12/27/24 at 1 P.M. The DON stated she expected falls or any change in condition to be documented on the facility's Dialysis Communication form, so the dialysis staff were aware of what had transpired prior to arriving. An interview and record review was conducted with the Dialysis Licensed Nurse (D-LN) on 1/3/25 at 9:20 A.M. The D-LN stated it would be very important for them to know if a resident fell or had any change of condition, prior to a dialysis treatment. The D-LN reviewed the facility's Dialysis Communication form for 12/2/24, and stated there was no documentation of a earlier fall. According to the facility's policy, titled End-Stage Renal Disease (ESRD), Care of Resident with, dd September 2010, .1. Staff caring for residents with ESR, including residents receiving dialysis outside the facility, shall be trained in the care and special needs of these residents .$. Agreements between the facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: .b. How information will be exchanged between the facilities . 555076 Page 2 of 2