Health inspection·September 12, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) was provided the necessary care and services after a fall. Residents Affected - Few * Resident 1 fell while the resident was being transferred by two staff members from the shower chair to the bed. The nursing staff did not conduct a post fall assessment and monitor the resident for any change in condition after the fall. This failure had the potential for Resident 1 not receiving appropriate care in a timely manner. Findings: On 9/7/23, medical record review for Resident 1 was initiated. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1 ' s History and Physical Examination dated 6/10/23, showed Resident 1 did not have capacity to understand or make decisions. Resident 1 had a diagnosis of osteopenia. Review of the fall risk assessment dated [DATE], showed Resident 1 was a low risk for falls. Review of the MDS Quarterly assessment dated [DATE], showed Resident 1 was totally dependent on two or more staff for transfers to or from the bed. Review of the Interdisciplinary Notes dated 8/31/23, showed on 8/21/23, while two staff members were in the process of transferring Resident 1 from the shower chair to the bed, Resident 1 began grabbing at the staff members arms and clothing causing all three of them to lose their balance. The two staff members lowered Resident 1 to the ground. The fall was not reported at that time. On 8/29/23, the resident exhibited severe pain during a brief change and an x-ray of the right lower extremity was ordered. The x-ray result showed a distal femur fracture, and the resident was sent to the emergency room for evaluation. However, further review of the medical record showed no documented evidence of the fall on 8/21/23. There was no documented evidence of the post fall assessment and monitoring for changes in condition after sustaining the fall on 8/21/23. On 9/7/23 at 1521 hours, an interview was conducted with RNA 1. When asked about Resident 1 ' s fall on 8/21/23, RNA 1 stated she and CNA 1 attempted to transfer Resident 1 from a shower chair to the bed by placing their (CNA 1 and RNA 1) arms underneath Resident 1 ' s armpits. According to RNA 1, Resident 1 held on to RNA 1 ' s shirt so RNA 1 and CNA 1 then placed Resident 1 on the floor because Page 1 of 2 555295 555295 09/12/2023 Regents Point - Windcrest 19191 Harvard Avenue Irvine, CA 92612

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 was sliding downwards. When asked about using a gait belt to transfer Resident 1, RNA 1 verbalized she did not use a gait belt to transfer Resident 1 from the shower chair to the resident ' s bed. According to RNA 1, she reported this incident to LVN 1. On 9/8/23 at 1318 hours, an interview with CNA 1 was conducted. When asked about Resident 1 ' s fall, CNA 1 stated she and RNA 1 attempted to transfer Resident 1 from the shower chair to the bed by placing their (CNA 1 and RNA 1) arms underneath Resident 1 ' s armpits. According to CNA 1, Resident 1 was holding on to their (CNA 1 and RNA 1) hands and clothing, so both CNA 1 and RNA 1 placed Resident 1 on the floor because they were unable to hold the resident. When asked if the facility provided staff education on how to transfer the residents, CNA 1 replied the staff were instructed to use the gait belts for transfer. When asked if she used a gait belt, CNA 1 stated she did not use a gait belt to transfer Resident 1 from the shower chair to the bed. On 9/12/23, at 1558 hours, an interview was conducted with LVN 2. When asked about Resident 1 ' s fall sustained on 8/21/23, LVN 2 stated she did not document or report about Resident 1 ' s fall because at that time, she did not identify Resident 1 ' s fall as a fall. On 9/12/23 at 1620 hours, an interview was conducted with the DON. The DON stated the staff did not report Resident 1 ' s fall to her until 8/30/23, after Resident 1 ' s x-ray result was received. The DON acknowledged thestaff should have reported and documented about Resident 1 ' s fall on 8/21/23. 555295 Page 2 of 2