Health inspection·January 19, 2024

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 ensure their post-fall protocol and prevention was implemented in accordance with the facility's policy and procedure for one of three sampled residents (Resident 1) when Resident 1 had a fall incident on December 2, 2023. This failure had the potential to place Resident 1 at risk for further falls and injuries. Findings: During an observation on Resident 1, on January 4, 2024, at 12:15 PM, in Resident 1's room, Resident 1 was lying in bed with the head of the bed elevated. A review of Resident's 1's admission Record (a document that gives summary of the resident's information) indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses that included dementia(a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), mood disturbance (feeling of distress or sadness, or symptoms of depression and anxiety), and anxiety(feeling of fear, dread, & uneasiness). A review of Resident's 1 nursing notes, dated December 2, 2022, at 3:22 PM, indicated Slipped out wheelchair at 14:05 (2:05 PM) in activity area. unwitnessed. Head to toe assessment done. Take to ER by gurney . Back from ER at 14:35. No injuries reported upon return to SNF. Need to consider a wheelchair alarm . During a review of Resident 1's clinical records provided by the facility on January 9, 2024, there was no documented evidence to indicate that a Physical Therapist evaluated Resident 1 following a fall incident on December 2, 2023. During a telephone interview with a Physical Therapist (PT 1), on January 16, 2024, at 5:17 PM, PT 1 stated that PT evaluation was not ordered after Resident 1's fall incident on December 2, 2023. PT further stated the purpose of PT evaluation post fall, as per facility protocol, was to identify the risk factors of the fall incident, such as incontinence, confusion, weakness, and environmental hazards, and for them [PT] to recommend measures to prevent fall incidents such as resident reorientation, bed and chair alarm, placing of bed mat, frequent monitoring and toileting. During a telephone interview with the Assistant Director of Nursing, on January 18, 2024, at 10:55 AM, the ADON stated that a Physical Therapist did not evaluate Resident 1 following a fall incident per facility protocol because the nurse on duty failed to place an order for Physical Therapy Page 1 of 2 555527 555527 01/19/2024 Southern Inyo Hospital D/P Snf 501 E Locust Lone Pine, CA 93545

F 0689 evaluation. Level of Harm - Minimal harm or potential for actual harm During a record review of the facility's undated policy and procedure titled, Fall Protocol & Prevention indicated .Physical Therapy will be notified via email and order entered (per Dr .) for assessment post fall . Residents Affected - Few 555527 Page 2 of 2