Health inspection·May 8, 2024

§483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. § 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. 72637 General Maintenance. (a) The facility, including the grounds, shall be maintained in a clean and sanitary condition and in good repair at all times to ensure safety and well-being of patients, staff, and visitors.... (c) All buildings, fixtures, equipment, and spaces shall be maintained in operable condition. On 3/12/2024, the California Department of Public Health (CDPH), received a facility reported incident (FRI) indicating a resident (Resident 1) was holding onto a sink in her bathroom when the sink fell from the wall. Resident 1 lost her balance and fell to the floor. On 3/26/2024, at 8:10 a.m., CDPH conducted an unannounced visit at the facility to investigate the FRI. Upon investigation, CDPH determined Resident 1's bathroom sink was loose and fell from the wall causing Resident 1 to fall and sustain a left hip fracture, a bump with discoloration to her left eye and a bump with discoloration to the back left side of her head. Following Resident 1's fall and injuries, the facility determined there were at least two other sinks in the facility that were loose and needed repair. The facility failed to: 1. Ensure the hand sink in Resident 1's bathroom was inspected during daily rounds by the maintenance staff and/or the facility's administrative staff, per their practice, to ensure the sink in Resident 1's bathroom, as well as in other residents' rooms, was mounted securely to the wall to prevent injury. 2. Follow its policy and procedure (P/P) titled "Maintenance Service" that indicated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. As a result of these deficient practices the sink in Resident 1's bathroom sink fell from the wall, while Resident 1 was holding onto this sink, causing Resident 1 to fall on the floor and sustain a left intertrochanteric femoral neck (the region on top of the thigh bone that connects to the hip bone) fracture and was transferred to the General Acute Care Hospital (GACH) for evaluation and treatment. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on 10/27/2017, with diagnoses including cerebral infarction [stroke] occurs when blood flow is disrupted to the brain) affecting Resident 1's left side, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), glaucoma (chronic, progressive eye disease), and a history of failing. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 12/28/2023, indicated Resident 1's cognitive (the ability to think, reason, and understood) skills for daily decision-making were severely impaired. The MDS indicated Resident 1 required moderate to maximal assistance to complete her activities of daily living ([ADL] activities related to personal care that include, bathing, dressing, getting in/out of bed, walking, toileting and eating). The MDS indicated Resident 1 was four foot seven inches tall and weighed 100 pounds (lbs.) A review of Resident 1's Change of Condition (COC) dated 3/10/2024, and timed at 8:29 a.m., indicated Resident 1 sustained a fall and was noted with a bump and discoloration on her left eye and a bump and discoloration to the back left side of her head. A review of the facility's Incident Investigation Summary, dated 3/10/2024, and timed at 5 a.m., indicated Resident 1 was washing up in bathroom in her room, while supervised by a Certified Nursing Assistant (CNA 1) when the toilet sink (hand sink) fell off the wall, Resident 1 lost her balance and slid on the floor on her left side. The Incident Investigation Summary indicated Resident 1 most likely hit her left orbital external (the outer portion of the resident's left eye) eye on a paper towel dispenser, then hit her left mid-upper parietal (back of her head) on the wall, before she slid to the floor. The Incident Investigation Summary indicated at that time Resident 1 had no pain or injuries. On reassessment (time not indicated), Resident 1 was noted with red discoloration and bumps to her left exterior-lateral orbital region and left mid-upper parietal part of her head. Resident 1 complained of minimal tolerable pain on a scale of 3 out of 10 (an 11 point scale where pain is rated zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain). Later in the evening (time not indicated), Resident 1 complained of pain to her left hip when crossing her left leg above her right leg. A review of Resident 1's Nursing Notes, dated 3/10/2024, indicated no documentation of Resident 1's fall or an assessment of Resident 1 after her fall. A review of Resident 1's Nursing Note dated 3/10/2024, and timed at 2:31 p.m., indicated Resident 1 verbalized pain to her left hip. The Nursing Note indicated Resident 1's physician was notified and an order for a STAT (immediate) X-ray was obtained. A review of Resident 1's X-ray Report, dated 3/10/2024, and timed at 4:37 p.m., indicated Resident 1 had an acute (a condition that is severe and has a sudden onset) left hip fracture. A review of Resident 1's Physician's Order dated 3/10/2024, and timed at 5:16 p.m., indicated to transfer Resident 1 to a GACH for evaluation related to her fall. A review of Resident 1's GACH records dated 3/10/2024, indicated Resident was admitted to the GACH on 3/10/2024, with a diagnosis of a left intertrochanteric femoral neck fracture, secondary to a mechanical fall (a fall caused by an external force). A review of the GACH's Hospital Course, dated 3/10/2024, indicated given Resident 1's frailty, advanced age, poor baseline mobility, and dementia, Resident 1's Family Member (FM) and Durable Power of Attorney ([DPOA] an agent that the resident has chosen allowing them to make decisions about the health care of the resident in case they are not able to make those decisions themself), requested conservative, nonoperative management. Resident 1 will return to custodial care for pain management and a hospice consultation. Resident 1 was at high risk for mortality (death), either with or without surgery. During an interview and a subsequent tour of the facility on 3/26/2024, at 10:19 a.m., with Maintenance Staff (MS 1), MS 1 stated after the sink fell from the wall in Resident 1's bathroom, they found two other sinks in the facility that were loose and were repaired. MS 1 could not recall the rooms the sinks were in loose condition. During a telephone interview on 3/27/2024, at 12 p.m., CNA 1 stated, she escorted Resident 1 to the bathroom (3/10/2024) in her wheelchair and placed her in front of the hand sink and stood her up so she (Resident 1) could wash her face. CNA 1 stated Resident 1 turned on the water in the sink and placed her hands on the sink when the sink fell to the floor. CNA 1 stated Resident 1 fell and landed on her left hip and bumped the left side of her head. CNA 1 stated she could not recall if there was anything wrong with the hand sink prior to Resident 1 using it. During an interview on 3/27/2024, at 1:30 p.m., the Maintenance Supervisor (MS) stated it takes a lot of weight to force a sink off the wall and Resident 1, (given her size and weight), should not have been able to pull it from the wall just by leaning on it. The MS stated the maintenance staff conducts daily rounds of the facility to identify any issues that the maintenance department needs to address, but stated he did not have a check list that was signed by him or the maintenance staff to prove they did rounds. The MS stated he was not aware of any problems with the hand sink in Resident 1's bathroom prior to it falling from the wall. During an interview on 3/27/2024, at 2:56 p.m., the Licensed Vocational Nurse (LVN 1) stated she was summoned to Resident 1's room by CNA 1 and found Resident 1 on the floor, the bathroom sink was on the floor with water coming out of the pipes. LVN 1 stated she assessed Resident 1 and noticed discoloration to Resident 1's left eye and on the back of her head. During an interview on 3/28/2024, at 12:44 p.m., the Administrator (ADM) stated, safety rounds are conducted daily by all staff to identify any hazards. The ADM stated he was not aware of any problems with the hand sink in Resident 1's bathroom and if there was a problem with the sink it should have been reported immediately to the maintenance department so it could have been repaired. A review of the facility's P/P titled "Safety and Supervision of Residents," revised 7/2017, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. A review of the facility's P/P title "Maintenance Service," revised 12/2009, indicated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of the maintenance personnel include but are not limited to maintaining the building in good repair and free from hazards. The facility failed to: 1. Ensure the hand sink in Resident 1's bathroom was inspected during daily rounds by the maintenance staff and/or the facility's administrative staff, per their practice, to ensure the sink in Resident 1's bathroom, as well as in other residents' rooms, was mounted securely to the wall to prevent injury. 2. Follow its P/P titled "Maintenance Service" that indicated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. As a result of these deficient practices the sink in Resident 1's bathroom fell from the wall, while Resident 1 was holding onto this sink, causing Resident 1 to fall on the floor and sustain a left intertrochanteric femoral neck fracture and was transferred to the GACH for evaluation and treatment. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.