Other·March 11, 2024

The following reflects the findings of the California Department of Public Health during the investigation of a complaint number CA00879988. Representing the Department, Health Facility Evaluator Nurse # 43452 A Class B State citation was written. 22 CCR § 72541 Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. 22 CCR § 72521 Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. On 1/17/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about a resident's accident. The facility failed to ensure a resident who was identified as a high risk of fall received adequate and continuous supervision and monitoring to prevent falls and injury for Resident 1 by failing to: 1. To report the injury of unknown origin to CDPH. 2. Ensure Resident 1 was supervised when he was left alone on 1/13/2024 at 9:44am in his room while sitting on a wheelchair. As a result, Resident 1 was on the floor for approximately 24 minutes alone and was found by Family Member 1 (FM 1) on 1/13/2024. Resident 1 sustained an abrasion (is a wound where an area of your skin rubs off) on frontal scalp (is the area located just in front of the head. It covers the hairline and the hair around the temples) area. The abrasion needed daily cleanse and applications of bacitracin (topical antibiotic [medication used to treat/prevent infections] ointment) ordered by the Physician. A review of Resident 1's Admission Record indicated Resident 1, a 86 years old male was admitted to the facility on 9/1/2017 with diagnoses including Parkinson's disease (a disorder in the brain that affects movement, often including tremors), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), dementia (loss of cognitive functioning-thinking, remembering, and reasoning), contracture of muscle, upper arms (occurs when muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) and dysphagia (difficulty swallowing food or liquid). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 12/28/2023, indicated Resident 1 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making. Resident 1 was fully dependent from staff for activities of daily living (ADL-eating, oral hygiene, toileting hygiene, upper and lower body dressing, roll left to right, lying to sitting on side of bed, and chair/bed-to-chair transfer). A review of Resident 1's Care Plan for high risk for falls and injury, initiated on 1/6/2020 and revised on 1/25/2024, indicated intervention included to provide assistance needed with transfers. A review of Resident 1's Care Plan for at risk for injury from tremors, involuntary muscle movement and muscle twitching related to Parkinson's disease, initiated on 1/6/2020, indicated a goal that Resident 1 will not have significant injury if increased tremors (repetitive, involuntary shaking of a body part, most commonly the hands or head), involuntary movement, muscle twitching occurs through the next review date, and resident will have no significant injury and will be able to cope with physical limitation and progression of the disease. A review of Morse Fall Risk Screen (a commonly used assessment tool to predict a patient's potential to experience a fall while in a healthcare facility) dated 1/13/2024, indicated Resident 1 scored 51 (a score of 45 and higher indicated the resident was at a high risk for falls). A review of Resident 1's Change of Condition (COC - a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) dated 1/13/2024 at 12:19 p.m., indicated, [Resident 1] had an unwitnessed fall. [Resident 1] was found lying on the floor next to wheelchair. [Resident 1] had a minor abrasion on crown of head..." During an observation in Resident 1's room and concurrent interview on 1/17/2024 at 10:52 a.m., Resident 1 was observed sitting on a wheelchair inside by himself with his eyes closed. Resident 1 was observed with an abrasion on the crown of the head. Resident 1 was unable to move his bilateral (both) upper and lower extremities (arm and legs) on his own. Resident 1 was nonverbal (not able to speak) and did not open his eyes when interviewed. During an interview with certified nursing assistant 1 (CNA 1) on 1/17/2024 at 1:45 p.m., CNA 1 stated, she was assigned to Resident 1 on 1/13/2024. CNA 1 stated, Resident 1 is fully dependent on staffs for ADL care, does not move his body on his own and nonverbal. CNA 1 stated, she transferred Resident 1 from bed to wheelchair using a Hoyer lift machine in the morning of 1/13/2024 after providing ADL care, left the resident's room and did not check on Resident 1 again. CNA 1 further stated, she clocked out for lunch on 1/13/2024 at 11:30 a.m. CNA 1 stated CNA 2 was covering for her and was monitoring the residents assigned to her [CNA 1] while she was on lunch break. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 1/17/2024 at 3:32 p.m., LVN 1 stated that on 1/13/2024, while she was passing noon time medications, FM 1 came up to her and reported that Resident 1 was on the floor. LVN 1 stated, she immediately went inside Resident 1's room and saw Resident 1 lying on his right side and found an abrasion on the crown of Resident 1's head. LVN 1 further stated, the last time she went in Resident 1's room was on 1/13/2024 at approximately 9 a.m., morning when she administered morning medications to Resident 1. During a review of the facility's video surveillance camera (Camera #1) with Administrator (ADM) and Assistant Director of Nursing (ADON) on 1/24/2024 at 11:36 a.m., the timeline that CNA 1 CNA 1 was seen inside Resident 1's room entering with linen cart and linen, ADON confirmed CNA 1 was doing the morning ADL care to Resident 1 was as follows: I. 1/13/2024 at 9:03 a.m. - LVN 1 entered Resident 1's room holding a drink supplement and a cup of apple sauce. II. 1/13/2024 at 9:11 a.m. - CNA 1 entered Resident 1's room with a linen cart. III. 1/13/2024 at 9:44 a.m. - CNA 1 exited Resident 1's room, since then, no staffs were seen entering Resident 1's room. IV. 1/13/2024 at 11:08 a.m., a sudden movement was seen inside Resident 1's room that appeared like a person fell on the floor while there was no one else inside the resident's room. V. 1/13/2024 at 11:30 a.m., - FM 1 was passing by and looked inside Resident 1's room and then went to talk to LVN 1 VI. 1/13/2024 at 11:31 a.m. - LVN 1 went to see Resident 1, looked inside the room and immediately called staffs for help. VII. 1/13/2024 at 11:32 a.m., - LVN 1 was seen inside Resident 1's room next to the person on the floor. LVN 1 remove the cloth from Hoyer lift and laid the cloth on the floor. VIII. 1/13/2024 at 11:33 a.m., CNA 4 and LVN 4 entered Resident 1's room and assisted LVN 1. During an interview with CNA 2 on 1/24/2024 at 2:51 p.m., CNA 2 stated, the incident of Resident 1 falling from the wheelchair happened while CNA 1 was on her lunch break. CNA 2 stated, she was busy with her assigned residents, and she was not covering CNA 1 while she was on her (CNA 1) lunch break. During an interview with ADON, on 1/29/2024 at 2:35 p.m., ADON stated, Resident 1 should be monitored and not left alone in the room while sitting on the wheelchair for a long period of time (From 9:44 a.m. to 11:31 a.m.) ADON stated and confirmed, the facility did not monitor Resident 1 while CNA 1 was on lunch break. ADON further stated, "No one knows how [Resident 1] ended on the floor and how he sustained the abrasion on the top of his head." During an interview with CNA 1 on 1/17/2024 at 1:45 p.m., CNA 1 stated, she was assigned to Resident 1 on 1/13/2024 7-3pm shift, CNA 1 stated that on 1/13/2024 morning, CNA 2 assisted her transfer Resident 1 from bed to wheelchair using a Hoyer lift machine after providing morning ADL care to Resident 1. CNA 1 further stated, she clocked out for lunch on 1/13/2024 at 11:30 a.m., and that CNA 2 was covering her and monitoring the residents assigned to her while she was on lunch break. During an interview with CNA 2 on 1/24/2024 at 2:51 p.m., CNA 2 stated that on 1/13/2024 at around 10:15 a.m. to 10:30 a.m., she helped CNA 1 transfer Resident 1 from bed to wheelchair using a Hoyer lift machine. CNA 2 stated, she clocked out for lunch on 1/13/2024 at 11:00 a.m. Surveyor notified CNA 2 that the facility's surveillance camera video recording was reviewed, and that CNA 2 was not seen entering Resident 1's room on 1/13/2024 from 9:03 a.m. to 11:08 a.m. CNA 2 then stated, she entered Resident 3's room and went inside Resident 1's room through the shared shower room for Resident 1 and Resident 3. During a review of the facility's video surveillance camera (Camera # 2) on 1/30/2024 at 10:18 a.m., indicated CNA 2 was nowhere near Resident 3's room and did not enter Resident 3's room on 1/13/2024 from 9:03 a.m. until 12:30 p.m. During an interview with DON on 1/29/2024 at 3:34 p.m., DON stated, "there should be at least two people (staff) while using a Hoyer lift machine, if not, this is unsafe, and it puts residents at risk of accidents and as well as the staffs." DON further stated, the facility should have monitored Resident 1 while the assigned staff (CNA 1) was on break. DON stated Resident 1 should have not been left alone for a long period of time while sitting on a wheelchair. A review of the facility's policy and procedures (P&P) titled, "Prohibition of abuse, neglect and/or misappropriation of resident property and mandated reporting", reviewed on 1/2024, indicated, "The facility will maintain an environment as free of accident hazards as possible, and that each resident receives adequate supervision." A review of the facility's P&P titled, "Hoyer Lift", reviewed on 1/2024, indicated, "Hoyer Lifts shall be used to transport residents/patients from their bed to the chair/bed and back... At least two (2) trained staff members are recommended to be present to assist with residents/patients being transported in a Hoyer Lift." A review of the facility's P&P titled, "Repositioning", reviewed on 1/2024, indicated, "Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning... Evaluate residents who sit or recline in a chair with the back of the chair (or the back of the bed) elevated to or above a 30-degree angle... does the resident need position changes more frequently than hourly." A review of the facility's P&P titled, "Falls and Fall Risk, Managing," reviewed on 1/2024, indicated, "Based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling... A review of the facility's P&P titled, "Assessing Falls and Their Causes", reviewed on 1/2024, indicated, "Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly." The facility failed to ensure a resident who was identified as a high risk of fall received adequate and continuous supervision and monitoring to prevent falls and injury for Resident 1 by failing to: 1. To report the injury of unknown origin to CDPH. 2. Ensure Resident 1 was supervised when he was left alone on 1/13/2024 at 9:44am in his room while sitting on a wheelchair. As a result, Resident 1 was on the floor for approximately 24 minutes alone and was found by Family Member 1 (FM 1) on 1/13/2024. Resident 1 sustained an abrasion (is a wound where an area of your skin rubs off) on frontal scalp (is the area located just in front of the head. It covers the hairline and the hair around the temples) area. The abrasion needed daily cleanse and applications of bacitracin (topical antibiotic [medication used to treat/prevent infections] ointment) ordered by the Physician. The above violation had a direct relationship to the health, safety, and security of Resident 1.