Health inspection·December 14, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to fully implement their post fall protocol for a resident who self -reported a fall. This had the potential to compromise the safety and well-being of Resident 1. Findings: On 11/03/23 the Department of Public Health received a complaint of a fall for Resident 1 on 11/03/23. On 11/15/23, Resident 1 ' s records were reviewed. Resident 1 was admitted to the facility on [DATE] with diagnoses to include osteoarthritis of knee (swelling of knee joints), syncope (passing out) and collapse, opioid dependence (drug for pain relief and causing sleepiness) per the facility admission Record. A review of Resident 1 ' s facility record indicated on 11/3/23 at 1:00 A.M., .Resident came down to nurses station mobile wheelchair stating he fell on his buttocks in his room at his bedside no c/o[sic] pain/discomfort v/s[sic] wnl[sic] breathing even and unlabored neurochecks initiated RN/MD[sic] made aware . Fall risk evaluation on 3/2/21 was 19, high risk for fall. Fall risk evaluation on 9/7/23 was 15, high risk for fall. There was no documented evidence of fall risk evaluation was done after Resident 1 ' s reported 11/3/23 fall. There was no documented evidence a pain assessment was performed after the fall. after Resident 1 ' s reported 11/3/23 fall. There was no documented evidence of an interdisciplinary team (IDT-health care team that included the nurse, social service, rehabilitation and activities) meeting to determine Resident ' s 1 incident of fall on 11/3/23 was done. On 11/15/2023 at 1:51 P.M., an interview with Resident 1 stated he had a fall four nights ago in Page 1 of 2 555206 555206 12/14/2023 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the middle of the night. Resident 1 stated he used the power wheelchair and ended up on the floor. Resident 1 stated he then used the call light but nobody came. Resident 1 stated he went to the nurse station later on and informed the nurse of his fall. On 11/15/2023 at 1:55 P.M., and interview was conducted with the resident roommate. Resident roommate stated around four nights ago midnight, he heard Resident 1 fooling around and heard a thud. Resident roommate then heard Resident 1 yelling. Resident roommate stated no employee came to our room. Resident roommate stated Resident 1 fell asleep and resident roommate fell asleep too. On 11/15/23 at 2:19 P.M., A concurrent interview and record review with Licensed Nurse (LN) 1. LN 1 stated when there was an incident of fall, IDT for fall, fall risk assessment, pain evaluation and risk management for internal investigation and performed. LN 1 stated before, facility documented incidence of fall on _e-interact and now, facility documented on IDT. LN 1 stated there was no fall risk evaluation after the fall, no IDT and no pain evaluation was performed for Resident 1 ' s fall. On 11/03/23 at 3:33 P.M., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated when there was a claimed fall, the licensed nurse should have documented the fall, notify the doctor and go from there. The DON stated she just found out Resident 1 had a fall, the licensed nurse documented on a different form and that was why the facility did not catch the incident. The DON stated when a licensed nurse document an incident of fall, we could catch it when she run the report for all residents fall incidents. The DON stated then once we know the residents with fall, we do our IDT for fall. The DON stated this was missed because the licensed nurse used a different form to document resident 1 ' s incident of fall. 555206 Page 2 of 2