Health inspection·February 15, 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 provide supervision for one of three residents with a fall history (Resident 2). As a result, Resident 2 had a repeat fall and sustained injuries. Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (a condition characterized by loss of memory, language, problem solving and other thinking abilities) and repeated falls according to the facility ' s admission Record. A review of the facility ' s document titled, Fall Risk Observation/Assessment, dated 9/29/23 indicated a score of 20. The document indicated, .A. Low risk 0-8 B. Moderate risk 9-15 C. High risk 16-42 . During a review of Resident 2 ' s progress notes (PN) dated 10/11/23, the PN indicated Resident 2 was found on the floor face down with swelling on the right eye, nosebleed, and erythema (redness) on both upper arms. During a review of the Interdisciplinary Team (IDT- team members with various areas of expertise who work together toward the goals of their residents) fall PN dated 10/12/23, the PN indicated resident was sitting alone in the wheelchair in her room and fell. The PN indicated interventions to not to leave resident unattended in the room. A review of Resident 2 ' s care plans did not include Resident 2 ' s fall incident on 10/11/23. During a review of the facility's document titled, SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Notes for RNs/LPN/LVNs, dated 12/23/23, the SBAR indicated Resident 2 was taken inside the room for medication administration. The SBAR indicated Resident 2 was found on the floor prior to giving the medication. The IDT PN dated 12/26/23 was reviewed. The PN indicated Resident 2 was taken to the room and a CNA who was assisting Resident 2 went out to call for assistance but Resident 2 leaned forward and fell on the floor. The PN indicated an intervention, Not to leave Resident 2 inside the room unless Resident 2 was in bed. During an observation on 2/9/24 at 9:59 A.M., Resident 2 was sitting in the wheelchair in the hallway across the nurse ' s station. Resident 2 ' s eyes were closed and was holding on to a small white stuffed bear. Resident 2 opened her eyes as Certified Nurse Assistant (CNA) 1 approached her. Page 1 of 2 555764 555764 02/15/2024 Palomar Heights Post Acute 1260 E Ohio Avenue Escondido, CA 92027

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 2 was observed with bluish-purplish discoloration (black eye) around both eyes. Resident spoke in a very low voice which was difficult to understand. CNA 1 was interviewed on 2/9/24, at 10:01 A.M. CNA 1 stated Resident 2 had a fall incident on 2/4/24 and was not sure about the details of the fall. CNA 1 stated Resident 2 got restless at times but did not get agitated. CNA 1 further stated Resident 2 was able to follow directions after explanation of instructions. During a review of Resident 2 ' s progress notes (PN) dated 2/4/24, at 11:00 A.M., the PN indicated Resident 2 had a witnessed fall while sitting across the nursing station. The PN indicated a medication nurse was five rooms away in the hallway when Resident 2 ' s chair alarm sounded. The PN indicated the medication nurse saw Resident 2 leaning forward but was not able to stop Resident 2 from falling forward to the floor. The PN further indicated Resident 2 sustained an abrasion on the right knee, bump on the right and left forehead above the eyebrows, and purplish discoloration around the right eye. An interview on 2/9/24, at 11:23 a.m. was conducted with Licensed Nurse (LN) 1 who was the medication nurse who witnessed Resident 2 ' s fall on 2/4/24. LN 1 stated she received report that Resident 2 was at risk for fall. LN 1 stated she was passing medications at the end of the hall, five rooms down from Resident 2 who was on the wheelchair with an overbed table in front of the wheelchair, across the nurse ' s station. LN 1 stated she heard Resident 2 ' s alarm, ran towards Resident 2, but Resident 2 already fell face down on the floor. LN 1 stated the overbed table was on Resident 2 ' s left side with Resident 2 ' s legs straight. LN 1 stated Resident 2 was assessed with a dime sized bump on the left side of the forehead. LN 1 further stated there was no staff at the nurse ' s station monitoring Resident 2. During an interview on 2/9/24, at 11:58 A.M. with CNA 2, CNA 2 stated he was assigned to Resident 2 on 2/4/24. CNA 2 stated Resident 2 was sitting in the wheelchair across the nurse ' s station. CNA 2 stated he left for break later than scheduled and therefore returned later. Upon return from his break, CNA 2 stated staff was already attending to Resident 2, and he was informed Resident 2 fell from the wheelchair. During an interview on 2/15/24 at 1:05 P.M. with the Director of Nursing (DON), the DON stated when a CNA was at lunch there should be someone else monitoring residents and answering call lights. The DON further stated Resident 2 should not have been left alone in the room because the assigned CNA could have used the call light in the room if she needed assistance with Resident 2. A review of the facility ' s policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised March 2018, the P&P indicated, .The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk or with a history of falls .If falling recurs despite initial interventions, staff will implement additional or different interventions . 555764 Page 2 of 2