Health inspection·November 9, 2023

F689 42 CFR §483.25: 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. 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. Cal. Health & Safety Code (HSC) Section § 1279.6: Patient Safety Plan. (a) A health facility, as defined in subdivision (a), (b), (c), or (f) of Section 1250, shall develop, implement, and comply with a patient safety plan for the purpose of improving the health and safety of patients and reducing preventable patient safety events. The patient safety plan shall be developed by the facility, in consultation with the facility's various health care professionals. On 10/3/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about quality of care/treatment and accidents. The facility failed to ensure facility staff provided 1:1 monitoring and supervision to prevent repeated falls for Resident 1 in accordance with the facility's policy and procedures (P&P) titled, "Falls and Fall Risk, Managing", dated, 3/2018. The facility identified Resident 1 as a high risk for falls. As a result, on 10/1/2023-Resident 1 fell out of his wheelchair (WC) while sitting in the lobby of the facility and suffered a laceration (a deep cut or tear in the skin) and bleeding above the right eyebrow. Resident 1 was transferred to General Acute Care Hospital (GACH) and treatment provided for the laceration. A review of Resident 1's admission records (facesheet) indicated, Resident 1, 93-years-old male, was initially admitted to the facility on 2/6/2022 and was readmitted on 6/6/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD-ongoing inflammatory lung disease that causes obstructed airflow from the lungs), type 2 diabetes (a problem in the way the body regulates and uses sugar), anemia (a condition in which the body does not have enough healthy red blood cells), dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (persistent and excessive worry that interferes with daily activities) and insomnia (difficulty falling or staying asleep). A review of Resident 1's history and physical dated 6/8/2023, indicated Resident 1 could make needs known but could not make medical decisions. A review of Resident 1's Minimum Date Set (MDS-a standardized assessment care screening tool) dated 7/28/2023, indicated Resident 1 required one person physical assist with transfers, walking in the room, dressing, toilet use and personal hygiene. A review of Resident 1's Fall Risk Assessment dated 7/28/2023, indicated Resident 1 was at high risk for falls. A review of Resident 1's Change of Condition (COC- a deterioration in health, mental status, or psychosocial [mental, emotional, social, and spiritual health] status) form dated 9/21/2023 at 5:57 PM, indicated Licensed Vocational Nurse 1 (LVN 1) on the evening shift (3PM to 11PM), who was in the middle of administering medications to residents, passed by the nursing station and found Resident 1 sitting on the floor. Resident 1 was touching his right forearm near his right elbow. LVN 1 noted Resident 1 was bleeding from the right forearm. The facility placed Resident 1 on close observation (monitoring for safety to prevent further falls) and X-rays (a process of taking an image of a specific body part). Resident 1's Medical doctor (MD) was notified, and the MD ordered an Xray of Resident 1's right elbow and forearm. A review of Resident 1's X-rays dated 9/22/2023, revealed no fractures of right elbow and right forearm. However, X-ray of the chest, revealed old fractures (a break in the bone) of the 6th through 9th right ribs (bones of the chest wall). A review of Resident 1's care plan for At Risk for Falls revised on 9/23/2023, indicated Resident 1 was a high risk for falls due to unsteady gait (a manner of walking). Interventions included to assess and anticipate Resident 1 ' s needs of food, thirst, toileting needs, comfort levels, body position and pain. Encourage Resident 1 to assume a standing position slowly ...keep environment free of clutter and safety hazards. A review of Resident 1's care plan for Actual fall initiated on 9/23/2023, indicated Resident 1 had an actual fall on 9/21/2023. The care plan also indicated resident 1 has impulsive behavior, attempts to get up unassisted, and had poor safety awareness. Interventions included to discuss ..., alternatives, reason, risk, and benefits with resident or resident representative. Interventions further indicated to instruct Resident 1 not to have sudden position changes, and to monitor the resident for steadiness and balance. A review of Resident 1's Nursing Progress Notes dated 9/25/2023, indicated Resident 1's MD gave an order to transfer Resident 1 to the GACH for further evaluation and management due to rib fractures and Resident 1 refusing MD's order for a follow up rib series x-ray ... Resident 1 was transferred to GACH on 9/25/2023 at 6 PM for further evaluation. A review of Resident 1's Nursing Progress Notes dated 9/27/2023, indicated that on 9/27/2023 at 4:04 PM, the case manager at the GACH notified the facility that Resident 1's chest X-ray completed during admission to GACH on 9/25/2023, was negative for right rib fractures. A review of Resident 1's Physician's Order Summary dated 10/1/2023, indicated the facility readmitted Resident 1 on 10/1/2023. A review of Resident 1's COC dated 10/1/2023, indicated LVN 3 documented that on 10/1/2023 at 11:30 PM, Resident 1 got up from a WC and had a fall. The COC indicated LVN 3 found Resident 1 on the floor with a bleeding laceration above the right eyebrow. LVN 3 applied dressing (padded material for wound care) to control bleeding. Emergency Medical Services (EMS-ambulance emergency services or paramedic services that provide urgent pre-hospital treatment and stabilization for serious illness and injuries and transport to definitive care) was called, and Resident 1 was transferred to GACH for further evaluation. A review of GACH Emergency Room Physician Notes for Resident 1 dated 10/1/2023, indicated EMS transferred Resident 1 to GACH on 10/1/2023 after Resident 1 fell from a WC. Resident 1 had a computerized tomography (CT- detailed imaging of a specific body part) scan of the head and cervical spine (neck region) with no acute (sudden onset) findings of fractures or internal (inside the body) bleeding. Resident 1 had a laceration on the forehead which was repaired with nine sutures (specialized thread used to close breaks in the skin). Resident 1 was transferred back to the facility on 10/2/2023 at 4 AM. During an interview with LVN 1 on 10/3/2023 at 10:55 AM, LVN 1 stated that on 9/21/2023 at around 5 PM, Resident 1 was sitting in WC in front of the nursing station. LVN 1 stated she was working at the nursing station and heard Resident 1 fall. LVN 1 stated she immediately went over to Resident 1 and observed that Resident 1 had a laceration on the right forearm area near the right elbow. LVN 1 stated she applied a pressure dressing on Resident 1's right forearm and assisted Resident 1 back into the WC. LVN 1 stated Resident 1 did not complain of any pain following the fall. LVN 1 stated she placed Resident 1 on close monitoring for safety to prevent further falls. LVN 1 stated she notified Resident 1's MD of Resident 1's fall. LVN 1 stated MD ordered an x-ray of Resident 1's right arm. LVN 1 stated Resident 1 had complained earlier in the day of right rib pain and that was the reason MD ordered an X-ray of the right ribs. LVN 1 stated Resident 1's right rib pain was not associated the resident ' s fall. During an interview with LVN 2 on 10/3/2023 at 3:15 PM, LVN 2 stated the facility readmitted Resident 1 from GACH on 10/1/2023 at around 8 PM. LVN 2 stated the facility transferred Resident 1 to GACH for evaluation post fall on 9/21/2023 and for urinary retention (a condition in which a person is unable to empty all the urine from the bladder [a hollow organ in the lower abdomen that stores urine]). LVN 2 stated Resident 1 was assigned a 1:1 monitor to for safety to prevent further falls. LVN 2 stated certified nursing assistant 1 (CNA 1) was assigned as a 1:1 sitter for Resident 1 to prevent Resident 1 from falling. LVN 2 stated upon readmission to the facility, LVN 2 completed a head to toe assessment on Resident 1 and that Resident 1's forearm laceration had healed from Resident 1's previous fall on 9/21/2023. LVN 2 stated Resident 1 was calm during the remainder of her shift, which ended at 11 PM. During an interview with CNA 1 on 10/3/2023 at 3:20 PM, CNA 1 stated that on 10/1/2023 at 8 PM, the facility readmitted Resident 1 from the GACH and that he [CNA 1] was assigned as a 1:1 sitter to monitor Resident 1 for safety to prevent falls. CNA 1 stated during his shift (3 Pm to 11 PM), Resident 1 was restless and continuously tried to get out of bed. CNA 1 stated he kept redirecting and reminding Resident 1 to remain in bed. CNA 1 stated that on 10/1/2023 at 10:58 PM, he [CNA 1] went to the nursing station and informed LVN 2 and several other staff members present (unsure who) that Resident 1 required continuous 1:1 monitoring for safety to prevent falls. CNA 1 stated that on 10/1/2023 at 11 PM, he left Resident 1 unattended and went home after his shift ended. CNA 1 stated he was unsure who was responsible to continue with 1:1 monitoring for Resident 1 after his shift ended at 11 PM. During an interview with the Medical Records Director (MRD) on 10/4/2023 at 11AM, MRD stated the facility did not have a policy and procedures on 1:1 resident monitoring. During an interview with LVN 3 on 10/4/2023 at 11:45 AM, LVN 3 stated that on 10/1/2023 at 11 PM, he started the night shift (11 PM to 7 AM) and received (hand off) report from the off going licensed nurse at the nursing station. LVN 3 stated Resident 1 was sitting in a WC across the desk from the nursing station at 11:15 PM and was unsure who placed Resident 1 in the WC. LVN 3 stated while at the nursing station, he saw Resident 1 quickly get up from the WC and fall to the ground. LVN 3 stated Resident 1 sustained a laceration above the right eyebrow and that the laceration was bleeding. LVN 3 stated he applied a dressing to the laceration and called EMS to transport Resident 1 to GACH. LVN 3 stated CNA 1 was assigned 1:1 to monitor Resident 1 for safety to prevent falls. LVN 3 stated he was unsure where the CNA assigned to Resident 1 was when Resident 1 fell. LVN 3 stated Resident 1 was transported to GACH on 10/1/2023 and that Resident 1 returned on 10/2/2023 at around 4 AM, was placed back into his bed and was assigned 1:1 monitoring for safety. During an interview and record review with the Director of Nursing (DON) on 10/4/2023 at 1 PM, the facility's P&P titled "Falls and fall Risk dated 3/2018 was reviewed. The DON stated Resident 1 was a high fall risk and confirmed that 1:1 sitter was Resident 1 specific to prevent further falls. The DON stated the facility readmitted Resident 1 on 10/1/2023 from GACH for possible rib fractures and urinary retention. The DON stated that on 10/1/2023, she told LVN 2 Resident 1 was on 1:1 monitoring for safety to prevent falls because Resident 1 was a high risk for falls. The DON stated that on 10/1/2023, LVN 3 informed her [DON] that Resident 1 had a fall from a WC on 10/1/2023 at 11:30 PM and was transported to GACH for further evaluation and management. The DON stated Resident 1 should have been on 1:1 monitoring at the time of the fall on 10/1/2023. The DON was unsure why the CNA that was scheduled on the 11PM to 7 AM shift for 1:1 monitoring was not with Resident 1. The DON stated Resident 1's fall was preventable if Resident 1 was on 1:1 monitoring. A review of the facility's P&P titled "Falls and Fall Risk, Managing" dated, 3/2018, indicated "based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling ...The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls ...If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant ...If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified." The facility failed to ensure facility staff provided 1:1 monitoring and supervision to prevent repeated falls for Resident 1 in accordance with the facility's P&P titled, "Falls and Fall Risk, Managing", dated, 3/2018. The facility identified Resident 1 as a high risk for falls. As a result, on 10/1/2023-Resident 1 fell out of his WC while sitting in the lobby of the facility and suffered a laceration and bleeding above the right eyebrow. Resident 1 was transferred to GACH, and treatment provided for the laceration. The above violations had a direct relationship to the health, safety, and security of all residents in the facility.