Other·November 30, 2018

F000 INITIAL COMMENTS

F000 DEFICIENCY) COMPLETE DATE The following reflects the findings of the Department of Public Health during the investigation of an Entity Reported Incident (ERI) investigation during an Abbreviated Standard Survey. ERI number: CA00577587 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 36171, RN The inspection was limited to the specific ERI investigation and does not represent the findings of a full inspection of the facility. One deficiency was issued for ERI CA00577587

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 11/16/2018 §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. This REQUIREMENT is not met as evidenced 056192 10/31/2018 HARBOR POST ACUTE CARE CENTER 21521 S Vermont Ave Torrance, CA 90502 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE by: Based on interview and record review, the facility failed to follow its policy and a resident's plan of care to provide adequate assistance of supervision to prevent falls for one of three sampled residents (Resident 1). Resident 1, who was assessed as a high risk for falls and required a two-person assist when transferring from the shower chair to toilet, had a fall in the bathroom when being transferred with a oneperson assist. This deficient practice resulted in Resident 1 falling and sustaining a hip fracture (broken bone), requiring a transfer to a general acute care hospital (GACH) and a five-day hospitalization. Resident 1 underwent surgery of a left hip hemiarthroplasty (surgical operation used to treat a fractured hip) and developed a pulmonary embolism (blood clot that travels to the lungs). Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on 7/30/15, and was readmitted 3/13/18. Resident 1's diagnoses included malignant neoplasm of the lung (lung cancer), hypertensive heart disease (heart disease caused by high blood pressure), muscle weakness, and difficulty in walking. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/23/18, indicated the resident had the ability to understand and be understood, required an extensive one-person physical assist for ambulating in the unit, and a 056192 10/31/2018 HARBOR POST ACUTE CARE CENTER 21521 S Vermont Ave Torrance, CA 90502 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE two-person assist with transfer and toilet use. According to the MDS, Resident 1's balance transitions and walking was not steady and required staff's assistance. A review of Resident 1's "Fall Risk" assessment, dated 12/29/17, indicated Resident 1 was assessed as a high risk for falls, had problems balancing while standing and walking, and used a wheelchair for mobility. A review of Resident 1's care plan titled, "High Risk for Falls," dated 12/27/17, indicated Resident 1's propensity (tendency) for injurious falls related to an unsteady gait (walking), unsteady balance, body weakness, and the use of cardiovascular agents (heart medications). The staff's interventions included to monitor Resident 1 and anticipate/intervene for factors causing previous falls such as bowel/bladder urgency, mobility problems, transferring, and walking, and remind resident to ask for assistance. On 3/15/18, at 8:50 a.m., during an interview, Resident 1 was observed sitting up in bed with an abduction pillow between the lower extremities. Resident 1 stated he fell while Certified Nursing Assistant 1 (CNA 1) was assisting him to the restroom via a shower chair to have a bowel movement. Resident 1 stated CNA 1 was alone while assisting him with toileting. Resident 1 stated it was CNA 1's usual routine to assist the resident with toileting and transferring alone. Resident 1 stated CNA 1 usually transferred him to the restroom alone and allowed him to dis-impact (manual removal of stool from rectum) himself. Resident 1 further stated he was a large guy so when he fell, CNA 1 had to go find assistance to help get him off of the floor because he was too heavy (weighing 286 pounds at the time of the fall) to 056192 10/31/2018 HARBOR POST ACUTE CARE CENTER 21521 S Vermont Ave Torrance, CA 90502 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE lift alone. During an interview, on 3/15/18, at 9:45 a.m., CNA 1 stated he felt so bad about the incident which caused Resident 1 to fall and sustain a fracture. CNA 1 stated he was alone with Resident 1 at the time of the fall. CNA 1 stated he was familiar with Resident 1's routine and he usually transferred the resident by himself although he was aware Resident 1 required a two- person assist. A review of Resident 1's Nursing Progress Note, dated 3/8/18 and timed at 10:28 a.m., indicated CNA 1 was assisting Resident 1 to the bathroom when the resident slid down and fell on the floor. The progress note indicated Resident 1 was assessed and the physician (MD) was notified. A review of Resident 1's Pain Assessment form, dated 3/8/18 and timed at 12:40 p.m., indicated Resident 1 complained of pain, but there was no score documented on the pain scale assessment (tool used to measure intensity of pain level lowest to highest). The form indicated Norco (narcotic pain medication used to treat moderate to severe pain) 10-325 milligrams (mg) one (1) tablet was administered to Resident 1 by mouth. A review of Resident 1's Physicians Order, dated 3/8/18, indicated to transfer Resident 1 to the GACH for further evaluation. A review of Resident 1's Pelvis X-ray exam results, dated 3/10/18, indicated a fracture of the left femur (thighbone). A review of the GACH's Discharge Summary, dated 3/13/18, indicated Resident 1 had a diagnosis of left hip fracture, acute pulmonary embolism (blood clot that travels to the lung) 056192 10/31/2018 HARBOR POST ACUTE CARE CENTER 21521 S Vermont Ave Torrance, CA 90502 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE probable due to poor mobility), and hypoxia (low oxygen). The discharge summary indicated Resident 1 required hemiarthroplasty (surgical operation used to treat a fractured hip) and developed a pulmonary embolism and was started on anticoagulants (medication to dissolve blood clots). A review of the facility's undated policy and procedure titled, "Falls and Fall Risk, Managing," indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.