Health inspection·October 25, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm 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 interview and record review, the facility failed to: Residents Affected - Few 1. Perform and document neurological checks (assessing mental status, level of consciousness, eye response to light, motor strength, feeling sensation, and vital signs {blood pressure, pulse, respiratory rate} every 15 minutes for one hour, every 30 minutes for one hour, every hour for two hours, every two hours for four hours, every four hours for 16 hours, every 8 hours for 24 hours) after an unwitnessed fall per the nursing standard of practice for one of four residents (Resident 1) reviewed for falls; and 2. Accurately score (low, medium or high risk of future falls) for a fall assessment after an unwitnessed fall for one of four residents (Resident 1), reviewed for falls. As a result, Resident 1 ' s head injury could have been detected earlier and a higher fall assessment score would have implemented more interventions to prevent future falls. Findings: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure with hypoxia (low blood oxygen levels causing difficulty breathing), per the facility ' s admission Record. On 10/5/23, Resident 1 ' s clinical record was reviewed. According to the facility ' s Nurses Note dated 5/17/23 at 8:20 A.M., Licensed Nurse 1 (LN 1) documented Resident 1 was found on the floor by a Certified Nurse Assistant (CNA 4). Resident 1 was on the left side of the bed and refused a neuro-assessment initially. Resident 1 denied hitting his head or having any pain. Resident 1 was found to have a 1-centimeter skin tear to the left lower leg with no bleeding. Resident 1 ' s pupils were equal and reactive to light, and 4-5 staff were required to assist the resident back to bed, due to non-compliance with care. The physician was notified, and neuro-checks were initiated per protocol. According to the facility ' s Nurses Note, dated 5/17/23 at 9:59 A.M., LN 1 documented Resident 1 was assessed for neurological checks and was verbally unresponsive. The physician was notified, and Resident 1 was sent to the hospital via paramedics. A care plan, titled Actual Fall, dated 5/18/23, listed interventions such as Neuro-checks included Page 1 of 4 555427 555427 10/25/2023 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the number of times to monitor/document/report as needed x 72 hours to physician for signs/symptoms: bruises, change in mental status, new onset confusion, sleepiness and inability to maintain posture. A review of the facility ' s seven-page Neurological Flowsheet was blank except for the first page, which contained vital signs that were obtained at 6:47 A.M., prior to the actual unwitnessed fall. No other documented neurological assessments could be located. Vital signs (blood pressure, pulse, respiratory rate and oxygen saturation rates) were documented by CNA ' s at 6:47 A.M., at 8:20 A.M., (at the time of fall), 8:50 A.M., 9:20 A.M., and 9:59 A.M. On 10/5/23 at 10:56 A.M., an interview was conducted with LN 3. LN 3 stated neurological checks were very important after an unwitnessed fall, to determine if there had been an injury to the head during the fall, which could initially be undetected. LN 3 stated the neurological examines were a standard nursing practice with specific time frames, to detect early signs of a possible head injury. LN 3 stated all neurological examines, such as pupil size, hand grips, and foot pushes were important to document a baseline and then determine if there were any changes during the follow-up neurological checks. On 10/5/23 at 11:32 P.M., an interview and record review was conducted with LN 1. LN 1 stated she checked on Resident 1 around 7:30 A.M., 5/17/23, after receiving report from the night shift. Resident 1 ' s bed was in a low position and the resident was awake. Resident 1 had refused his Bi-pap (bilevel positive airway pressure mask to assist with breathing while sleeping), stating he preferred to use the nasal cannula instead because it was more comfortable. LN 1 recalled Resident 1 ' s roommate (Resident 5) was not in the room, and it was Resident 5 ' s habit to rise early, for breakfast in the main dining room. LN 1 stated on 5/17/23 at 8:40 A.M., she was notified at by CNA 4 that Resident 4 was found on the left side of his bed, by the window. LN 1 stated she called the physician and was instructed to perform 72-hours of neurological checks and if any changes to contact the physician. LN 1 stated sometime later, Resident 1 became verbally unresponsive, so the physician and family were notified. Resident 1 was sent to the hospital and had not returned to the facility. LN 1 reviewed the facility ' s Neurological Flowsheet that was initiated by her on 5/17/23 at 8:20 A.M. LN 1 stated the neurological flowsheet was blank except for initial vital signs. LN 1 stated she recalls the CNAs giving her a piece of paper with Resident 1 ' s vital signs and it was her responsibility to perform neurological checks per the facility ' s protocol. LN 1 stated she must have forgotten to document them and does not recall what the assessments were. LN 1 stated per the standard, if it was not documented, it was not done. LN 1 stated she thought she had documented them (neurological checks) and if she had not, it was her error. LN 1 stated frequent neurological checks were important to detect early signs of head injury. On 10/5/23 at 12:09 P.M., an interview and record review was conducted with the Director of Nursing (DON). The DON stated she expected all LNs to perform and document neurological checks and all unwitnessed falls. The DON stated neurological checks were important to recognize early signs of a possible head injury. The DON reviewed Resident 1 ' s neurological checks and stated there was missing entries. The DON reviewed the CNA vital sign logs ad stated the vistal signs were all 30 minutes apart, and initially the vital signs should have been obtained 15 minutes apart. The DON stated vital signs alone cannot detect a head injury and neuro checks needed to be conducted by the LNs. 555427 Page 2 of 4 555427 10/25/2023 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0689 Level of Harm - Minimal harm or potential for actual harm According to the facility ' s policy, titled Fall Prevention Program, dated December 2022, .4. b. Implement routine rounding schedule. C. Monitor for changes in resident ' s cognitive, gait, ability to rise/sit, and balance, .f. Monitor vital signs in accordance with the facility policy. The facility did not have a policy related to 72-hour neurological checks. Residents Affected - Few 2. Resident 1 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure with hypoxia (low blood oxygen levels causing difficulty breathing), per the facility ' s admission Record. On 10/5/23, Resident 1 ' s clinical record was reviewed. According to the facility ' s admission Fall Assessment Risk, dated 5/12/23 at 9:37 P.M., a fall risk score of 20 was documented, indicating Resident 1 was at risk for falls. Per the fall assessment, Resident 1 had one to two falls prior to admission within the past 3 months. Resident 1 was chair bound and had problems with balance when trying to stand. A care plan, titled At Risk for Falls related to Weakness, limited mobility, history of falls was initiated on 5/15/23. The care plan listed interventions such as bed in low position at night, educate the resident about safety reminders, place the call light within reach, and provide appropriate foot ware. According to the facility ' s Nurses Note dated 5/17/23 at 8:20 A.M., Licensed Nurse 1 (LN 1) documented Resident 1 was found on the floor by a Certified Nurse Assistant (CNA 4). The facility ' s post (after) Fall Assessment Risk, dated 5/17/23 at 3:41 P.M., listed the future fall risk score of 14 (a lower score which indicated a lower risk of falls). Balance was listed as jerking or unstable when (resident) made turns. On 10/5/23 at 11:32 A.M., an interview and record review was conducted with LN 1. LN 1 stated residents were required to have a Fall Rik Assessment on admission and then every 3 months. LN 1 stated if a resident had a fall within the facility, then an additional Fall Risk Assessment would be performed after each fall. LN 1 stated the Fall Risk Assessment was important after a fall to evaluate future risk of falls and to implement additional interventions, to avoid any future falls. LN 1 stated if a resident had a fall within the facility, she would expect the Fall Risk Assessment score to go higher, then the previous score. The reason the score would go up to a higher number is because the risk of fall is higher, and more interventions were needed to be put in place. More interventions, such as bed in low position, move the resident closer to the nurse ' s station, frequent checks of the resident, and even 1:1 supervision of the resident. LN 1 reviewed Resident 1 admission Risk Assessment, dated 5/12/23, and stated she completed the assessment with a score of 20, which indicated the resident was at risk of falls. LN 1 then reviewed the post Fall Assessment, dated 5/17/23, which she had also completed. LN 1 stated the post fall score was listed as 14, which was incorrect, because the number should have been listed higher than 20. LN 1 stated when she completed the post fall assessment, she did not review the admission fall assessment. LN 1 stated the difference between the two assessments was section 3 on the post fall assessment, related to ambulation. LN 1 stated she had never seen Resident 1 ambulate while in the facility and she should have 555427 Page 3 of 4 555427 10/25/2023 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated a limited status, which would have raised the fall risk score. LN 1 stated the post fall assessment was incorrect and placed the resident at a higher risk of falls because additional interventions were not put in place. On 10/5/23 at 12:09 P.M., an interview and record review was conducted with the Director of Nursing (DON). The DON stated if a resident experienced a fall while at the facility, she expected the post Fall Assessment score to to be a higher number compared to the previous Fall Assessment. The DON stated Fall Assessments were important to determine the risk of future falls and to implement additional interventions to avoid any future falls. According to the facility ' s policy, titled Fall Prevention Program, dated December 2022, .2. Upon admission, the nurse will complete a fall risk assessment along with along with the admission assessment to determine the resident ' s level of fall risk .8. When a resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post fall assessment . e. Review the resident ' s care plan and update as indicated .f. Document all assessments and actions . 555427 Page 4 of 4