Health inspection·December 13, 2021

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. On 11/5/2021, an unannounced visit was made to the facility to conduct a recertification survey. Resident 68 had fall at the facility that resulted in a right hip fracture. The facility failed to: 1. Follow the facility’s policy and procedure on reporting an unusual occurrence. Resident 68’ s was an 87-year-old Female admitted to the facility on 3/13/15. Resident 68’s diagnoses included generalized muscle weakness, osteoarthritis (degeneration of joint cartilage and the underlying bones) and essential hypertension (elevated blood pressure without a known secondary cause). During a review of Resident 68's Minimum Data Set ([MDS] an assessment and care screening tool), dated 10/01/20, the MDS indicated Resident 68’s cognition (thought process) was not intact, and Resident 68 could not make decisions for self. The MDS further indicated Resident 68 needed extensive assistance from staff when transferring from a bed to chair or wheelchair. During an interview on 11/2/21, at 12:16 pm, Resident 68’s family member (FM 1) stated that Resident 68 had a fall in the facility. FM1, stated the facility told her Resident 68 fell while attempting to get out of bed, and sustained a broken right hip that required surgery. During a concurrent interview and record review, on 11/04/2021, with Licensed Vocational Nurse (LVN 2), of Resident 68’s care plan titled, Risk for Falls dated 9/06/21, LVN 2 stated the care plan indicated the clip alarm (a mobile alarm that is attached to the residents clothing that would sound if the resident attempted to get up in the wheelchair) was discontinued on 3/29/2021. LVN 2 stated that Resident 68 was a fall risk due to a history of falls, barely walking, wheelchair use and lap buddy (a cushioned device that fits in a wheelchair and assists with reminding a person not to get up) usage. During an interview on 11/4/21, at 10:02 a.m., LVN 2 stated the facility did not report Resident 68’s fall incident, nor post fall surgery, to the Department (DPH). During a record review of a document titled, “Incident Falls Investigation Report,” dated 8/30/21, the report, indicated on 8/27/2021 at 7:30 p.m., Resident 68 fell out of bed unwitnessed. The report, however, did not indicate Resident 68’s fall was reported to DPH from the facility. During an interview with Director of Nursing (DON), on 11/05/2021, at 9:48 a.m., DON stated the process for reporting a fall was the same as reporting every other incident. DON state when a resident fell, the resident’s family and the facility’s Administrator (ADM) were notified, and the fall incident investigated. During an interview with Administrator (ADM 2), on 11/05/2021, at 10:44 a.m., ADM 2 stated an unwitnessed fall with injury was not an unusual occurrence and did not need to be reported. During a review of Resident 68’s Physician’s Transfer Summary Orders dated 8/27/21, the orders indicated Resident 68’s transfer to a general acute care hospital (GACH) was necessary due to Resident 68’s fall with complaints of pain to the right hip and upper leg. During a review of the clinical radiology record dated 08/27/21 at 9:48 p.m., the clinical radiology record indicated Resident 68 had a right hip fracture. During a review of GACH orders dated 08/28/21 at 08:49 a.m., the orders indicated Resident 68 was admitted to the surgical unit for right hip arthroplasty (a surgical procedure to restore the function of a joint). During a review of the facility’s undated policy and procedure (P/P) titled Unusual Occurrence Policy, the P/P indicated the facility will report unusual occurrences which threatened the welfare, safety or health of patients, to the Health Department (Licensing and Certification). The P/P also indicated the facility will notify the health department and the report of the incident will be kept in the incident file and retained for at least one year. In violation of the above cited standards, the facility failed to: 1. Follow the facility’s policy and procedure on reporting an unusual occurrence. This violation(s) caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a resident.