Health inspection·February 16, 2024

§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. §72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 12/14/2023, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) regarding a resident (Resident 1) who fell multiple times on 12/12/2023 and sustained an acute distal coccygeal (tailbone) fracture (a break in the bone). On 1/2/2024 CDPH conducted an unannounced visit to the facility to investigate the FRI. Upon investigation CDPH determined Resident 1, who had a history of multiple falls, was not supervised, monitored, or provided with a Mat alarm (an alarm used on top of a mattress or in a wheelchair to monitor when a resident rises) in his wheelchair as recommended by the Interdisciplinary Team ([IDT] a group of health care professionals with various areas of expertise who work together toward the goals of a resident) as an intervention to prevent Resident 1 from falling and sustaining an injury. The facility failed to: 1. Ensure Resident 1's care plan was revised to include IDT recommendations made after Resident 1's fall on 11/13/2023 which included continued use of the Mat alarm, frequent visual checks, and placing Resident 1 in front of or close to the nursing station. 2. Ensure Resident 1's care observation was endorsed to the nursing staff at the nursing station when Resident 1 was placed next to a nursing station on 12/12/2023 and was left unsupervised. Resident 1, without staff knowledge, self-propelled himself in his wheelchair to the facility's dining/activity room where there were no staff present, stood up from his wheelchair unassisted, and fell. 3. Ensure licensed staff followed the facility's P&P titled, "Care Plans, Goals and Objectives," that indicated care plans shall incorporate goals and objectives that lead the resident's highest obtainable level of independence. 4. Ensure the licensed nurses and the IDT followed the facility's P&P titled, "Safety and Supervision of Residents" in implementing interventions to reduce Resident 1's accident risks and hazards by communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions and ensuring interventions are implemented and documented. These deficient practices resulted in Resident 1 sustaining two falls on 12/12/2023. On 12/12/2023 at 8:45 p.m., Resident 1 was taken to a nursing station by Certified Nursing Assistant 6 (CNA 6) without alerting nursing staff that she was leaving Resident 1 there and to monitor him. Resident 1 left the nursing station without staff knowledge and entered the facility's dining/activity room where he stood up from his wheelchair unassisted and unsupervised and fell. After the fall at the dinning/activity room, Resident 1 was taken to the nursing station and approximately 20 minutes later, in the presence of Licensed Vocational Nurse (LVN 1), Resident 1 stood up from his wheelchair unassisted and unsupervised, and fell to the floor. Resident 1 sustained a fracture (break) to his distal coccyx (tailbone). A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 91 year old male, was admitted to the facility on 3/3/2023 with diagnoses including dementia (progressive loss of memory and impaired ability to remember or make decisions) and difficulty walking. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 3/10/2023 indicated Resident 1's cognitive skills for daily decision-making were severely impaired. The MDS indicated Resident 1 was not steady when moving from a seated to a standing position and could only stabilize with staff assistance. The MDS indicated Resident 1 required extensive one-person physical assist to move on and off the unit. A review of Resident 1's Morse Fall Scale (assessment of a resident's likelihood of falling) Reports for 2023 indicated Resident 1 had falls on 4/16/2023, 5/9/2023, 5/12/2023, 5/30/2023, 11/13/2023 and 12/12/2023. A review of Resident 1's IDT meeting note, dated 11/14/2023 indicated Resident 1 had poor safety awareness, forgetfulness, and disorientation. The IDT note indicated Resident 1 needed constant redirection and reorientation of location. The IDT's recommendations were to continue the Mat alarm, frequent visual checks, and place Resident 1 in front of or close to the nursing station. A review of Resident 1's Care Plan dated 11/13/2023 indicated the IDT's recommended interventions to continue the use the Mat alarm, frequent visual checks, or to place Resident 1 in front of or near the nursing station, were not included. A review of Resident 1's Tracking Record for Improving Patient Safety Report, dated 12/14/2023 indicated on 12/12/2023 at 8:21 p.m., Resident 1 wheeled himself to the dining room. The Tracking report indicated Resident 4, who was in the dining room, witnessed Resident 1 get out of his wheelchair and fall to the floor. The Tracking report indicated Resident 4 called for assistance and LVN 1, CNA 2 and CNA 3 arrived to find Resident 1 on the floor. The Tracking report indicated Resident 1's fall was unwitnessed by staff and Resident 1's wheelchair alarm was not in use. A review of Resident 1's Tracking Record for Improving Patient Safety Report, dated 12/14/2023 indicated on 12/12/2023 at 8:45 p.m., after Resident 1 experienced an unwitnessed fall a few minutes prior (8:21 p.m.) and was taken in his wheelchair to the nursing station. The Tracking report indicated while LVN 1 was on the phone, Resident 1 got up from his wheelchair and fell again. A review of Resident 1's Health Status Note dated 12/13/2023 indicated Resident 1's physician ordered a STAT (urgent) X-ray of Resident 1's sacrum (triangular bone near buttocks). A review of Resident 1's Radiology (X-ray) Report dated 12/13/2023 indicated Resident 1 sustained a distal coccygeal fracture. During an interview on 12/29/2023, at 1 p.m., LVN 1 stated, on 12/12/2023, CNA 2 called her to attend to Resident 1. LVN 1 stated she went to the activity room to see what was going on and observed Resident 1 lying on the floor outside the activity room. LVN 1 stated, she, CNA 2, and CNA 3 assisted Resident 1 back into his wheelchair. LVN 1 stated 15 minutes after she assisted Resident 1 back into his wheelchair, she (LVN 1) observed Resident 1 at the nursing station getting up from his wheelchair and falling onto the floor landing on his buttocks. LVN 1 stated Resident 1 needed to be closely supervised. During a concurrent interview and record review on 1/2/2024 at 2:05 p.m., with the Director of Staff Development (DSD), Resident 1's Morse Fall Score Reports dated 3/4/2023, 4/16/2023, 5/9/2023, 5/12/2023 and 11/13/2023 were reviewed. The Morse Fall scores indicated Resident 1 scored between 55-75 indicating Resident 1 was at high risk for falls. The Morse Fall Score Report indicated Resident 1 would overestimate or forget limits of his ability to ambulate safely. The DSD stated the purpose of the Morse Fall Scale Report was to determine Resident 1's risk for falls and to develop a care plan with interventions to prevent falls and injuries. The DSD stated Resident 1's Morse Fall Score Report indicated Resident 1 was at high risk for falls due to his diagnosis of dementia and poor safety awareness and his care plans should be revised to reflect effective goals and interventions after each fall. During an interview on 1/12/2024 at 11a.m., CNA 6 stated she was assigned to Resident 1 on 12/12/2023 during the evening shift (3 p.m. - 11 p.m.). CNA 6 stated on 12/12/2023 at approximately 8 p.m., she wheeled Resident 1 to the nursing station. CNA 6 stated during that time there were staff present in the hallway and at the nursing station, so she believed Resident 1 was being supervised. CNA 6 stated she did not tell anyone that Resident 1 was at the nursing station or to watch him after she left him there. CNA 6 stated Resident 1 propels himself in a wheelchair independently and often tries to get out of the wheelchair unassisted. During an interview on 1/12/2024 at 4:35 p.m., the Director of Nursing (DON) stated she reviewed Resident 1's care plan dated 11/13/2023 and confirmed Resident 1's care plan was not revised to reflect specific interventions such as conducting frequent visual checks and placing a wheelchair alarm on Resident 1's wheelchair as discussed during the IDT meeting held after Resident 1's fall on 11/13/2023. A review of the facility's P/P titled, "Safety and Supervision of Residents" dated 7/2017 indicated Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. The P/P indicated the IDT care team shall analyze information obtained from assessments and observation to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P/P indicated the facility will implement interventions to reduce accident risks and hazards including the following: Communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as needed, ensuring that interventions are implemented and documented. The P/P indicated how the facility will monitor the effectiveness of interventions to include ensuring interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying, or replacing interventions as needed, and evaluating the effectiveness of new or revised interventions. A review of the facility's P/P, titled "Care Plans, Goals and Objectives," revised 4/2009 indicated care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives are defined as desired outcome for a specific resident problem. When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. The facility failed to: 1. Ensure Resident 1's care plan was revised to include IDT recommendations made after Resident 1's fall on 11/13/2023 which included continued use of the Mat alarm, frequent visual checks, and placing Resident 1 in front of or close to the nursing station. 2. Ensure Resident 1's care observation was endorsed to the nursing staff at the nursing station when Resident 1 was placed next to a nursing station on 12/12/2023 and was left unsupervised. Resident 1, without staff knowledge, self-propelled himself in his wheelchair to the facility's dining/activity room where there were no staff present, stood up from his wheelchair unassisted, and fell. 3. Ensure licensed staff followed the facility's P&P titled, "Care Plans, Goals and Objectives," that indicated care plans shall incorporate goals and objectives that lead the resident's highest obtainable level of independence. 4. Ensure the licensed nurses and the IDT followed the facility's P&P titled, "Safety and Supervision of Residents" in implementing interventions to reduce Resident 1's accident risks and hazards by communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions and ensuring interventions are implemented and documented. These deficient practices resulted in Resident 1 sustaining two falls on 12/12/2023. On 12/12/2023 at 8:45 p.m., Resident 1 was taken to a nursing station by Certified Nursing Assistant 6 (CNA 6) without alerting nursing staff that she was leaving Resident 1 there and to monitor him. Resident 1 left the nursing station without staff knowledge and entered the facility's dining/activity room where he stood up from his wheelchair unassisted and unsupervised and fell. After the fall at the dinning/activity room, Resident 1 was taken to the nursing station and approximately 20 minutes later, in the presence of Licensed Vocational Nurse (LVN 1), Resident 1 stood up from his wheelchair unassisted and unsupervised, and fell to the floor. Resident 1 sustained a fracture (break) to his distal coccyx (tailbone). These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. 2