Health inspection·April 21, 2023

On 2/15/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint investigation about quality of care for Resident 1. The facility failed ensure Resident 1, who was assessed as a high fall risk, was not left seated on the edge of a low air loss (LAL - a pressure-relieving mattress used to prevent and treat bed sores) mattress bed unsupervised. This deficient practice resulted in Resident 1 falling off of the bed on October 14, 2022, at 7:45 a.m., sustaining a fracture (break in a bone) to the resident's left lower leg. Resident 1 was transferred and admitted to a general acute care hospital (GACH) on October 15, 2022. Resident 1 required open reduction and internal fixation (ORIF - a type of surgery used to stabilize and heal a broken bone) on October 17, 2022. Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on October 13, 2022, with diagnoses including, generalized muscle weakness, difficulty walking, left knee arthritis (joint inflammation), severe morbid obesity (100 pounds or more above your ideal body weight), and stage 2 (two) pressure injury (when pressure reduces or cuts off blood flow to the skin and blisters or sore forms an open wound) of the sacral (a triangle-shaped bone in the lower spine that forms part of the pelvis) region. A review of Resident 1's "Nursing Admission/Readmission Assessment" dated October 13, 2022, timed at 6 p.m., indicated Resident 1 arrived at the facility via ambulance. Resident 1 was non-ambulatory (did not walk) and used a wheelchair for mobility. Resident 1, "Requires max assist, ... Used a hoyer lift (a device used to transfer/lift a person) to transfer [Resident 1] from regular bed to bariatric bed (is a heavy-duty bed that's usually wider than standard hospital beds to safely accommodate larger individuals safely and comfortably in hospitals, clinics rehabilitation centers and at home). A review of Resident 1's "Nursing Fall Risk Observation/Assessment" dated October 13, 2022, indicated Resident 1 did not fall in the last 90 days and was non-ambulatory and used a wheelchair for locomotion (movement). The nursing fall risk observation/assessment indicated Resident 1 scored 22 (high risk for fall - [reference range,16 to 42]). A review of Resident 1's "Nursing Daily Skilled Charting Form" dated October 13, 2022, indicated Resident 1 had unsteady balance and gait (manner of walking) and was on skilled (having great knowledge and experience in a trade or profession) physical therapy (PT - exercises and physical activities to help condition muscles and restore strength and movement) and occupational therapy (OT - activities with specific goals to help people of all ages prevent, lessen, or adapt to disabilities). A review of Resident 1's physician orders dated October 13, 2022, indicated the following for Resident 1: a. PT Evaluation and Treatment as recommended. b. OT Evaluation & Treatment as recommended. c. Pressure relieving device for pressure relief and wound management (bariatric - relating to or specializing in the treatment of obesity) mattress d. Both upper ("1/4" side rails) up for mobility enablers/repositioning secondary to generalize weakness per family/resident ' s request. A review of Resident 1's "Devices and Physical Restraints (any action or procedure that prevents a person's free body movement to a position of choice and/or normal access to his/her body by the use of any method, attached or adjacent to a person's body that he/she cannot control or remove easily) Orders/Consent" document dated October 13, 2023, timed at 6:10 p.m., indicated a physician obtained a telephone consent from Resident 1 for the use of both upper and lower 1/4 side rails up for mobility enablers/positioning secondary to generalized weakness. A review of Resident 1's Progress Note dated October 14, 2022, timed at 7:45 a.m., indicated Licensed Vocational Nurse 2 (LVN 2) documented that "while night shift was endorsing to [morning] shift (7 a.m. to 3 p.m.), facility staff at the nursing station heard a loud sound coming from the room ... and saw [Resident 1] lying flat on the floor ... [Resident 1] stated she was sitting on the edge of the bed when she slid to the floor." A review of Resident 1's Situation Background Appearance Review and Notification (SBAR), dated October 14, 2022, timed at 7:45 a.m., indicated Resident 1 was evaluated for falls. The SBAR indicated Resident 1 had worsening of pain to the left knee rated at six out of 10 (6/10 - Numerical pain assessment tool where zero is no pain and 10 is severe pain). The SBAR indicated, om October 14, 2022, at 8 a.m., a Medical Doctor (MD) was notified of the fall and an X-ray of the left leg was ordered. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated October 15, 2022, indicated Resident 1 had the capacity to understand and make decisions. Resident 1's cognition (mental ability to make decisions of daily living) was intact. The MDS indicated Resident 1 required extensive two staff assist for dressing, bed mobility, transfer, and toilet use. The MDS indicated Resident 1 did not walk, was not able to turn around, and had impairment on one side to the lower extremities (legs) and used a walker and wheelchair for mobility. A review of Resident 1's Facility Radiology Patient Report dated October 15, 2022, at 6:52 a.m., indicated Resident 1 had ... "partially displaced mid-shaft (mid-bone) tibial (the inner and larger of the two bones between the knee and the ankle) fracture without extension to the tibial prosthesis (a device that replaces a body part)." A review of Resident 1's facility Progress Note dated October 15, 2022, timed at 8:15 a.m., indicated LVN 2 documented that MD was notified of Resident 1's left leg X-ray result, and the MD ordered to transfer Resident 1 to a GACH. A review of Resident 1's Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form dated October 15, 2022, indicated Resident 1 received Norco (strong controlled pain medication) 10-325 milligrams (mg - unit dose measurement) for eight out of 10 (8/10- numerical pain assessment wherein zero is no pain and 10 as the worst pain) left lower leg pain on October 15, 2022, at 11 a.m. A review of Resident 1's Fire Department (FD) Patient Care Report dated October 15, 2022, timed at 2:22 p.m., indicated "Dispatch Complaint: Fall with blunt leg injury (an injury resulting from an impact with a dull, firm surface or object)." Provider Primary Impression: Traumatic injury (physical injury of sudden onset and severity which require immediate medical attention) on October 14, 2022, at 2:44 p.m. The cause of injury was ground level fall. The facility reported Resident 1 suffered a mechanical fall (an external force [example the environment]) caused the patient to fall) on 10/14/2022 and was treated with splinting (a rigid or flexible device or compound used to support, protect, or immobilize) and imaging (Xray). Resident 1 opened eyes spontaneously at 2:53 p.m. and 3:13 p.m. Resident 1 denied any weakness, dizziness, loss of consciousness or other complaints before falling. Resident 1 was transferred to the hospital (GACH) on October 15, 2022. A review of Resident 1's Facility Discharge Summary report dated October 15, 2022, indicated that, Resident 1 "was transferred to GACH emergency room (ER) via 911 (the telephone number used to reach emergency medical, fire, and police services) for left lower leg fracture following a fall. The discharge summary report indicated abnormal Xray of left tibia and fibula (the outer and usually smaller of the two bones between the knee and the ankle in humans), Xray of left knee region." A review of Resident 1's GACH History and Physical (H&P) dated October 16, 2022, indicated Resident 1 had pain in the left leg and a repeat Xray showed a distal (away from the center of the body) left tibia fibula fracture. Resident 1 was scheduled for surgery on October 17, 2022. Resident 1 was admitted at the GACH for further evaluation and care. The GACH H&P indicated Resident 1 had a past history of left knee replacement (a surgical procedure to replace parts of injured or worn-out knee joints). A review of Resident 1's GACH Discharge Summary dated October 25, 2022, timed at 9:22 p.m., indicated Resident 1 had an ORIF of the left tibia on October 17, 2022. On February 15, 2023, at 1:30 p.m., during an interview with Registered Nurse 1 (RN 1) supervisor, RN 1 stated she was not working on the day Resident 1 fell. RN 1 stated a resident must be cleared by the PT department staff before a resident can sit alone on the side of the bed. RN 1 stated a resident could fall and get injured if the resident was not safe to sit on the side of the bed alone. On February 23, 2023, at 12:54 p.m., Family Member 1 (FM 1) stated on October 14, 2022, while he was visiting, a staff member (either a nurse or therapist) let Resident 1's bed siderail down and sat Resident 1 up on the edge of the bed. FM 1 stated the staff member told FM 1 that the staff member needed to go get a gurney (medical transport device) and transport Resident 1 for therapy. FM 1 stated the staff member left the room for quite a while and left Resident 1 sitting on the edge of the bed. FM 1 stated Resident 1 complained that her legs were hurting and slid off the LAL mattress bed and fell down. FM 1 stated he (FM 1) prevented Resident 1 from hitting her head on the floor. FM 1 stated Resident 1 fell forward and ended up on her back. FM 1 stated he (FM 1) yelled for the nurses to help him. FM 1 stated Resident 1 complained "of a lot of pain to both legs." On March 1, 2023, at 1:38 p.m., during a telephone interview, RN 1 stated she remembered she was receiving the report from the night shift (11 p.m. to 7 a.m.) nurse on the morning of October 14, 2022, when she saw a therapist (unnamed) working with Resident 1 in the resident's room. RN 1 further stated the therapist assigned to Resident 1's room was the same therapist that sat Resident 1 on the edge of the bed. RN 1 stated, a little after 7 a.m. on October 14, 2022, she observed Resident 1 was lying in the bed with the half siderails (a structural support attached to the frame of a bed and intended to prevent a patient from falling) up and FM 1 was at the resident's bedside RN 1 stated a resident could fall if left unsupervised and seated on the edge of a bed. A review of the facility's policy and procedures titled "Bed Safety and Bed rails," dated August 2022, "2. Consideration is given to the resident's safety... 10. Additional safety measures are implemented for residents who have been identified as having a higher than usual risk for injury ..." A review of the facility's undated policy and procedures titled "Falls Management" indicated it is the facility's policy "that our physical environment remains free of accident hazards as possible. Residents will be assessed for fall risk and interventions will be implemented to reduce the risk of falls ... The Procedure for risk identification/Prevention included ... 2. New or existing residents scoring as high risk will have intervention implemented to reduce the potential for falls outlined ... The facility failed ensure Resident 1, who was assessed as a high fall risk, was not left seated on the edge of a LAL mattress bed unsupervised. This deficient practice resulted in Resident 1 falling off of the bed on October 14, 2022, at 7:45 a.m., sustaining a fracture to left lower leg. Resident 1 was transferred and admitted to a GACH on October 15, 2022. Resident 1 required an ORIF on October 17, 2022. The above 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 Resident 1.