Health inspection·December 24, 2024

The following reflects the findings of the California Department of Public Health (CDPH) during annual recertification survey. Recertification Survey: F1YY11 A Class B Citation was issued for Recertification Survey: F1YY11 22 CCR §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. 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. On 12/2/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the annual recertification survey. The facility failed to notify CDPH, Licensing and Certification and the local health officer an unusual occurrence within twenty-four (24) hours of confirmed occurrence unusual occurrences to the State Survey Agency and send a written report within two working days regarding Resident 51 falling. On 5/9/2024, Resident 51 had unwitnessed fall sustained on 5/9/2024 and was transferred to a general acute care hospital (GACH), was diagnosed with head injury, and was admitted further evaluation and management. This deficient practice resulted in delayed investigation for the fall by CDPH. A review of Resident 51's Admission Record indicated Resident 51 was originally admitted to the facility on 4/29/2024 and was re-admitted on 5/17/2024, with diagnoses that included traumatic subdural hematoma (a type of bleeding near the brain that can happen after a head injury) without loss of consciousness, cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and hypertensive chronic kidney disease (a condition in which chronic high blood pressure damages the kidneys). A review of the Fall Risk evaluation dated 4/30/2024, indicated Resident 51 score was 20 (If a total score is 10 or greater, the resident should be considered at high risk for potential falls). A review of the Resident Care Plan dated 4/30/2024, indicated Resident 51 tries to get up of bed unassisted. The resident care plan goal indicated Resident 51 will be free of injury resulting from falls and will not have further fall incidents. The resident care plan interventions included to apply a tab alarm (a device that alerts staff when a resident is moving) in bed, to not leave the resident in room unattended, low bed and floor mat. A review of the History and Physical report completed on 5/20/2024, indicated Resident 51 did not have the capacity to understand and make decisions. A review of Resident 51's Minimum Data Set (MDS - a resident assessment tool) dated 11/21/2024, indicated Resident 51s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated Resident 51 required setup or clean-up assistance with eating and oral hygiene, required substantial to maximum assistance for toileting hygiene, shower bathing and upper and personal hygiene, and was non-ambulatory. A review of the SBAR (an acronym for Situation-Background-Assessment-Recommendation is a technique used to provide a framework for communication between members of the health care team) form and progress notes dated 5/9/2024, indicated that on 5/9/2024 at around 12:40 pm Resident 51 was found on the floor from an unwitnessed fall. Resident 51 was assessed and had no complaints of pain, no visible injuries, vital signs were within normal limits and neuro checks were initiated and Resident 51's doctor was notified of the fall. The doctor order was issued to transfer Resident 51 to GACH for a higher level of care and evaluation. A review of Resident 51's GACH records dated 5/9/2024 indicated, that on 5/9/2024, Resident 51 had an unwitnessed fall and was found down on the ground/next to his bed at the skilled nursing facility. His initial Glasgow coma scale (GCS- neurological assessment tool that measures a patient's level of consciousness and the severity of a brain injury) was 14 (Mild traumatic brain injury). Resident 51 was intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea (airway/windpipe). The tube keeps the trachea open so that air can get through) for altered mental status (AMS- a change in mental function that stems from illnesses, disorders and injuries affecting the brain); a head computerized tomography scan (CT scan) revealed an acute on chronic right frontal convexity subdural hematoma measuring approximately 11 millimeters (mm-unit of measurement) in depth with associated 4mm of leftward midline shift. On 5/10/2024 Resident 51 was admitted to Intensive Care Unit (ICU-a unit in a hospital that provides the critical care and life support for acutely ill and injured patients). During an interview on 12/5/2024 at 4 pm Director of Nursing (DON) stated, "if the acute on chronic injury was due to a fall, facility should have reported fall incident per CDPH guidelines and facility policy." A review of facility policy and procedures titled "Reporting unusual occurrences", dated 7/12/2024 indicated, "the facility shall notify the Department of Health Services, Licensing and Certification and the local health officer(s) by telephone, of all unusual occurrences, within twenty-four (24) hours of the occurrence confirmed in writing or by fax. Policy further states unusual occurrences include but are not limited to ...occurrences which threaten the welfare, safety, or health of residents such as falls with fractures or other injuries that are considered avoidable." The facility failed to notify CDPH, Licensing and Certification and the local health officer an unusual occurrence within 24 hours of confirmed occurrence unusual occurrences to the State Survey Agency and send a written report within two working days regarding Resident 51 falling. On 5/9/2024, Resident 51 had unwitnessed fall sustained on 5/9/2024 and was transferred to GACH, was diagnosed with head injury, and was admitted further evaluation and management. This deficient practice resulted in delayed investigation for the fall by CDPH. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 51.