Health inspection·January 11, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide required supervision for one of three sampled residents, Resident 1, who was dependent on staff for toileting and was left unattended while using the toilet. This failure resulted in Resident 1 attempting to get off the toilet independently without staff supervision which led to a fall and a head injury that resulted in Resident 1's hospitalization on [DATE] and death on [DATE]. Findings: A review of Resident 1's clinical record titled, admission Record, (a document that contains the resident's personal information) indicated Resident 1 was admitted to the facility on [DATE] with a history that included weakness to the right side of the body following cerebrovascular disease (also called cerebrovascular accident or stroke-damage to the brain from interruption of its blood supply) difficulty walking, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 1's clinical record titled, History and Physical Examination, dated [DATE], by the Physician (Phys), indicated, Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's clinical record titled, Post Fall Interdisciplinary Team Notes, (IDT- team members from different disciplines working together and sharing resources regarding resident care), dated [DATE] at 8:26 PM, by the Director of Nursing (DON) indicated, .[Resident 1] had an episode of unwitnessed fall on [DATE] during am [day] shift around 1:15 PM. [Resident 1] was found sitting on floor in the bathroom with her head next to the sink. Visible injury noted to [Resident 1's] forehead on R [right] side temporal [head] location. Location bruised with bleeding noted .transfer [Resident 1] to ER [emergency room] for further eval [evaluation] and treatment .Root Cause .[Resident 1] scores 7 on BIMS [BIMS- an assessment tool, 0 = severe cognitive impairment (problems with thinking, reasoning, memory, or attention) to 15 = intact cognition], requires assistance with ADLS [activities of daily living- an individual's daily self-care activities], transfers and mobility . A review of Resident 1's clinical record titled, Progress Notes, dated [DATE] at 1:56 PM, by Licensed Nurse (LN) 1 indicated, .when asked by nurse what happened resident stated, 'oh honey I don't know, I just tried getting up from the toilet to pull up my underwear and next thing you know I am on the floor . Page 1 of 4 555080 555080 01/11/2024 Tracy Nursing and Rehabilitation Center 545 West Beverly Place Tracy, CA 95376

F 0689 Level of Harm - Actual harm Residents Affected - Few A review of Resident 1's clinical record titled, Progress Notes, dated [DATE] at 6:37 PM, by LN 2, indicated after the fall, Resident 1 was admitted to the hospital for a subarachnoid hemorrhage (bleeding in the space that surrounds the brain). A review of Resident 1's clinical record titled, Morse Fall Risk Screen, (an assessment tool used to determine the resident ' s risk of falls), dated [DATE] at 5:47 PM, indicated, Resident 1 scored a 41 moderate risk of falls (High Risk = 45 and higher, Moderate Risk = 25-44, Low Risk = 0-24). A review of Resident 1's clinical record titled, Minimum Data Set Section GG - Functional Abilities and Goals, (MDS - an assessment tool used to plan the care of a resident in nursing homes), dated [DATE], indicated Resident 1 was dependent (helper does all the effort and resident does none of the effort to complete the activity) on staff for toileting hygiene (the ability to maintain the area between the anus and vagina], to adjust clothes before and after voiding [urine] or having a bowel movement [stool]). The record further indicated, Resident 1 utilized a manual wheelchair and walker, and was dependent on a helper for indoor mobility (walking from room to room with or without an assistive device [wheelchair or walker]). A review of Resident 1's clinical record titled, Care Plan, initiated on [DATE], indicated, Resident 1 was a high risk for falls and injury related to poor judgement, attempting to get out of bed unassisted. A review of Resident 1's clinical record titled, Care Plan, dated [DATE], indicated, Resident 1 had an Occupational Therapy focus (OT- therapy designed to develop, recover, and improve needed function for daily living) that included a self-care deficit as evidenced by needed assistance with lower body dressing and toileting hygiene. Resident 1's Activities of Daily Living (ADL- an individual's daily self-care activities) independence fluctuated due to dementia, cognitive deficit (mental decline), and poor safety judgement. A further review of Resident 1's clinical record titled, Care plan, dated [DATE], indicated, Resident 1 was at high risk for weakness and intolerance in participation of care and ADLs. For interventions, the Certified Nursing Assistant (CNA) was expected to observe Resident 1 for signs and symptoms of the inability to participate in care and ADLs and to assist Resident 1 with ADLs if needed. During a phone interview on [DATE], at 9:17 AM, Family Member (FM) 1 stated Resident 1 was not doing well since her fall on [DATE] and had limited speech after the event. FM 1 further stated Resident 1 was now on hospice (focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life). During an interview on [DATE], at 10:45 AM, LN 3 stated factors that increased Resident 1's risk for falls was a diagnosis of dementia, advanced age, and weakness. LN 3 stated staff should not have left Resident 1 unattended in the bathroom. During an interview on [DATE], at 12:35 PM, LN 1 stated the CNA should not have left Resident 1 in the bathroom without supervision. LN 1 stated Resident 1 was found on the floor of the bathroom with blood coming from her head. LN 1 stated Resident 1 was a risk for falls and had fallen prior to admission to the facility. During an interview on [DATE], at 12:57 PM, CNA 1 stated staff should have remained just outside of Resident 1's bathroom while Resident 1 was using the toilet. 555080 Page 2 of 4 555080 01/11/2024 Tracy Nursing and Rehabilitation Center 545 West Beverly Place Tracy, CA 95376

F 0689 Level of Harm - Actual harm Residents Affected - Few During an interview on [DATE], at 1:09 PM, CNA 2 stated when Resident 1 requested privacy while using the bathroom, staff should have given her privacy but remained in the room to provide immediate assistance after Resident 1 had completed using the toilet. During an interview on [DATE], at 1:45 PM, the Director of Staff Development (DSD) stated she and the DON investigated the events leading up to Resident 1's fall. The conclusion was made that the CNA assisted Resident 1 to the bathroom and then left Resident 1's room to perform another task. Resident 1 was later found on the floor of the bathroom with a head injury. The DSD stated the CNA should not have left Resident 1 alone while she was on the toilet. During a phone interview on [DATE], at 3 PM, CNA 3 stated she assisted Resident 1 to the toilet and then shut the bathroom door for requested privacy. CNA 3 further stated Resident 1 was still on the toilet when she left Resident 1's room to perform another task. CNA 3 stated her normal practice was to stay with the resident while he/she was in the bathroom. CNA 3 further stated she thought Resident 1 would wait for help before standing up. CNA 3 stated the DON and DSD talked to her about the incident and CNA 3 was told she should have remained with Resident 1 at all times when Resident 1 was in the bathroom. During a phone interview on [DATE], at 3:08 PM, Medical Doctor (MD) 1 stated he was Resident 1's primary physician. MD 1 further stated Resident 1 was no longer alive and he had to look up what her cause of death was. MD 1 stated Resident 1 was a high risk for falls due to her taking Eliquis (generic name apixaban- a blood thinner medication) and her diagnosis of dementia. MD 1 explained it was not appropriate to leave the resident alone on the toilet and staff should have remained with Resident 1 until she was done using the bathroom and then should have been helped back to bed or the wheelchair. During a subsequent phone interview on [DATE], at 5:40 PM, MD 1 stated Resident 1's cause of death was subarachnoid hemorrhage. A review of Resident 1's Discharge Summary, from the hospital, dated [DATE], in the section CONDITION AT DISCHARGE, indicated, .[Resident 1] Unable to ambulate due to severe stroke . Further review of the section Imaging, indicated, .CT [computerized tomography scan - a series of images taken from different around the body] BRAIN WO [without] CONTRAST .Result Date: [DATE] .Previously identified left sided subacute infarcts [infarction- injury or death of tissue resulting from lack of blood supply] . are not well visualized .No hemorrhagic conversion [rupture of blood vessels after blood flow is restored after a stroke] or new acute infarcts .MRI [magnetic resonance imaging- imaging that uses strong magnetic fields to generate detailed images of organs, bones, muscles and blood vessels] BRAIN WO CONTRAST .Result Date: [DATE] .No acute intracranial hemorrhage [brain bleed] . A review of Resident 1's Discharge Summary, from the hospital, dated [DATE], in the section REASON FOR ADMISSION, indicated, .[Resident 1] .recent admission on 12/21 (week ago) of acute CVA [cerebrovascular accident- damage to the brain from interruption of its blood supply] .patient recovered well and was discharged to skilled nursing facility for rehabilitation after starting on apixaban .[Resident 1] returns to hospital today [[DATE]] after suffering a fall in the toilet, noticed mild bleeding with hematoma [solid swelling of clotted blood within the tissues] on the right frontal area [front part of the brain]. In ED [Emergency Department], CT head showed small to moderate amount of subarachnoid hemorrhage on the left posterior side .and right prefrontal [frontal lobe of brain] scalp 555080 Page 3 of 4 555080 01/11/2024 Tracy Nursing and Rehabilitation Center 545 West Beverly Place Tracy, CA 95376

F 0689 hematoma along with old right cerebellar [brain] infarct . Level of Harm - Actual harm Further review of the section HOSPITAL COURSE, indicated, .Patient was admitted for traumatic subarachnoid hemorrhage after a fall while on apixaban .Given her advanced age, comorbidities, recent strokes ischemic [CVA] as well as subarachnoid hemorrhage, [FM 1] decided to initiate hospice care at care home and does not want [Resident 1] to go back to nursing home. Plan to discharge [Resident 1] to care home with hospice today . Residents Affected - Few A review of Resident 1's CERTIFICATE OF DEATH dated [DATE], indicated, .date of death XXX[DATE] . The section CAUSE OF DEATH, indicated, .the chain of events, diseases, injuries, or complications that directly caused death .Immediate cause (final disease or condition resulting in death) . A. SUBARACHNOID HEMORRHAGE .Time interval between onset and death .1 MON [MONTH] . A review of the facility's Policy and Procedure (P&P) titled, Bathroom, Assisting a Resident to, dated 2/2018, indicated, .Purpose: The purpose of this procedure is to assist the resident with ambulating to the bathroom. Preparation: Review the resident's care plan to assess for any special needs of the resident .Steps in the Procedure - Assist the resident to the bathroom. Close the bathroom door .Wait outside the door, if safety permits .When the resident has signaled or called for you, return to the bathroom. If the resident needs help in cleaning himself .Clean the perineum [area between the anus and vagina] .Assist the resident to stand .Reposition the resident's clothing . 555080 Page 4 of 4