Health inspection·December 11, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00926530. 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. Code of Federal Regulations, Title, 22, 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least 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. California Code of Regulations, Title 22, Section 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 11/5/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident neglect. The facility failed to: 1. Ensure Resident 1 who had a history of falls and was identified to have fall risk indicators was not left unattended when the certified nursing assistant (CNA) left Resident 1 sitting on the edge of the bed on 11/5/2024. 2. Identify fall precautions and adopt and implement a plan of care for Resident 1 to ensure that Resident 1 was attended during transitions and bed mobility. 3. Ensure CNA 1 was trained in fall prevention techniques. These failures resulted in Resident 1 falling on 11/5/2024 at 12:12 am and being sent to General Acute Care Hospital (GACH) on 11/5/2024. Resident 1 sustained a mildly displaced right 10th through 12th rib fracture, right 10th rib segmental fracture and severely impacted proximal humeral fracture. A review of Resident 1's admission record indicated a 74-year-old female was admitted to the facility on 10/2/2024 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood), history of falling, unsteadiness on feet, and need for assistance with personal care. A review of Resident 1's Nursing documentation evaluation dated 10/2/2024 at 4:55 pm, indicated Resident 1 was identified with a fall risk indicator. A review of Resident 1's Nursing documentation evaluation dated 10/2/2024 at 4:55 pm, indicated Resident 1 with fall risk factors including history of falls in last 6 months and was on psychotropic (relating to or denoting drugs that affect a person's mental state) and cardiac (relating to drugs treat heart condition) medications. A review of Resident 1's History and physical (H&P) dated 10/4/2024 indicated Resident 1 did not have the capacity for medical decision making due to cognitive decline (the mental processes that allow people to think, understand, and complete tasks). A review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/7/2024, indicated Resident 1 had moderate cognitive impairments. The MDS indicated Resident 1 required substantial/maximal assistance for most of her Activities of Daily Living (ADLs-such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating) and partial/moderate assistance for oral hygiene, personal hygiene. A review of Resident 1's Care Plan initiated 10/4/2024 indicated Resident 1 was at risk for falls due to impaired mobility. The interventions included to monitor for and assist with toileting needs. A review of Resident 1's Care Plan initiated 10/4/2024 indicated Resident 1 was at risk for falls due to impaired mobility. The interventions included Therapy/Rehab-PT (physical therapy) treatment and to provide verbal cues for safety and sequencing when needed; to provide verbal cues for proper pacing and energy conservation techniques; to place call light within reach while in bed or close proximity to the bed; to remind resident to use call light when attempting to ambulate or transfer; to maintain a clutter-free environment in the resident's room and consistent furniture arrangement; when resident is in bed, to place all necessary personal items within reach; and to monitor for and assist toileting needs. A review of a Change of Condition (COC) dated 11/5/2024 at 12:12 am, indicated Resident 1 had a fall on 11/5/2024. The COC indicated Resident 1 was seen sitting on the floor next to the foot of the bed in her room and had pain 10/10 (10 being the worst) to the back after the fall. The COC indicated Resident 1 was transferred to the hospital per her request and the MD (Medical Doctor) was made aware. A review of a Physician's Order dated 11/5/2024 indicated "Transfer to Acute hospital via 911 for further eval (evaluation) s/p (status post-after) fall. A review of the computed tomography scan (CT scan)- dated 11/5/2024 at 4:57 am indicated "Recent appearing mildly displaced right 10th through 12th rib fractures. The CT scan indicated the right 10th rib fracture is segmental. Recent. appearing severely impacted proximal humeral fracture." During an interview on 11/6/24 at 10:54 am, Family Member (FM) 1 stated she spoke with the Licensed Vocational Nurse (LVN) 1 who informed her that Resident 1 had a fall earlier that morning (11/6/24) and had requested to be sent to GACH because Resident 1 was experiencing severe pain which had not resolved after the resident had taken some pain medication. FM 1 stated that she (FM 1) called the GACH where Resident 1 was admitted and was informed that Resident 1 had a right hip and several rib fractures. During an interview on 11/6/2024 at 1:45 pm, LVN 1 stated Resident 1 was incontinent of bowel and bladder and did not get up overnight (on 11/5/2024). LVN 1 stated she changed Resident 1's incontinence briefs in the bed. LVN 1 stated she heard a scream coming from Resident 1's room around midnight and when she (LVN 1) got to Resident 1's room, she found Resident 1 on the floor. LVN 1 stated CNA 1 who was assigned to Resident 1 reported that Resident 1 asked to be taken to the bathroom, so CNA 1 sat Resident 1 on the side of Resident 1's bed with the resident's feet on the floor and went to the bathroom "to get it prepared". LVN 1 stated according to CNA 1 while in the bathroom, she (CNA 1) heard Resident 1 scream, CNA 1 ran back to the room, and found Resident 1 on the floor. She stated that Resident 1 was a fall risk and Resident 1 should not have been taken out of bed and left unsupervised. During an interview on 11/6/24 at 2:15 pm, the Assistant Director of Nursing (ADON) stated that Resident 1 was a fall risk because she had a history of falls, had some cognitive impairments, and had a (history of) humerus (arm bone) fracture. The ADON stated that Resident 1 should not have been left sitting at the bedside unsupervised to prevent falls. During a review of the facility's policy and procedure (P&P) titled, "Fall Management," with an effective date 5/26/2021, the P&P indicated, "To reduce risk for falls and minimize the actual occurrence of falls." The same P&P indicated; "Patients will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury." The facility failed to: 1. Ensure Resident 1 who had a history of falls and was identified to have fall risk indicators was not left unattended when the CNA left Resident 1 sitting on the edge of the bed on 11/5/2024. 2. Identify fall precautions and adopt and implement a plan of care for Resident 1 to ensure that Resident 1 was attended during transitions and bed mobility. 3. Ensure CNA 1 was trained in fall prevention techniques. These failures resulted in Resident 1 falling on 11/5/2024 at 12:12 am and being sent to GACH on 11/5/2024. Resident 1 sustained a mildly displaced right 10th through 12th rib fracture, right 10th rib segmental fracture and severely impacted proximal humeral fracture. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.