Health inspection·August 7, 2024

F689 The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00901349. Class A Citation was written. 42 C.F.R §483.25(d) Free of Accidents §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. 42 C.F.R. § 483.40 Behavioral Health Services Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. 22 CCR §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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient.] 22 CR §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 achieved. 22 CR §72543. Patients' Health Records. (f) Patients' health records shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each patient. On 6/20/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a facility-reported incident investigation regarding quality of care. The facility failed to ensure, Resident 1, who was assessed as high risk for falls, did not fall four times and sustained injuries. The facility failed to: 1. Ensure Resident 1, whose identified care needs included psychiatric and physical fall and self-harm risks, remained adequately supervised and free of accidents by providing her with a full-time 1:1 sitter (one to one staff that is immediately at hand to help prevent a fall or redirect a patient from engaging in a harmful act) per a care plan titled, "High Risk for Injury/Accidents and Falls," dated 11/24/23, to prevent Resident 1 from falling on 1/25/2024, 4/11/24, 4/28/24, and 5/7/2024 and sustain injuries. 2. Review, evaluate, and update the patient care plan by ensuring that after Resident 1's first fall on 1/25/2024, the resident's care plan titled "High Risk for Injury/Accidents and Falls," interventions for the prevention of falls, were evaluated for effectiveness to prevent Resident 1 from future falls on 4/11/2024, 4/28/24, and 5/7/2024. 3. Ensure staff provided Resident 1 with 1:1 sitter to assist the resident with supervision in accordance with the facility policy and procedure (P&P) titled, "Sitters." 4. Develop an individual, written patient care plan upon admission to include a fall risk evaluation to achieve the objective of reducing Resident 1's fall risk based on identified care need including history of repeated falls. 5. Properly document in detail consistent with good medical practice the reporting of Resident 1's fall on 9/28/23 to licensed attending provider, or alternatively, to report fall on 9/28/23 to licensed attending to provider. 6. Provide Resident 1, who demonstrated aggressive behaviors toward self and others that included attempting to throw herself on the floor, and who lacked decision-making capacity, with a 1:1 sitter as part of the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care reflecting her identified fall and behavioral risks. 7. Document on Resident 1's "Fall Risk Evaluation" form that a physician was notified when Resident 1 fell and suffered a laceration on the forehead on 9/28/2023. These deficient practices resulted in Resident 1 falling on 1/25/2024 and sustaining dislocated (a separation of two bones where they meet at a joint) left hand 5th finger, left arm ulna (a bone in the forearm (the region of the upper limb between the elbow and the wrist)) shaft (a long structure) fracture (break in bone), and subsequent falls on 4/11/24 and 4/28/24 without injuries, and another fall on 5/7/2024 when the resident sustained a hematoma on the right eyebrow requiring transfer to the acute care hospital (GACH) for evaluation and treatment. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 72-year-old female, was admitted to the facility on 8/29/23 with diagnoses including an unspecified injury of the head, repeated falls, and an unspecified psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality). A review of Resident 1's Care Plan (CP) titled "High Risk for Injury/Accidents and Falls," dated 9/18/23, indicated Resident 1 was a high risk for falls and injuries, with a history of falls and an actual fall on 9/18/23.The CP goals included Resident 1 would have no injury/accidents or falls in the next three months. The CP interventions (specific care and services facility staff needed to provide a resident to promote healing and prevent a worsening of a condition) included the following interventions for Resident 1: 1. Maintain the resident's environment safe and hazard free. 2. Monitor residents' whereabouts often. 3. Keep the resident's bed in the lowest position. 4. Place a floor mat at the resident's bed. 5. Keep the resident's call light in reach. A review of Resident 1's Fall Risk Evaluation dated 9/28/23 at 6:36 AM, indicated Resident 1 had one to two falls (actual number falls not specified) in the past three months. Fall Risk Evaluation indicated Resident 1 was transferred to a general acute care hospital (GACH) on 9/28/23 for evaluation due to the fall on 9/28/23 and suffered a laceration on the forehead. The Fall Risk Evaluation did not indicate if a physician was notified about the fall with injury. A review of Resident 1's CP titled, "High Risk for Injury/Accidents and Falls," dated 11/24/23, indicated Resident 1 was a high risk for falls and injuries, with a history of falls. The CP goal indicated Resident 1 would not have injury/accidents or falls in the next three months. The CP interventions included the following interventions to prevent repeated falls for Resident 1: 1. Provide Resident 1 with 1:1 sitter as necessary for safety. 2. Frequent visual checks. 3. Keep the resident's bed in lowest position. 4. Keep floor mat at the resident's bed side. 5. Keep a call light in resident's reach. 6. Maintain environment safe and hazard free A review of Resident 1's Progress Notes for the months of 4/2024, 5/2024, and 6/2024, indicated there was no documentation Resident 1 was provided with a 1:1 sitter for safety and to prevent Resident 1 from falls. A review of Resident 1's Progress Notes dated 1/25/24 and timed at 10:10 AM indicated, Resident 1 was found by staff on the floor mat by her bed on 1/25/24 at around 9 AM. Resident 1 complained of mild (pain level not documented) left hand and right hip pain. A review of Resident 1's Progress Notes dated 1/25/24 at 2:13 PM indicated, Resident 1 had swelling of the left hand and right hip pain. A review of Resident 1's Progress Notes dated 1/25/24 at 9:42 PM, indicated, Resident 1 was noted to have left hand swelling. A review of Resident 1's untitled CP , initiated on 1/25/24, indicated Resident 1 was "noted with swelling on the left hand and pain and right hip pain. Medical doctor (MD) was present and assessed with order." The CP indicated Resident 1 had a dislocated (a separation of two bones where they meet at a joint) left 5th digit as evidenced by x-ray of left hand (date not indicated). The CP goal for Resident 1 was to have no further decline and increase in pain level for the next three months. The CP interventions included: 1. Provide Resident 1 with a 1:1 sitter around the clock (initiated on 1/28/24). 2. Inform MD and responsible party that Resident 1's left 5th finger was dislocated. 3. Resident 1 was sent to emergency room (ER) for further evaluation. The CP indicated that on 1/27/2024, Resident 1 returned to the facility from ER with a splint (a medical device to support and immobilize a joint/body part). The CP did not indicate if Resident 1 was provided with a sitter. A review of Resident 1's Progress Notes dated 1/27/24 at 4:30 PM, indicated, Resident 1 was readmitted from a GACH and at the GACH it was confirmed Resident 1 had a dislocated left 5th finger. Resident 1's Progress Notes indicated the GACH's physician (MD) was unable to put Resident 1's finger back in place and a splint (a medical device that stabilizes a part of your body and holds it in place) was applied. A review of Resident 1's Progress Notes dated 1/29/24 at 5:41 PM, indicated, the facility's social worker discussed with Resident 1's conservator (a court appointed person or organization to be legally responsible for someone who cannot manage alone) regarding the conservator providing a 1:1 sitter for Resident 1. The progress notes indicated the conservator could only provide a 1:1 sitter for Resident 1 from 10 AM to 1 PM. The progress notes did not indicate Resident 1 was provided a 1:1 sitter for safety to prevent repeated falls. A review of Resident 1's Progress Notes dated 1/30/24 at 1:13 PM, indicated, Resident 1 was arguing with staff, trying to kick and bite the staff. A review of Resident 1's Progress Notes dated 1/30/24 at 3:52 PM, indicated, Resident 1 was trying to throw herself on to the floor and was scratching and trying to hit staff. Resident 1 was also twisting her (Resident 1's) body and arms while in bed. A review of Resident 1's Progress Notes dated 1/30/24 at 4:10 PM, indicated Resident 1 was getting out of bed to her wheelchair all night and staff had to prevent Resident 1 from falling. The progress notes indicated staff tried to redirect Resident 1 to stay in bed, but Resident 1 was kicking, biting, and moving upside down in bed. A review of Resident 1's untitled CP dated 1/30/24, indicated Resident 1 was physically aggressive toward staff and was trying to throw self on the floor. The CP goals indicated Resident 1 would not harm self or others through review date of 4/30/24. The CP included the following interventions: 1. Continue 1:1 sitter at the bedside. 2. Give the resident choices about care. 3. Assess the resident sensory (relating to sensation or to the senses) deficits. 4. Redirect resident. The same CP did not indicate if a sitter was provided to Resident 1. A review of Resident 1's History and Physical (H&P) from a GACH dated 1/31/24 at 11:17 AM, indicated, Resident 1 was in the emergency department (ED) to be evaluated for aggressive behavior at the facility. The H&P indicated Resident 1 was observed to be combative, agitated, and aggressive both physically and verbally with lashing out at staff. A review of Resident 1's Physician's Progress Notes from the GACH dated 2/11/24 at 1:48 PM, indicated Resident 1 was noted to be confused and was trying to get out of bed. The Physician's Progress Note's indicated Resident 1 was on fall precaution and that Resident 1 was noted to have significant swelling of a left-hand 5th digit. The physician progress notes indicated the GACH physician admitted Resident 1 for dehydration (excessive loss of body water), metabolic encephalopathy (a group of conditions that cause brain dysfunction), urinary tract infection ([UTI] - infection of any part of the urinary system), and impaired balance (unsteadiness), strength, and mobility. Resident remained in the GACH from 2/11/24 and was discharged back to the facility on 2/13/24. A review of Resident 1's Physician's Progress Notes from the GACH dated 2/12/24 at 4 PM, indicated Resident 1's assessment included left ulna shaft fracture and dislocated left 5th finger with an open wound. A review of Resident 1's H&P from the facility dated 2/14/24, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's CP titled, "Resident is high risk for fall related to (r/t) repeated falls," revised 3/15/24, indicated the goal for Resident 1 was to be free of falls and injuries through the review date of 8/28/24. The CP interventions included the following: 1. Evaluate the resident for the risk for falls on admission and as necessary (PRN). 2. Provide 1:1 sitter as deemed necessary for safety. 3. Initiate fall risk precautions. 4. Review information on past falls and attempt to determine the cause of falls and record possible root causes. A review of Resident 1's CP titled "The Resident had an actual fall. Fall Risk score:13 (High risk for fall)," dated 1/25/24, indicated "the resident had an assisted fall on 4/11/24 with no injury or pain." The CP did not indicate where the resident fell from or the circumstances of the fall. The same CP indicated Resident 1 had a witnessed fall on 5/7/24 and was transferred to a GACH via 911 for further evaluation. The CP interventions indicated Resident 1 to have 1:1 sitter at all times and to conduct frequent room visit. A review of Resident 1's Progress Notes dated 4/11/24 at 5:46 AM, indicated Resident 1 slid to the floor from her wheelchair in the hallway. A review of Resident 1's CP (untitled) dated 4/15/24, indicated Resident 1 was at risk for falls with the following interventions to achieve a goal for Resident 1 to be free of falls: 1. 1:1 Sitter (initiated on 5/7/24). 2. Assist with ambulation and transfers. 3. Evaluate fall risk as needed. A review of Resident 1's CP dated 4/28/24, indicated Resident 1 had a witnessed/assisted fall on 4/28/24. The CP interventions included to determine and address causative factors of fall. A review of Resident 1's Progress Notes dated 4/28/24 at 6:22 AM, indicated Resident 1 was trying to get out of bed and a Certified Nursing Assistant (CNA) helped her to slide to the floor in an assisted fall. A review of Resident 1's Progress Notes dated 4/30/24 at 10:58 AM, indicated Resident 1 stood up and tried to walk. Resident 1 bit CNA that tried to assist Resident 1 back to bed. A review of Resident 1's Progress Notes dated 5/7/24 at 9:50 AM, indicated that during an interview with Resident 1, the resident stated she rolled out of bed and fell on her face. The Progress Notes indicated Resident 1's roommate stated the resident's roommate heard a loud thump and saw Resident 1 on the floor face down. The Progress Notes indicated Resident 1 developed a bump on her forehead and complained of pain, 911 was called, and Resident 1 was transferred to a hospital for further evaluations. A review of Resident 1's Progress Notes dated 5/7/24 at 10:23 AM i