Health inspection·May 10, 2024

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. 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. The following reflects the findings of the California Department of Public Health during the Recertification Survey. Recertification Survey Number: 8FS211 Representing the Department: Health Facilities Evaluator Nurse: 36395 A Class B Citation was issued for the Recertification Survey Number: 8FS211. On 4/16/2024, the California Department of Public Health (CDPH) State Survey Agency (SSA) made an unannounced visit to the facility to conduct annual recertification survey. The facility failed to report that Resident 13 fell in the facility on 11/26/2023 at 7:15 P.M. and sustained right femoral (thigh bone) neck comminuted (broken bone in more than two piece) fracture. Resident 13 was transferred to a general acute care hospital (GACH) and required emergency care and girdle stone (procedure to remove the affected femoral head and neck of the thigh bone) surgery. As a result, the fall was not investigated timely by CDPH State Survey Agent ( SSA) and had the potential for the facility to continue not reporting falls with injuries. A review of Resident 13's Admission Record indicated Resident 13 was initially admitted to the facility on 10/11/2023 and readmitted on 2/17/2024 with diagnoses including generalized muscle weakness (decreased strength of the muscles affecting both distal [farther away from the center if the body] and proximal [near to the center of the body] muscle), difficulty walking, and end stage renal disease (ESRD -kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance). A review of Resident 13's Fall Risk Morse Fall Scale, dated 10/14/2023, indicated Resident 13 had a weak gait (pattern of walking), and scored (24 -44 considered moderate risk for potential falls) for fall risk. A review of Resident 13's Change in condition (COC a sudden clinically deviation from a patient's baseline in physical, cognitive, behavioral, or functional domain) dated 11/26/2023, indicated Resident 13 fell backwards on 11/26/2023 at 7:15 P.M., when the door was opened by the transportation team which pushed the wheelchair backwards from the footrest that he was using as a walking device. Resident 13 had a nurse assessment done and pain medication was administered before he was transferred to the hospital. A review of Resident 13's Nursing notes dated 11/26/2023, at 9:47 P.M., indicated Resident 13 was transferred to the hospital on 11/26/2023, at 9:20 P.M., for unwitnessed fall. A review of Resident 13's Xray of the femur resulted on 11/27/2023, at 5:01 A.M., indicated that Resident 13 had a right femoral neck fracture with superior dislocation of the femoral shaft. A review of Resident 13's Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 3/8/2024, indicated Resident 13's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were intact and required substantial/maximal assistance from staff with activities of daily living (ADL-bed mobility, dressing, toilet use, showering and personal hygiene). During an interview on 4/16/2024, at 2:30 P.M., with Resident 13, Resident 13 stated about three months ago Resident 13 had a fall in his room and "broke my right hip." Resident 13 stated there was a transportation team came in for Resident 13's roommate, the transportation team stepped out of the room and closed the door which is usually left open. Resident 13 stated, "I got up to go to the bathroom using the wheelchair while holding to the handles in the back for support. When I got to the bathroom door, the transport team came back to the room, open the door to the room which then pushed the footrest of the wheelchair I was holding onto, as a result it also pushed me back, I lost my balance and ended up falling backwards. I was taken to the hospital and found out I broke my right hip." During an interview on 4/19/2024, at 1:41 P.M., with the Quality Assurance (QA) and the Director of Nursing (DON), the QA and the DON stated that the fall was not reported even though Resident 13 had suffered a fracture that resulted in a transfer to the hospital and that required surgery. QA stated unusual occurrent events need to be reported within 2 hours to the SSA, ombudsman (an official who investigates complaints [usually lodged by private citizens] against businesses, public entities, or officials). A review of facility's policy and procedures titled "unusual occurrent reporting" with revised date of 12/2007, indicated, "As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations." The facility failed to report that Resident 13 fell in the facility on 11/26/2023 at 7:15 P.M. and sustained right femoral neck comminuted fracture. Resident 13 was transferred to a GACH and required emergency care and girdle stone surgery. As a result, the investigation for the fall was not investigated timely by CDPH SSA and had the potential for the facility to continue not reporting falls with injuries. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.