Health inspection·June 14, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure nursing staff implement a plan of care related to fall prevention for 1 of 3 residents. Failure to implement a plan of care had the potential for Resident 1 to fall and sustain injury. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included dementia (with impaired ability to make decisions that interferes with doing everyday activities), hemiparesis (weakness or the inability to move on one side of the body) and generalized weakness per the facility's face sheet. and MDS. A review was conducted on Resident 1's [NAME] Fall Risk Assessment Tool (a tool used to identify resident's risk for falling while in the facility), dated 5/10/23. Resident 1 had a [NAME] Fall Risk Assessment Tool score of 5 (A [NAME] score of 3 or more identifies a resident at risk for falling). This documentation indicated Resident 1 was a high risk for fall. A review of Resident 1's Progress Notes, dated 5/12/23, was conducted. This documentation indicated, Resident 1 was found lying on the floor, on her left side @ 8:50 P.M by Unit Clerk. Per this documentation, it also indicated Resident 1 stated she hit her head on the floor and was trying to get out of bed. A review of Resident 1's plan of care titled, At risk for fall/injury, dated 5/10/23, was conducted. The plan of care indicated, . Versacare Bed Alarm On: High intensity sound (3 lights on) . An interview with Certified Nursing Assistant (CNA) 1 was conducted on 5/25/23 at 1:25 P.M. CNA 1 stated Resident 1's bed alarm was not on when Resident 1 was found on the floor. CNA 1 stated that she forgot to turn the bed alarm on after transferring Resident 1 from wheelchair to bed. CNA 1 stated she should have made sure that bed alarm was on before leaving the room. The CNA further stated the bed alarm was for Resident 1's safety. An interview with Licensed Nurse (LN) 1 was conducted on 5/25/23 at 3:35 P.M. LN 1 stated Resident 1's bed alarm was not on, when Resident 1 was found lying on the floor on 5/12/23. LN 1 stated CNA 1 should had put the bed alarm on, per Resident's 1 care plan. LN 1 stated CNA 1 should have always turned the bed alarm on. LN 1 further stated, by not having the bed alarm on was a safety issue and put Resident 1 at risk for falling. Page 1 of 2 555216 555216 06/14/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0656 Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the DON on 5/25/23 at 1:10 P.M. The DON stated Resident 1 was a fall risk. The DON also stated Resident 1 had an unwitnessed fall on 5/12/23. The DON further stated Resident 1's bed alarm was not on when staff found her on the floor. The DON stated Resident 1's plan of care had intervention which included bed alarm on at all times. The DON stated not having the bed alarm on at all times was a safety issue. The DON acknowledged bed alarm should have been turned on but was not. Residents Affected - Few A review of facility policy and procedure titled, Fall Prevention, dated 3/1/22, was conducted. This policy indicated, . To provide guidelines for initial and post-fall assessment, planning, implementation . for fall prevention. 2. Verify implementation of Universal Fall precautions for all 555216 Page 2 of 2