Health inspection·July 18, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00902571. Representing the Department, HFEN # 42342 A Class A Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations Free of Accident Hazards/Supervision/Devices §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Title 22, California Code of Regulations § 72311. Nursing Service - General (a)Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. Title 22, California Code of Regulations § 72523. Patient Care Policies and Procedures. (a). Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 5/31/2024, the California Department of Public Health (CDPH, the Department) made an unannounced visit to the facility to investigate a complaint allegation regarding resident neglect when the resident had a fall resulting in injury during toileting. As a result of the investigation, the Department determined the facility failed to provide care and services to mitigate the risk of a fall for Resident 3, who was assessed at high risk for recurrent falls by failing to: 1. Ensure Resident 3 received assistance with toileting and Resident 3 was not left in the room unattended as indicated in Resident 3's Care Plan (CP) interventions titled, "High Risk for Fall," created on 3/31/2024. 2. Ensure Resident 3 received adequate supervision to reduce risk factors leading to falls and injury as indicated in the facility's policy and procedures (P & P) titled," Falls Management Program," reviewed in 1/2024. 3. Provide mod/max (moderate/maximum) assist for Resident 3 for peri care (wipe and clean after using the bathroom) and contact guard (help with balance by touching) with minimum assistance when Resident 3 was using the toilet as indicated in Resident 3's Occupational Therapy's (OT) Treatment Encounter Note, dated 4/30/2024. As a result of these failures, on 5/9/2024 at 6:45 p.m., Resident 3 fell while in the bathroom. Resident 3 sustained a mild displaced comminuted subcapital (a hip injury that can have serious complications) fracture of the right femoral neck (right hip). Resident 3 was transferred to a General Acute Care Hospital (GACH) on 5/10/2024 where Resident 3 underwent a closed reduction percutaneous fixation (a surgical procedure to set [reduce] a broken bone without cutting the skin open) of the right femoral neck fracture. A review of the Resident 3's Admission Record indicated Resident 3 was originally admitted to the facility on 10/05/2023 with a subsequent admission on 5/14/2024 with diagnoses that included atrial fibrillation (an irregular and often very rapid heart rhythm), congestive heart failure (CHF- A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), non-displaced fracture of the sixth and seventh cervical vertebra (C6 and C7-broken neck), low blood pressure, Benign Prostatic hyperplasia (BPH- enlarged prostate), abnormalities with walking and repeated falls. A review of Resident 3's Morse Fall Risk Screen (assessment tool for prediction of a resident's potential for experiencing a fall while in a facility) dated 3/27/2024 indicated Resident 3 had a history of falling and was at high risk for recurrent falls. A review of Resident 3's history and physical (H&P) dated 3/28/2024 indicated, Resident 3 has limited capacity to understand and make decisions. The H&P indicated Resident 3 required family assistance with making complex medical decisions. The H&P indicated Resident 3 was admitted to the facility after a recent hospitalization for cervical fracture due to recurrent falls in the facility. The H&P indicated for Resident 3 to wear a cervical thoracic orthosis (CTO- neck brace with piece that extends down to protect the spine) brace when out of bed and wear standard, rigid cervical collar (an instrument used to support the neck and spine and limit head movement after an injury) when in bed and with showers. A review of Resident 3's Care Plan titled" High Risk for Fall," created on 3/31/2024 indicated Resident 3 was at high risk for falls and injury related to limitation of mobility, repeated falls, and low blood pressure. The care plan interventions indicated, "Provide assistance needed in toileting and do not leave the resident unattended." A review of Resident 3's Minimum Data Set (MDS-a standardized assessment and care planning tool), dated 4/3/2024 indicated Resident 3's cognition (mental ability to make decisions for daily living) was moderately impaired. Resident 3 was totally dependent with toileting hygiene and transfers from bed to chair. The MDS indicated Resident 3's ability to get on and off a toilet or commode was not attempted due to a medical condition or safety concerns. A review of Resident 3's Change in Condition Evaluation (COC) form dated 5/9/2024, timed at 6:45 p.m. indicated Resident 3 was found sitting on the bathroom floor wearing a neck brace. The COC form indicated Resident 3 was able to move both arms and legs and denied any pain. A review of Resident 3's GACH X-Ray result of the right femur (thigh), dated 5/10/2024, indicated Resident 3 sustained a mild displaced mildly comminuted subcapital fracture of the right femoral neck. A review of Resident 3's GACH orthopedic record, dated 5/11/2024, indicated Resident 3 underwent a closed reduction percutaneous fixation of the right femoral neck fracture resulting from a right non-displaced femoral neck fracture. During an interview on 5/15/2024 at 11:10 a.m., Resident 5 (Resident 3's roommate) stated on 5/9/2024 (unable to recall the time), a staff member (Licensed Vocational Nurse 1 [LVN 1]) brought Resident 3 in a wheelchair to Resident 3 and Resident 5's room and left Resident 3 in the room watching television. Resident 5 stated he observed Resident 3 wheel himself into the bathroom and close the door. Resident 5 stated, after about 10 minutes, he became concerned because Resident 3 had not come out of the bathroom, so he pushed the call light. Resident 5 stated a staff member (LVN 1) responded to the call light, and he informed the LVN 1 that Resident 3 had been in the restroom for a long time. Resident 5 further stated LVN 1 opened the bathroom door and found Resident 3 on the floor. During an interview on 5/15/2024 at 3:08 p.m. LVN 1 stated on 5/9/2024 (unable to recall the time) she left Resident 3 in his (Resident 3) room sitting in the wheelchair eating dinner. LVN 1 stated after 10 minutes she returned to the nursing station and noticed the call light for Resident 3 and 5's room was on. LVN 1 stated she went to Resident 3 and 5's room and Resident 5 told her that Resident 3 wheeled himself to the bathroom. LVN 1 stated when she opened the bathroom door, she found Resident 3 sitting on the floor. LVN 1 stated she then called for assistance to pick Resident 3 up and put Resident 3 back into Resident 3's bed. LVN 1 stated Resident 3 had a history of falls that resulted in a broken neck and Resident 3 was required to wear a neck brace. LVN 1 stated Resident 3 required supervision while walking. During a concurrent interview on 6/3/2024 at 12:53 p.m., and a review of Resident 1's Change in Condition Evaluation (COC) form dated 5/10/2024, the COC form indicated on 5/10/2024 at 11 a.m., the Physical Therapist (PT) 1 informed LVN 2 Resident 3 was having crucial pain and was refusing physical therapy (PT). LVN 2 stated when she assessed and touched Resident 3's upper right thigh, Resident 3 yelled in pain with facial grimacing. Resident 3 had tried to move Resident 3's leg and verbalized that she has 7/10 pain on the right upper thigh (0 = no pain, 7 = severe pain and 10 = worse pain). LVN 2 stated she notified the Medical Director (MD) and received an order to transfer Resident 3 to the GACH for evaluation. During an interview on 6/3/2024 at 2:48 p.m. Certified Nursing Assistant 1 (CNA 1) stated he was assigned to Resident 3 on 5/9/2024 from 3 p.m. to 11 p.m. CNA 1 stated he saw Resident 3 sitting in his wheelchair in Resident 3's room when he started his shift at 3 p.m. CNA 1 stated that (5/9/2024) was his first-time taking care of Resident 3, so he was not too familiar with Resident 3's care. CNA 1 stated he was not aware Resident 3 was at risk for falls. CNA 1 stated he asked LVN 1 about the level of assistance needed for Resident 3 and was told Resident 3 was able to stand and assist with transfers and Resident 3 had on a neck brace. CNA 1 stated he asked because he did not know the resident and there was no huddle (verbal reports on status and needs of the residents) given before the shift. CNA 1 stated, "I did not know he was confused and started to sundown (a state on confusion that occurs in the late afternoon and lasts into the night) otherwise I would have checked on him more frequently". CNA 1 stated, "I did do more visual checks after the fall for the rest of the evening." CNA 1 stated (on 5/9/2024, at 645 p.m.) LVN 1 flagged him to come to Resident 3 and 5's room and he saw Resident 3 sitting on the bathroom floor. CNA 1 stated he assisted LVN 1 transferring Resident 3 to Resident 3's bed. During a concurrent interview and a review of Resident 3's OT Treatment Encounter Note dated 4/30/2024, on 6/3/2024 at 4 p.m., the Treatment Encounter Note indicated Resident 3 required contact guard assist with minimal assist. Resident 3 required mod/max assist for peri care and brief management for safety due to limited balance. The OT stated Resident 3 was able to stand with contact guard and minimal assistance because Resident 3 has severe impairment in balance. The OT stated Resident 3 needed to be cued to hold on to the grab bar while the OT pulled down Resident 3's pants and wiped Resident 3. The OT stated Resident 3 required 50-75% (percentage) assistance from the OT and needed 50% rest breaks in between tasks because Resident 3 would get tired and lose his balance. The OT stated Resident 3 was able to follow commands, but he had periods of confusion and poor safety awareness overall due to his cognitive impairment. The OT stated Resident 3 required assistance from at least one person to use the bathroom. The OT stated Nursing Staff (in general) were made aware of Resident 3's level of assistance for toileting verbally and they have asked "us, PT/OT staff" to put "our, PT/OT's" notes under the therapy tab in the electronic medical record system so they (nursing staff) could access and review the notes at any time. During an interview on 6/6/2024 at 11:28 a.m. the Director of Nursing (DON), stated Resident 3's cognition was severely impaired at admission, and Resident 3 was admitted as a high fall risk. The DON stated Resident 3 required increased supervision due to high risk for falls. Resident 3 was moved closer to the nursing station after the unwitnessed fall incident on 5/9/2024. The DON could not state why the facility did not provide supervision and assistive devices to Resident 3 to prevent avoidable accidents. The DON stated, "When I did meet him (Resident 3) after the fall, I saw that he was very confused and forgetful, so we decided to call the family to get a personal sitter to sit with him all day." During a concurrent interview on 6/6/2024 at 12:28 p.m. the DON stated Resident 3's level of assistance should be communicated to oncoming staff by outgoing staff and during huddle at change of shift. The DON stated all staff need to be aware that Resident 3 was moderately confused and required moderate assistance to use the bathroom so the staff could have better anticipated Resident 3's needs regarding safety and supervision. A review of the facility's policy and procedures (P & P) titled," Falls Management Program" reviewed in 1/2024 indicated: for staff to provide residents with hazard free environment, adequate supervision and reduce risk factors leading to falls and injury" The P & P indicated, "It is the policy of this facility to provide residents with a safe environment which is free from accident hazard as is possible. The facility will provide residents with adequate supervision and assistive device to prevent accidents. As a result of the investigation, the Department determined the facility failed to provide care and services to mitigate risk of a fall for Resident 3, who was assessed at high risk for recurrent falls by failing to: 1. Ensure Resident 3 received assistance with toileting and Resident 3 was not left in the room unattended as indicated in Resident 3's CP interventions tilted, "High Risk for Fall," created on 3/31/2024. 2. Ensure Resident 3 received adequate supervision to reduce risk factors leading to falls and injury as indicated in the facility's policy P & P titled," Falls Management Program," reviewed in 1/2024. 3. Provide mod/max assist for Resident 3 for peri care and contact guard with minimum assist when Resident 3 was using the toilet as indicated in Resident 3's OT Treatment Encounter Note, dated 4/30/2024. As a result of these failures, on 5/9/2024 at 6:45 p.m., Resident 3 fell while in the bathroom. Resident 3 sustained a mild displaced comminuted subcapital fracture of the right hip. Resident 3 was transferred to a GACH on 5/10/2024 where Resident 3 underwent a closed reduction percutaneous fixation of the right femoral neck fracture. The above violations jointly, separately, or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 3.