Other·February 9, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00876006. Representing the Department, HFEN # 43497 A Class "B" Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations: F689 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. Title 22 California Code of Regulations: § 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 12/27/2023, the California Department of Public Health (State Survey Agency [SSA]) made an unannounced visit to the facility to investigate a complaint related to resident neglect and quality of care and treatment of a resident. The facility failed to ensure the Resident 1's environment remained free of accident hazards by failing to: 1.Ensure a box was not placed in the hallway and obstructing the path, and 2.Follow the facility's policy and procedures titled, "Fall Management," to ensure there was no obstacles in footpath. As a result, Resident 1 fell on 12/14/2023 while walking in the hallway, Resident 1 complained of pain and was transferred to general acute care hospital (GACH) on 12/19/2023 at 10:47 AM Resident 1 was diagnosed with left closed inferior pubic ramus fracture (pelvic fracture involves damage to the hip bones, sacrum [is a shield-shaped bony structure that is connected to the pelvis], or coccyx [the bony structures forming the pelvic ring]) and had new onset of decrease in functional mobility (is a person's physiological ability to move independently and safely). A review of Resident 1's Admission Record, indicated Resident 1, a 74 years old female was admitted on 8/30/2016 and readmitted on 12/19/2023, with medical diagnosis including unspecified fracture of left pubis (pelvic fracture), schizophrenia (a mental disorder characterized by continuous or relapsing episodes of psychosis [A mental disorder characterized by a disconnection from reality]), bipolar disorder (a disorder associated with episodes of mood swings), hyperlipidemia (elevated cholesterol), urinary tract infection (bladder infection), syncope (fainting), and collapse (to fall down). A record review of Resident 1's "High Risk for Fall" care plan, initiated and dated 3/10/2023, indicated Resident 1 had high risk for fall that may result to physical harm due to history of falls, and cognitive deficits (confusion or memory loss that is happening more often or is getting worse during the past 12). The goal indicated the resident's risk of falls and injuries will be minimized with interventions, and safely enhance physical function to the highest practicable level. Interventions included to keep the environment free of hazards, provide assistance as identified in transfer and mobility. The care plan did not indicate any update or revision until 12/14/2023. A record review of Resident 1's Fall Risk Assessment dated 6/27/2023, indicated Resident 1 was at high risk for falls. The facility did not provide any Fall Risk Assessment for Resident 1 after 6/27/2023. A record review of Resident 1's Physical Therapy Discharge Summary dated 6/30/2023, indicated Resident 1 met long term and short-term goals. Resident 1 reached maximum potential with skilled services (services provided by a licensed professional for the purposes of promoting, maintaining, or restoring the health of an individual or to minimize the effects of injury). Resident 1 exhibited little to no functional deficits as a result of skilled rehabilitation. Resident 1 discharged from physical therapy. Resident 1 independent with bed mobility and transfers. Resident 1 able to ambulate greater than 150 feet. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care planning tool), dated 9/10/2023, indicated Resident 1 had moderately impaired cognition (problems with reasoning, memory, knowledge and understanding). The MDS indicated Resident 1 required supervision with bed mobility, transfers, walking in corridor, dressing, eating, toileting, and personal hygiene. A record review of Resident 1's Progress Notes dated 12/14/2023, at 4:41 PM indicated Resident 1 tripped over a box that was on the side of the hallway. Resident 1 landed on the floor with her palms rolled over. Resident 1 was assessed with no discoloration or injury noted. Resident 1 complained of left hip pain. Resident 1 attempted and insisted on getting up from the chair and landed on the floor. Resident 1 insisted on getting up due to inability to tolerate pain on the left hip. Resident 1 was assisted back to bed and provided with pain medication. Medical Doctor was notified same day and time with an order for an X-ray (invisible electromagnetic energy beams to produce images of internal tissues, bones, or organs in film) to the left hip. A review of Resident 1's Medication Administration Record (MAR), dated 12/01/2023 - through 12/27/2023, indicated, Resident 1 received Tylenol (medication for general body pain) 650 milligram (mg, unit for measurement) PO (by mouth) on 12/14/2023 at 6:20 PM and on 12/16/23 at 6:10 AM for pain. The same MAR did not indicate the pain level. A record review of Resident 1's Progress notes dated 12/19/2023 at 9:59 AM, indicated Resident 1's Medical Doctor was contacted yesterday (12/18/2023) concerning Resident 1's left hip pain due to status post fall on 12/14/2023 and resident not getting out of bed and walking as she did before the fall. Medical Doctor called with new orders to transfer resident to the hospital for further evaluation. A record review of Resident 1's Progress noted dated 12/19/2023 at 10:47 AM, indicated Resident 1 was transferred to the hospital via ambulance. A record review of Resident 1's GACH After Visit Summary Report dated 12/19/2023, indicated Resident 1 was seen for hip pain and was diagnosed with left closed inferior pubic ramus fracture (pelvic fracture). Resident 1 will require pain control and Physical/Occupational (aimed to diagnose function or movement-related problems) evaluation for improved mobility over the next six to eight weeks while the fracture is healing. A record Review of Resident 1's Physical Therapy Evaluation and Plan of Treatment dated 12/20/2023, indicated Resident 1 fell in the facility on 12/14/2023. An x-ray of the left hip soon after that was negative. Resident 1 was sent out for further assessment on 12/19/2023 due to pain and was found to have pelvic fracture. Resident 1 was referred to physical therapy due to new onset of decrease in functional mobility (is a person's physiological ability to move independently and safely) placing Resident 1 at risk for further decline in function, immobility and falls. Prior to Resident 1's fall Resident was independent and ambulated 1000 feet in the facility multiple times throughout most days. A record Review of Resident 1's Physical Therapy Evaluation and Plan of Treatment dated 12/20/2023, indicated Resident 1 current functional assessment, indicated maximal assistance with bed mobility. Resident 1 required a front wheel walker. Resident 1 was able to take one small step forward and back with each lower extremity. Resident 1 ambulated 10 feet laterally along the bedside. Resident 1 exhibited decreased step length (the distance measured from the heel print of one foot to the heel print of the other foot), decreased velocity (walking speed), and decrease stride length (the point of initial contact of one foot and the point of initial contact of the opposite foot). During an interview with Unit Secretary (US), on 12/27/2023 at 11:25 AM, US stated, on the day that Resident 1 fell, the facility received a delivery, and a box was placed against the wall by the nurse's station. US stated, she came to the nurse's station, and she saw Resident 1 on the floor, but did not witness her actual fall. US stated, Resident 1 was crying in pain and the nurses assessed the resident and placed her back in the wheelchair. US stated, the box should not have been placed in the hallway. US stated the box belonged in the facility's basement. During an interview with the Director of Nurses (DON), on 12/27/2023 at 11:30 AM, DON stated, Licensed Vocational Nurse 1 (LVN 1) should have stopped what he was doing with the resident and assisted Resident 1. DON stated, LVN 1 should have removed the box away from the hallway and placed it inside the medication room that is located behind the nurse's station. DON stated, the box should not have been placed in the hallway because this is an accident hazard. During an interview with LVN 1, on 12/28/2023 at 11 AM, LVN 1 stated he was in the hallway helping another resident in a wheelchair when Resident 1 fell on 12/14/2023 at 3:45 PM. LVN 1 stated, Resident 1 liked to walk around the facility and on this day, there was box that was placed in the hallway against the wall by the nurse's station. LVN 1 stated, he told Resident 1 to wait while he moved the resident in the wheelchair away from the hallway, but Resident 1 did not listen and stepped on the box that were obstructing the way and Resident 1 fell. LVN 1 stated he should have stopped what he was doing and moved the box and placed them away from the hallway. LVN 1 stated the box should not have been placed in the hallway because residents walk around the facility, and this is an environmental hazard. LVN 1 stated this box should have been stored inside the medication room. A review of the facility's policy and procedures titled, "Fall Management" dated 4/2/2023, indicated, "A fall prevention program will be developed for each resident that provide staff with creative functional strategies to minimize the risk for falls and undue injuries from such incidents, while recognizing the resident's rights and their need to maintain their highest level of functioning. Fall risk factors may include environmental factors that contribute to the risk of falls include obstacles in footpath, wet floor, and poor lighting." The facility failed to ensure the Resident 1's environment remained free of accident hazards by failing to: 1.Ensure a box was not placed in the hallway and obstructing the path, and 2.Follow the facility's policy and procedures titled, "Fall Management," to ensure there was no obstacles in footpath. As a result, Resident 1 fell on 12/14/2023 while walking in the hallway, Resident 1 complained of pain and was transferred to GACH on 12/19/2023 at 10:47 AM Resident 1 was diagnosed with left closed inferior pubic ramus fracture and had new onset of decrease in functional mobility. The above violation had a direct relationship to the health, safety, and security of Resident 1.