Health inspection·June 29, 2023

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00839086 Representing the Department, HFEN # 43321 State Citation (A) was written 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. 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 5/17 2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint investigation regarding Resident 1's accidents. As a result of the investigation, CDPH determined that the facility failed to: 1. Identify and evaluate hazard(s) and risk(s) related to the resident's specific risk and causes to prevent further falls and injuries in accordance with the facility's policies and procedures (P &P) "Falls and Fall Risk, Managing," revised 12/2007, P & P titled "Fall Risk Assessment," revied 12/2007, facility's P & P titled "Falls - Clinical Protocol," revised 12/2012, and "Fall Prevention Program," dated 3/8/2023. 2. Implement appropriate interventions related to the specific risks and causes to prevent the resident from falling in accordance with the facility's policies and procedures "Falls and Fall Risk, Managing," revised 12/2007, P & P titled "Fall Risk Assessment," revied 12/2007, facility's P & P titled "Falls - Clinical Protocol," revised 12/2012, and "Fall Prevention Program," dated 3/8/2023. 3. Implement Resident 1's care plan for Risk for Fall which indicated that the physician would document the presence of uncorrectable risk factors including reason why an additional search for causes is unlikely to be helpful in accordance with the facility's policies and procedures "Falls and Fall Risk, Managing," revised 12/2007, P & P titled "Fall Risk Assessment," revied 12/2007, facility's P & P titled "Falls - Clinical Protocol," revised 12/2012, and "Fall Prevention Program," dated 3/8/2023. "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." A review of the facility's P & P titled "Fall Risk Assessment," revied 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." The policy indicated "The staff with the support of the Attending Physician, will evaluate functional and psychological factors (factors that concern a person's mind and thoughts) that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition. A review of the facility's P & P titled "Falls - Clinical Protocol," revised 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." The policy also indicated "If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions." A review of the facility's P & P titled "Fall Prevention Program," dated 3/8/2023, indicated that it is the facility's goal to reduce and minimize episodes of falls and injuries. The policy indicated that in the event a resident is determined to be a risk for falls, the facility will initiate fall prevention measures such as, but not limited to, low bed, floor mat, bed / wheelchair alarm, pressure sensitive alarm, transfer pole, assisted devices / transfer aides and nonskid footwear. The same policy further indicated the facility should use least restrictive devices prior to application of physical restraints as it relates to the actual fall including least restrictive devices such as half lap trays (a wheelchair accessory that provide a sturdy surface to temporarily hold items or arms conveniently) and self-releasing belts. As a result, Resident 1 fell three times and sustained head injuries in the facility on the following dates: a. On 3/2/2023, Resident 1 was found on the floor with a bump and laceration (a cut or tear in skin or flesh) on his left forehead after falling out of his wheelchair. b. On 4/12/2023, Resident 1 was found on the floor with a laceration on his left forehead after he stood up from his wheelchair and fell. c. On 5/2/2023, Resident 1 was found on the floor with a skin scrape measuring 1 centimeter (cm, unit of measurement) x 0.3 cm on his forehead after attempting to reach for an object from his wheelchair. A review of Resident 1's Admission Record (Face sheet) indicated Resident 1 was admitted to the facility on 2/22/2023 with diagnoses including rheumatoid arthritis (a chronic inflammatory disease that causes joint inflammation [A normal part of the body's response to injury or infection] and pain), difficulty in walking, muscle wasting and atrophy (loss of muscle tissue), muscle weakness and polyneuropathy (damage in the peripheral nerves). A review of Resident 1's fall assessment, dated 2/22/2023 (day of admission), indicated Resident 1 was a high risk for fall secondary to his balance problem while standing, balance problem while walking, jerking or instability when making turns, required use of assistive devices and use of antiseizure (medication used to treat seizure [uncontrollable shaking caused by abnormal electrical activity in the brain]) and psychotropic medications (medication used to treat mental health disorders). Resident 1 scored a 10 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 care plan for At Risk for Fall Injury dated 2/22/2023 indicated to minimize the risk for falls in the next three months. Interventions included to assess resident for propensity for falls, assess current fall precaution interventions, monitor anticipate/intervene for factors causing prior falls, and maintain call light within reach. A review of Resident 1's Change of Condition (COC) completed by Licensed Vocational Nurse 1 (LVN 1), dated 3/2/2023, indicated Resident 1 fell out of his wheelchair on 3/2/2023. The COC indicated "Patient (Resident 1) was observed by Physical Therapist (PT) sitting in wheelchair. PT delivered letters to social services and returned to floor. PT heard a thud (a dull, heavy sound, such as that made by an object falling to the ground) in room. PT observed resident on floor face down. Patient (Resident 1) stated only pain on his forehead. CNA (Certified Nursing Assistant) utilized a gait belt to assist resident back to bed. Patient stated he was reaching for the newspaper on the floor when he fell. Patient was instructed to use call light for assistance when he needs help. Patient stated he will try next time." The COC indicated Resident 1 experienced pain on the back of his neck 45 minutes after his fall. A review of Resident 1's Physician Order, dated 3/2/2023, indicated "Forehead injury - cleanse area with normal saline (N/S, a solution used to clean wounds), and pat dry. Apply triple antibiotic (an ointment applied to the skin to treat and prevent minor skin infections) to area. Leave open to air. Ice pack as needed for swelling for 10 days." A review of Resident 1's Treatment Record for March 2023 indicated Resident 1 received treatment to his forehead laceration of cleansing with normal saline, pat dry and application of triple antibiotic ointment once a day for 10 days from 3/2/2023 to 3/11/2023. A review of Resident 1's Care Conference Review (CCR), dated 3/2/2023, indicated six staff members (Director of Nursing [DON], Minimum Data Set Nurse [MDS 1], Licensed Vocational Nurse 1 [LVN 1], Dietary Services Supervisor [DSS], Social Services Director [SSD], and Certified Nursing Assistant 1 [CNA 1]) met to discuss Resident 1's incident of fall on 3/2/2023. The CCR indicated Resident 1 was sitting on his wheelchair while reading a newspaper when the newspaper fell, and he tried to pick it up. Resident 1 lost his balance and fell face down and obtained a "bump and small laceration in his left forehead." The CCR indicated initial treatment was rendered and ice pack was applied to the bump on the left forehead. The CCR also indicated Resident 1 was observed with a purplish discoloration on the "left small finger." A review of the Interview Record written by Physical Therapy Assistant 1 (PTA 1), dated 3/2/2023, indicated PTA 1 observed Resident 1 sitting on his wheelchair when he walked by Resident 1's room. After 30 seconds, he heard a "thud" come from Resident 1's room. He saw Resident 1 on the floor. The note indicated that according to Resident 1, he was reaching for a newspaper on the floor when he fell from his chair. A record review of Resident 1's care plan for high risk for fall dated 3/2/2023, indicated a goal of reduce the risk of fall times 90 days. Interventions included to provide safety education to the resident, and risk of falling, call light within reach and answered promptly, encourage resident to call for assistance as needed, and keep bed at lowest position and wheels locked. A record review of Resident 1's care plan for high risk for fall related to actual fall on 3/2/2023, dated 3/2/2023, indicated interventions included the following: 1. As needed the physician will document the presence of uncorrectable risk factors including reason why any additional search for causes is unlikely to be helpful. 2. Staff and Physician will re-evaluate the situation and consider other possible reason for falling. 3. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature of category of falling until falling reduces or stops or until a reason is identified for its continuation for example if the individual continues to try to get up and walk without waiting for assistance. A review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool), dated 3/7/2023, indicated Resident 1 has moderate impairment in cognition (thought process). The MDS also indicated Resident 1 needed limited assistance in bed mobility (moving to and from lying position, turning side to side) and eating but needed extensive assistance (resident involved in activity and staff provide weight-bearing support) in transferring, walking, locomotion on and off unit, dressing, toilet use and personal hygiene. A review of Resident 1's post-fall assessment (first fall) dated 3/8/2023, indicated Resident 1 was a high risk for fall secondary to having a history of 1-2 falls in the past 3 months, balance problem while standing, balance problem while walking, change in gait pattern when walking through doorway, jerking or instability when making turns, required use of assistive devices, use of psychotropics and having arthritis. Resident 1 scored 15 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 Physician Progress Note by Physician 1, dated 3/10/2023, indicated, under the section "History" that Resident 1 has generalized weakness. Under the section "Assessment" of the progress note indicated Resident 1 has a gait disorder. A review of Resident 1's Physician Progress Notes by Physician 1, dated 4/7/2023, indicated, under the section "History" that Resident 1 has generalized weakness and per Physical Therapist. Resident 1 uses a walker but have episodes of sudden loss of control and is a fall risk. Under the section "Assessment" of the progress note indicated Resident 1 has rheumatoid arthritis (RA) and a gait disorder. A review of Resident 1's COC, dated 4/12/2023, indicated Resident 1 was "Observed lying on floor, curled up in a semi-fetal position (a position where the person's knees are curled inward toward his/her chest) at foot of bed with head pressed against the wall adjacent to bathroom door." The COC further indicated that at 12:05 pm, LVN 1 ran into Resident 1's room and observed Resident 1 lying on his left side in a semi-fetal position at the foot of the bed with his head pressed against the wall adjacent to the bathroom door. Resident 1's wheelchair was two feet away from him. The COC indicated that when Resident 1 was asked what happened, he stated "he was organizing his clothes because his wife was coming to pick up laundry." A review of the Physician Order, dated 4/12/2023, indicated "Left forehead injury - cleanse area with N/S, pat dry, apply triple antibiotic, and leave open to air. Apply ice pack for swelling for 10 days." A review of Resident 1's Treatment Record for April 2023 indicated Resident 1 received treatment to his left forehead laceration of cleansing with normal saline, pat dry and application of triple antibiotic ointment once a day for 10 days from 4/12/2023 to 4/19/2023 (day of visit). A review of Resident 1's Care Conference Review (CCR), dated 4/12/2023, indicated five (DON, DSS, SSD, Physical Therapy Assistant 1 [PTA 1] and CNA 1) interdisciplinary members met to discuss Resident 1's fall incident on 4/12/2023. The CCR indicated "Resident was observed by a licensed nurse (unidentified) that pass by on a fetal position and obtained a scratch to the left forehead." The note further indicated "Upon further investigation and medication regimen review (an evaluation of the resident's medications with a goal to promote positive outcomes and minimize adverse consequences related to the medication), resident has gabapentin (medication for nerve pain), bupropion (medication for depression), Paxil (medication for depression) that can cause drowsiness, sedation, dizziness that may cause resident to fall. The diagnosis of the resident is also one of the reasons that resident will fall, such as anemia (a condition in which the blood does not have enough healthy red blood cells), RA, peripheral neuropathy and resident was admitted here with nausea and vomiting. Therefore, it is concluded that the cause of the fall is the medication and resident's anemia, RA and peripheral neuropathy." A review of Resident 1's updated care plan for high risk for fall related to actual fall on 3/2/2023 and 4/12/2023, dated 4/12/2023, indicated interventions included as needed the physician will document the presence of uncorrectable risk factors including reason why any additional search for causes is unlikely to be helpful. A review of Resident 1's post-fall assessment (second fall), dated 4/14/2023, indicated Resident 1 is a high risk for fall secondary to having a history of 1-2 falls in the past 3 months, balance problem while standing, balance problem while walking, use of psychotropics and having arthritis. Resident 1 scored 10 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 fall risk re-assessment, dated 4/24/2023, indicated Resident 1 is a high risk for fall secondary to having a history of 1-2 falls in the past 3 months, balance problem while standing, balance problem while walking, change in gait pattern when walking through doorway, jerking or instability when making turns, required use of assistive devices, use of psychotropics medications and having arthritis. Resident 1 scored 17 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 COC, dated 5