Health inspection·January 10, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for one of 34 sampled residents (Resident 1) that includes the instructions needed to provide effective and person-centered care when there was an intervention which was not applicable upon admission for Resident 1 who was at risk for fall. This failure had the potential to place Resident 1 at risk not to receive the appropriate intervention to prevent fall. Findings: Review of Resident 1's admission Record indicated, she was admitted to the facility on [DATE] with diagnoses including encephalopathy (a group of conditions that cause brain dysfunction), presence of left artificial hip joint, and orthostatic hypotension (a drop in blood pressure that occurs when moving from a laying down position to a standing position). Review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 3/19/23 indicated, she was cognitively intact. The MDS also indicated, Resident 1 had hip fracture (a partial or complete break in the bone), displacement intertrochanteric fractures of left femur (a kind of the change in position and fracture of thigh bone), and history of falling. During a concurrent interview and record review on 1/10/24 at 10:45 a.m. with Director of Nursing (DON), Resident 1's fall score and Radiology Report were reviewed. DON stated, She fell at home, then she had a hip fracture. She had ORIF (Open Reduction and Internal Fixation, a type of surgery used to stabilize and heal a broken bone), then she came to us for rehab . DON stated, the resident's fall score was 13 upon admission on [DATE]. DON stated, a fall score above 10 was at risk for fall. DON stated, Resident 1 had unwitnessed fall on 4/12/23 around 4:45 p.m. DON stated, Resident 1 was sitting in wheelchair, and it was locked for her safety. DON stated, her bed was next to Resident 1, and a table was in front of her because she was waiting for her dinner, then she had unwitnessed fall. DON stated, We don't know why. She couldn't tell us why she fell. DON stated, there was a small skin tear on the left thumb, and it was not bleeding. Otherwise, there was no injury. DON stated, during the neuro check (an evaluation of a person's nervous system), Resident 1 was noted skin discoloration on her right mid back, and that's why the doctor ordered stat X-ray. DON stated, otherwise Resident 1 was fine. DON stated, We ordered stat X-ray on 4/12, then it was done next day, then had a result on 4/14. Radiology Report dated 4/13/23 indicated, . Right 7th rib fracture . DON stated, they sent her to the hospital, but she refused treatment, so she returned the same day. So, we monitored her for her safety. DON stated, Resident 1 left the facility at 10:30 a.m. on 4/14/23 without chief Page 1 of 2 555827 555827 01/10/2024 Atherton Park Post-Acute 1275 Crane Street Menlo Park, CA 94025

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few complaint, then came back from the hospital at 5:30 p.m. on 4/14/23. DON stated, CT scans (a computerized x-ray imaging procedure to check any part of the body) were offered in the hospital, but Resident 1 and her son refused. DON stated, the resident had history of orthostatic hypotension. Review of Resident 1's clinical record titled, Provider Note from the hospital, dated 4/14/23, indicated, . Patient recently sustained a rib fracture on the right side after a fall on 4/12 . Medical Decision Making . status post recent hip fracture who sustained unwitnessed fall on 4/12 with right seventh rib fracture transferred here today from SNF (Skilled Nursing Facility) without clear chief complaint and no endorsed symptomatology or focal complaints by patient (other than right rib pain at site of fracture) . son . at bedside . He is a physician and felt he would be better to forego scanning/radiographs . Patient discharged to SNF . with recommendation to follow-up with primary care provider and return precautions given . Son declines CT scans for pt (patient) . Long discussion with son who is a physician . During a concurrent interview and record review on 1/10/24 at 11:40 a.m. with DON, Resident 1's fall care plan (CP) upon admission reviewed. The CP indicated, . The resident is at risk for falls . Hx (history) of repeated falls . Date initiated: 03/16/2023 . Review information on past falls and attempt to determine cause of falls. Record possible root causes . Resident is HIGH FALL RISK . DON stated, it was for falls at the facility, not the previous falls at home, so she did not have the record when asked if there was a documentation for root causes and information on past falls for Resident 1 upon admission. DON stated, this care plan was intended to remind staff to check for possible root causes when a resident falls at the facility. When asked if it was applicable care plan for the resident upon admission, DON stated, it was not applicable care plan for the resident at that time. Review of the facility's Policy and Procedure titled, Care Plans-Baseline revised in March 2022 indicated, . A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident . 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident . 555827 Page 2 of 2