Health inspection·October 13, 2023

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to correctly identify one (Resident 1) of three sampled residents as a high fall risk and revise the fall care plan accordingly and as needed to maintain Resident 1's physical well-being. This failure resulted in an uwitnessed fall and Resident 1 sustained a subdural hematoma (a collection of blood in the top of the brain), left humeral head fracture (broken upper arm bone) and fracture of the pubic ramus (broken bone in the pelvis) requiring hospitalization. Findings: A review of Resident 1's admission record indicated resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness, cancer of the spine, difficulty in walking, abnormalities of gait (manner of walking), and mobility. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 6/26/23 indicated Resident 1 was cognitively intact. Furthermore, Resident 1 needed supervision when the resident moved between surfaces including to and from bed and into a standing position. A review of Resident 1's Change in Condition assessment dated , 7/26/23 at 4:20 a.m., by Licensed Vocational Nurse 1 (LVN 1), indicated Resident 1 had an unwitnessed fall and was found lying in bed with an injury to the left eyebrow and left forehead. A review of Resident 1's hospital History and Physical notes, dated, 7/26/23 at 5:07 a.m., indicated the resident was admitted to the Intensive Care unit (ICU, which provides treatment for critically ill patients) with diagnoses of subdural hematoma, left humeral head fracture and fracture of the pubic ramus. During an interview on 8/3/23, at 11:30 a.m., with Resident 1, Resident 1 had a hard time remembering the incident that caused his injuries. During an interview on 8/3/23, at 11: 57 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, on 7/26/23 at 4:15 a.m., she was sitting in the hallway, and was approximately five feet away from the door of Resident 1's room. CNA 1 stated she heard the sound of Resident 1's walker but did not see Resident 1 get up to the bathroom and again later heard the sound of his walker. CNA 1 stated, she did not assist Resident 1 because the resident was independent in ambulating with a walker and was not a fall risk. CNA 1 further stated after two to three minutes, Resident 1's call light was Page 1 of 3 555466 555466 10/13/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0656 Level of Harm - Actual harm Residents Affected - Few turned on and when CNA 1 answered the call light, she stated she saw Resident 1 lying in his bed holding the call light with both hands. CNA 1 further stated she saw Resident 1 with a cut on his left eyebrow and a bump on his left, upper forehead. Resident 1 was refusing to move his left arm. CNA 1 stated Resident 1 was never confused in the past and was confused. Resident 1 was only able to state his name, did not know where he was, did not know his birthdate or how he fell. CNA 1 stated she did not hear Resident 1 fall but found a smear of blood outside the door of Resident 1's bathroom. CNA 1 stated Licensed Vocational Nurse (LVN)1 assessed the resident and called 9-1-1. A review of the 9-1-1 first responder, Emergency Medical Technician- Paramedic (EMT-P, a medical professional who specializes in emergency treatment) notes dated, 7/26/23 at 5:36 a.m., indicated, Per staff, patient had an unwitnessed fall at some point during the night and was found lying on his back next to his bed. Patient was assisted to his bed and staff called 9-1-1 due to increased ALOC (altered level of consciousness) and the injury to the patient's head .Staff reports that patient is normally alert and oriented x 3 (aware of time, place, and person) walking and talking. A review of Resident 1's Nurse's Note dated, 7/26/23 at 4:20 a.m., by LVN 1 indicated, Resident 1 was sent to the hospital emergency room via 9-1-1 for further medical evaluation. A review of the physician's order dated 7/27/23 at 5:00 a.m., indicated, May send resident to the ER (Emergency room) for further evaluation via 9-1-1. During a concurrent interview and record review, on 8/3/23 at 12:52 p.m., with the Administrator registered nurse (ADM), Resident 1's Fall Risk Assessment (a screening tool used to assess Resident 1's risk of falling), dated 6/17/23 was reviewed. The fall risk assessment indicated a score of 7 (10 was considered high risk for fall). The fall risk assessment indicated, Resident 1's balance problem while walking (additional score of 1) and Resident 1's medications of Losartan (a medication to control high blood pressure) and Spironolactone (a medication which makes the body get rid of extra fluids), for an additional score of 2, were not added to the initial fall risk assessment score of 7. ADM acknowledged Resident 1's fall risk assessment score should have been 10 (high risk) for falls and was scored incorrectly. ADM also stated Resident 1 was referred for physical therapy evaluation on 7/10/23 because Resident 1 was leaning forward when using the walker. A review of Resident 1's care plan, titled Falls, dated 3/13/23 indicated the resident was at risk for falls due to cardiac dysrhythmia (abnormal heartbeat) and hypotension (low blood pressure). The care plan indicated a goal that Resident 1 will be free from injuries and the interventions were, to assist Resident 1 with ADLs (activities of daily living) as needed, evaluate resident's physical abilities at least on a quarterly (every 3 months) basis .and provide cueing/supervision as needed. A review of Resident 1's care plan titled, Cognition, dated 3/13/23 indicated the resident had poor cognitive skills as evidenced by poor/lack of safety awareness with risk of injury. During an interview on 9/22/23, at 10:45 a.m., with Director of Nursing (DON), DON stated CNA 1 should have checked on Resident 1 when CNA 1 heard the resident go to the bathroom. DON stated staff were educated by the facility on fall prevention but was unable to show documentation of fall prevention training. A review of the Physician's Order dated 7/10/23 indicated for Resident 1 to have a physical therapy (PT) evaluation for gait training and muscle weakness. 555466 Page 2 of 3 555466 10/13/2023 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0656 Level of Harm - Actual harm During an interview on 8/18/23, at 2:45 p.m., with Physical Therapist (PT) 1, PT 1 stated she did the PT evaluation on Resident 1 and Resident 1 was a high risk for falls. PT 1 further stated Resident 1 needed contact guard assist or someone had to be there to assist the resident in transferring and walking with the four-wheel-walker and told the Rehabilitation Director (RD). Residents Affected - Few A review of Resident 1's Physical Therapy Evaluation and Plan of Treatment (PTEPOT), dated 7/14/23 by PT 1, indicated the goals for Resident 1 were to be safe and reduce fall risks. Also, Resident 1 needed contact guard assist (CGA, the caregiver places one or two hands on the patient's body to help with balance) in transfers and in ambulation with the four-wheel walker (FWW). During an interview on 8/29/23, at 1: 57 p.m., with RD, RD stated Resident 1 was referred for rehabilitation due to being a high fall risk and reported to ADM the result of PT 1's evaluation. During another interview, on 9/25/23 at 4:21 p.m., with ADM, ADM confirmed RD communicated Resident 1 was identified as high fall risk. A review of Resident 1 ' s fall care plan, dated 3/13/23, was not revised after PT 1's evaluation on 7/14/23 for high fall risk interventions. During a review of the facility's policy and procedure (P&P) titled, Fall Prevention Policy and Procedure, the P&P indicated, Staff will incorporate appropriate safety interventions, in the least restrictive environment, to help reduce the incidence of falls . The interdisciplinary (group of healthcare professionals working together) clinical team will use their initial assessment to determine how to provide the safest environment for each patient . Safety education is provided to patients, family, and staff . Upon admission Nursing staff will assess each resident and determine if they are a fall risk. A care plan will be initiated and carried out. 555466 Page 3 of 3