Health inspection·May 12, 2023

§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 § 72311 Nursing Service -General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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. On 3/20/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigation a complaint regarding Resident 1's accident, abuse, and neglect. The facility failed to provide one to one supervision monitoring (a sitter), and to ensure that the care plan reflected the actual assessment for one of six sampled residents (Resident 1), who was identified as high risk for fall and have had multiple falls on 2/26/2023 and 3/8/2023. As a result, Resident 1 sustaining a right eyebrow laceration (a deep cut or tear in skin or flesh) on 2/26/2023, where Resident 1 was transferred to General Acute Care Hospital (GACH) for a physical examination, a Computed Tomography (CT, a medical imaging scan used to obtain detailed internal images of the body) of the brain and spine, and laceration repair. Resident 1 sustained an abrasion on the right side of the forehead on 3/8/2023 above the laceration on 2/26/2023. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on 2/25/2023 with diagnoses including injuries of abdomen, difficulty in walking, dementia (loss of cognitive functioning such as thinking, remembering, or reasoning to such extent that it interferes with a person ' s daily life and activities) and repeated falls. A review of Resident 1's fall risk assessment, dated 2/26/2023 at 4:43 am, indicated Resident 1 was high risk for fall secondary to his disorientation, history of 1-2 falls in the past three months, being chair bound, poor vision status, balance problem while standing, balance problem while walking, decreased muscular coordination, change in gait pattern when walking through doorway, jerking or unstable when making turns and required use of assistive devices (cane, wheelchair or walker). Resident 1 scored 18 on the fall risk assessment and with any score of 10 or greater, the resident is considered a high risk for potential falls. A review of Resident 1's admission data collection (Admission assessment), dated 2/26/2023 at 12:20 pm, indicated Resident 1 was admitted on 2/25/2023 at 7:50 pm with diagnoses that included multiple falls and dementia. A review of Resident 1's Change of Condition (COC), dated 2/26/2023 at 4:52 pm, indicated Resident 1 was admitted to the facility on 2/25/2023 at 7:50 pm and per the hospital report during transfer, resident have history of multiple falls and a diagnosis of dementia. The COC further indicated that on 2/26/2023 at 4:30 pm "Resident observed standing by the door of room (deducted) and noted with one inch laceration with blood on his right eyebrow." A review of Resident 1's Physician Order, dated 2/26/2023, indicated to transfer Resident 1 to the nearest hospital via 911 (universal telephone number the gives the public direct access to the Public Safety. Answering point where emergency services such as the fire department, police or paramedics can be dispatched to a location). A review of Resident 1's Progress Notes, dated 2/26/2023, indicated Resident 1 was sent out to GACH via medical emergency transportation for laceration over his right eyebrow at 4:40 pm. A subsequent note indicated Resident 1 came back from the hospital (GACH) at 11:20 pm with five sutures on his right eyebrow. A review of Resident 1's GACH After Visit Summary from the Emergency Room, dated 2/26/2023, indicated Resident 1 was diagnosed with laceration of the forehead. Resident 1 underwent a CT scan of the brain and spine and was treated with a laceration repair. A review of Resident 1's CT of the brain result from the GACH, dated 2/26/2023, indicated a result of "Possible small right anterior frontal scalp hematoma (a solid swelling of clotted blood within the tissues)." A review of Resident 1's baseline care plan, dated 2/27/2023, indicated Resident 1 ' s initial admission goals is to regain his physical strength and balance due to status post multiple falls. A review of Resident 1's care plan, no title, initiated on 2/27/2023, indicated Resident 1 is at risk for fall due to his cognitive impairment and dementia. The goal of the care plan is to minimize Resident 1 ' s incidence of fall and injury for the next three months. Interventions included in the care plan are one on one monitoring (a sitter). A review of Resident 1's Progress Note, dated 2/27/2023, indicated Resident 1 attempted to stand on several occasions without assistance. A review of Resident 1's Progress Note, dated 2/27/2023 at 6:30 pm, indicated Resident 1 tried to get out of bed by himself and despite explaining risks involved, he continued to try to get out without assistance or pressing the call light. There was no indication that Resident 1 had a sitter. A review of Resident 1's Progress Note, dated 2/28/2023, indicated Resident 1 is "getting up and down climbs over the side rails." A review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool), dated 3/1/2023, indicated Resident 1 has impaired cognition (thought process) and needed extensive assistance (resident involved in activity, staff provide weight-bearing support) in bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. A review of Resident 1's COC, dated 3/8/2023, indicated "Patient is observed sitting in bed with new wound injury to right forehead." The same COC indicated that the patient was observed with a new cut on right side of forehead with serosanguineous (contains or relates to both blood and the liquid part of blood) discharge) on side of face. A review of Resident 1's Progress Note, dated 3/8/2023, indicated "at 7:15 am this morning during round resident was found in bed aware and alert with purple discoloration and small cut on his right side of upper forehead and above right eyebrow. Resident is confused and was unable to remember what happened or how he has discoloration or cut on forehead ..." There was no indication that Resident 1 had a sitter. A review of Resident 1's care plan titled "Fall Risk," revised dated on 3/8/2023, indicated Resident 1 is at risk for fall related to the alleged falls on 2/26/2023 and 3/8/2023 in addition to his diagnosis of dementia, history of multiple falls, hypertension (high blood pressure) and use of psychotropic (a chemical substance that changes functions of the nervous system, and results in alterations in perception, mood, consciousness, cognition, or behavior) medications. The goals of the care plan are to: 1) Reduce the risk of Resident 1 ' s falls in the next 90 days, 2) Resident 1 will be free from fall related to injuries in the next 90 days. Interventions added into the care plan on 3/8/2023 included 72 hours of one-on-one monitoring due to alleged fall; Anticipate resident ' s needs prior to leaving room; and Provide safety education to the resident and risks of falling. During an interview on 3/20/2023 at 12:08 pm, Certified Nursing Assistant 1 (CNA 1) stated he found Resident 1 on 3/8/2023 at approximately 6:45 am holding a napkin on his forehead. CNA 1 stated the napkin had dried blood and Resident 1 had a bump in his forehead. CNA 1 stated Resident 1 told him he fell. During an interview on 3/20/2023 at 12:29 pm, Licensed Vocational Nurse 1 (LVN 1) stated that on 3/8/2023 at approximately 7 am, after being informed by staff, she went into Resident 1 ' s room and found him to have an abrasion and swelling on his forehead. According to LVN 1, Resident 1 stated he fell. LVN 1 was unable to state if Resident 1 was provided a safety education as indicated in the care plan. LVN 1 stated Resident 1 had no sitter at the time of the fall. During an observation and a concurrent interview on 3/20/2023 at 12:40 pm, Resident 1 was observed with a linear (arranged in or extending along a straight or nearly straight line) scar (an area of fibrous tissue that replaces normal skin after an injury) above his right eyebrow and a small bump above the scar. When asked how he got both the scar and the bump, Resident 1 stated "I fell." Resident 1 was not able to expand on how he fell. During an interview on 3/20/2023 at 1:22 pm, the Director of Nursing (DON) stated that on 3/8/2023, Resident 1 was found to have an abrasion on the right forehead just above the laceration from a fall on 2/26/2023. The DON stated she saw blood on the side rail of Resident 1 ' s bed and thought he may have bumped his head on the side rail. The DON stated and confirmed that Resident 1 is "a very fall risk," and that she knew Resident 1 had multiple falls from his previous facility when Resident 1 was admitted to the facility. The DON further confirmed and stated that Resident 1 ' s care plan, with no title, initiated on 2/27/2023 was done after the incident on 2/26/2023, indicating Resident 1 was at risk for fall due to his cognitive impairment and dementia. During a phone interview on 3/20/2023 at 1:50 pm, Responsible Party 1 (RP 1) stated Resident 1 have had a history of fall and dementia. RP 1 further stated the facility was aware of Resident 1 ' s high risk for fall from the day Resident 1 was admitted to the facility. During an interview on 4/11/2023 at 11:40 am, the DON stated and confirmed there was a discrepancy on Resident 1's fall risk assessment and some of his fall care plans. The DON stated and confirmed Resident 1 was identified as high fall risk based on his fall risk assessment on 2/26/2023 but three of the fall risk care plans only identified Resident 1 as "at risk." The DON further stated it was important to identify resident as high risk versus at risk for accuracy. The DON also stated and confirmed that Resident 1 received 1 on 1 monitoring after the first incident of unknown origin on 2/26/2023 for only 72 hours. A review of the facility's policy and procedures (P &P) titled "Fall Risk Assessment," revised on 12/2007, indicated "The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable." A review of the facility's P & P "Falls - Clinical Protocol," revised on 12/2012, indicated "Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling." A review of the facility's P & P, titled "Falls and Fall Risk, Managing," revised 12/2007, 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 form falling and to try to minimize complications from falling." The facility failed to provide one to one supervision monitoring, and to ensure that the care plan reflected the actual assessment for one of six sampled residents (Resident 1), who was identified as high risk for fall and have had multiple falls on 2/26/2023 and 3/8/2023. As a result, Resident 1 sustaining a right eyebrow laceration on 2/26/2023, where Resident 1 was transferred to GACH for a physical examination, a CT of the brain and spine, and laceration repair. Resident 1 sustained an abrasion on the right side of the forehead on 3/8/2023 above the laceration on 2/26/2023. The above violation had a direct relationship to the health, safety, and security of Resident 1.