Health inspection·November 1, 2024

The following reflects the findings of the California Department of Public Health (CDPH) during the investigation of a complaint. Complaint Number: CA00917289. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations. 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. 42 CFR §483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Title 22, California Code of Regulations § 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. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. Title 22, California Code of Regulations § 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 09/10/2024, CDPH made an unannounced visit to the facility to investigate a complaint allegation regarding resident neglect, falls and accidents. As a result of the investigation, CDPH determined that the facility failed to: 1. Implement fall prevention measures by monitoring for the effectiveness of the interventions as indicated in Resident 1's fall care plans dated 9/19/23 and 3/4/24 and modify the interventions based on the needs of Resident 1 to prevent recurrent falls and injury for Resident 1. 2. Revise Resident 1's care plan titled "Fall Risk" on 5/24/24, after Resident 1 had a fall on 5/24/24. 3. Implement its' facility's policy and procedures (P&P) titled "Falls and Fall Risk, managing" dated 1/25/24, by failing to implement additional or different interventions, or indicate why the current approach remains relevant after Resident 1 experienced multiple falls and injury. 4. Implement its' P&P titled "1:1 Supervision/Sitters" undated, by failing to ensure Resident 1 was provided additional supervision and/or companionship in obtaining sitters or companion care due to Resident 1's medical, physical, or psychosocial wellbeing. As a result, Resident 1 had multiple falls on 10/10/23, 11/20/23, 2/25/24, 5/24/24, 7/5/24, and 8/21/24. On 8/21/24 at 5:25 pm, Resident 1 had a fall and was transferred to a general acute care hospital (GACH) via 911 (emergency response telephone number), where Resident 1 was diagnosed with a traumatic head injury (injury to the head acquired from an outside force, usually a violent blow) resulting in a left subdural (area between the brain and skull) hematoma (a collection of blood outside of blood vessels usually caused by injury or surgery that damages the blood vessels) and nondisplaced (connected) left 3rd to 6th rib fractures. GACH admitted Resident 1 to the Intensive Care Unit (ICU, a special department or unit of a hospital or health care facility that provides intensive care medicine, for patients that are seriously ill), for further management and care. A review of Resident 1's "Admission Record" dated 9/10/24, indicated Resident 1 was admitted to the facility on 9/19/23, with diagnoses including metabolic encephalopathy (a condition affecting the brain due to a chemical imbalance in the blood), dementia (a condition of the brain that causes memory loss, confusion, trouble finding, words, misjudging distances and problems performing familiar tasks) with other behavioral disturbance, aphasia (a condition involving language, effecting the ability to communicate) following cerebral infarction (stroke), impulse disorder (behavioral conditions affecting the way one controls their actions and reactions) , and epilepsy (seizure disorder). A review of Resident 1's fall risk assessment dated 9/19/23, indicated Resident 1 had a score of 14 (a score of 10 or above represents high risk for fall). The fall assessment further indicated Resident 1 had balance problems while standing, balance problems while walking, decreased muscular coordination, and used of assistive devices for mobility. A review of Resident 1's fall risk care plan dated 9/19/23, indicated Resident at risk for fall due to recent fall, use of psychotropic medication (drugs that affect mood, thoughts and behaviors used to treat mental illness), balance problem, and poor safety awareness. The same care plan further indicated prevention interventions included, to place the call light within reach and staff to answer/respond to the residents call lights promptly. The same care plan indicated to maintain safe environment, room free of cluster, remind resident to use assistive device, toileting schedule, refer to PT (physical therapy, treatment that to help manage pain, improve movement, regain strength after surgery)/OT (occupational therapy, treatment that helps people overcome physical, sensory or cognitive problems, with basic tasks people do every day to care for themselves e.g., grooming, dressing), lap buddy (cushioned device that fits the wheelchair and assists with reminding a persona not to get up by themselves) in wheelchair check and release every two hours and reposition, keep frequently used items within reach, siderails/padded as per Medical Doctor (MD) order. A review of Resident 1's Short Term Care Plan for status post (after) fall (10/10/23) regarding left leg pain initiated on 10/10/23 indicated interventions included to monitor the resident for 72 hours, notify MD, notify Resident 1's family responsible party (RP) and STAT (without delay) x-ray. A review of Resident 1's Interdisciplinary Team (IDT, a meeting where team members from different heads of department get together and plan and review resident's care) meeting notes dated 11/20/23 indicated resident is impulsive continues to get up unassisted due to impaired cognition. Frequent urge to get up unassisted. Reinforce use of call light. A review of Resident 1's Care Plan Short Term Fall and Incidence dated 11/29/23, indicated interventions of: provide safe environment at all times, encourage resident to use call light and an intervention written in by hand but illegible. A review of Resident 1's Care Plan Short Term Fall and Incidence dated 2/25/24, indicated Resident 1 was found on floor going to/coming from bathroom transferring self without nursing assistance on 2/25/204 at 8 am. The care plan further indicated interventions included to provide the resident with a safe environment at all times, handle gently, encourage resident to use call light for all needs, provide resident with free of cluster, place all personal belongings within reach, encourage resident to ask for assistance from staff for all transfers (to and from wheelchair, bed, etc.), anticipate resident need to use the restroom, neurological check (neurological exam, a way to evaluate a patient's nervous system, to detect threatening conditions) for 72 hours, monitor for pain every shift. A review of Resident 1's "Fall Risk" care plan dated 2/25/24, indicated, Resident 1 was at risk for fall related to dementia, impulse control disorder, and epilepsy, recent fall, history of multiple falls, balance problem, memory problem, poor safety awareness and refuses to use call light. The care plan further indicated interventions included to place the call light within the resident's reach and staff to answer the call light promptly. The care plan further indicated to encourage the resident to call for assistance if needed, maintain a safe environment, the resident's room be free of clutter, assist with ADLs (Activities of Daily Living) as needed, and to remind the resident to use assistive device, monitor for adverse side effect (ASE, undesirable or harmful effect) from medications. A review of Resident 1's IDT meeting notes dated 2/26/24 indicated no injury, fell when coming from bathroom. Resident 1 is being "closely monitored by staff, grouped in a room with roommates on closed monitoring" meaning the other two residents were being monitored by sitter (healthcare worker who provides care and support to patients: by monitoring, assisting, providing safety, and/or companionship). A review of Resident 1's "Fall Risk "care plan with a revision date on 2/25/24 indicated status post fall (2/25/24) resident is move close to nursing station and on close supervision. A review of Resident 1's Nursing Progress Note dated 2/26/24, Licensed Vocational Nurse (LVN) indicated that on 2/25/24 at 8 am Resident 1 had slid out of his wheelchair while transferring self, coming from the bathroom. The nursing progress note further indicated the resident's Responsible Party (RP, is the individual or entity that has the legal control, manages, or directs the entity and the disposition of the entity's funds and assets, and at least 18 years older) had requested a sitter nurse to monitor Resident 1 because he has dementia and has fallen multiple times. The LVN documented that staff were encouraging Resident 1 to ask for assistance with all transfers even if the resident believed he could transfer himself. The nursing progress note further indicated RP again mentioned Resident 1 had dementia and cannot remember to use the call light (to call for assistance) and could barely remember anyone's name. The nursing progress note further indicated RP was offered to have a "pad alarm" (pressure-sensitive pad that can be placed under a person in bed or chair, which will alarm when the person starts getting up) placed on the resident's wheelchair for safety but was told that Resident 1 "did not qualify" for a sitter. The nursing progress note indicated that RP is tired of Resident 1 falling and that RP would feel bad if the resident was to die, break a hip, or hurt himself from falling. A review of Resident 1's "Physician Orders" dated 3/4/2024, indicated for pad alarm on bed while Resident 1 "is in bed to alert nursing staff when the resident is attempting to get out of bed by self, apply pad alarm on wheelchair while resident is in wheelchair to alert nursing staff when resident is attempting to get out of wheelchair by self, wheelchair and monitor pad alarm placement and functioning/mark "ON" is Pad Alarm is in place and functioning/mark "OFF" if pad Alarm is not in place and not functioning." A review of Resident 1's "Fall Risk" care plan for the fall on 3/4/24, indicated no revision was indicated for the use of the tab or pad alarm, or interventions indicated for the behaviors of the resident removing the tab or pad alarm. A review of Resident 1's "Renew SBAR" form (Situation, Background, Assessment, and Recommendation, used to communication critical information in a change of condition) dated 3/4/24, indicated Resident 1 was having multiple episodes of taking/removing the tab alarm. The SBAR indicated that staff were conducting rounds to visually monitor Resident 1 who was a high fall risk. The SBAR indicated the resident was refusing the tab alarm (alarm connected to resident's clothes that will monitor movement) and change of tab alarm to pad alarm. A review of Resident 1's "Renew SBAR" dated 5/24/24 at 5:50 pm, indicated Resident 1 had fall, witnessed by a staff who reported that "the resident is on the floor sitting down beside his bed, and resident stated he was trying to get up on the wheelchair and lost balance." A review of Resident 1's "Fall Risk" care plan for the fall on 5/24/24, no revision was indicated after the fall on 5/24/24. A review of Resident 1's Short Term Care Plan dated 6/3/24, indicated, change of condition (COC - significant decline or improvement in their health that requires intervention) status post fall on 5/24/24, with interventions to monitor Resident 1 for 72 hours, notify MD, and notify family/RP. No new interventions noted. A review of Resident 1's Minimum Data Set (MDS a federally mandated Resident assessment tool) dated 6/25/24, indicated Resident 1 had a moderately impaired (confusion about where one is and what is happening) cognition (ability to think, understand and make daily decisions). Resident 1's MDS further indicated Resident 1 required supervision or touching assistance, where a helper provides verbal cures and/ or touching/ steadying and/or contact guard assistance as resident completes activity; for toileting, sit to lying, sit to stand, chair to chair transfer, and toilet transfer. A review of Resident 1's "Renew SBAR" dated 7/7/24 at 4:30 pm, indicated, RP visited Resident 1 on 7/7/2024 and informed a Registered Nurse (RN) that on 7/5/24 at around 11:20 pm while sleeping, Resident 1 fell, rolled out of bed, complained of intermittent rib pain during inspiration (breathing in), and an x-ray was ordered. A review of Resident 1's "Incident of fall" care plan dated 7/7/24 indicated, "[Resident 1] claimed he fell on Friday 7/5/24 at 11:20 pm." The incident of fall indicated the resident stated he was asleep and rolled out of bed on the right side," and reported incident to RP. The care plan interventions included, monitor vital signs, medicate for pain, rehabilitation (restoring someone to health or normal life through training and therapy) post fall assessment, keep environment free of hazards..., place call light within reach, answer promptly, keep frequently used items within reach, discuss with resident the necessity for use of preventative equipment to ensure safety, bed in lock position, fall precaution every shift and obtain an x-ray will report the result to MD. A review of Resident 1's "SBAR Communication Form" dated 8/21/24, indicated Resident 1 had an "unwitnessed fall (8/21/24 at 5:25 pm) and was noted on the floor lying on the floor on his back with his head against the wall, bed in lowest position, skin intact, no visible injuries, resident stated he felt dizzy due to fall and was immobilized until paramedics arrived." A review of Resident 1's care plan titled "Post Unwitnessed Fall" dated 8/21/24 indicated interventions including, check range of motion, continue interventions on the at-risk plan, monitoring and report change in status pain bruises, new onset confusion, sleepiness, inability to maintain posture, agitation, neuro (means nerve and nervous system) checks for 72 hours, and transfer the resident to a GACH. During a review of GACH Emergency Department (ED) Provider Note dated 8/21/2024 at 11:43 pm, indicated Resident 1 with a witnessed non-syncopal (without loss of consciousness) fall with head trauma and back pain. The ED provider note indicated computed tomography scan (CT scan-is a medical imaging technique used to obtain detailed internal images of the body) brain, c-spine (neck region of your backbone, spinal column) ... ordered. The ED provider note indicated Resident 1 diagnoses included traumatic injury of the head initial encounter. A review of GACH Neurocritical (pertaining to intensive care management of patients with life-threatening neurological and neurosurgical illnesses such as massive stroke, bleeding in or around the brain) Progress Note dated 8/22/2024 indicated Resident 1 complained of headache and back pain (pain level for both not documented). The neurocritical progress note indicated that the CT imaging for Resident 1, "Revealed 10 millimeter (mm-unit of measurement) left (L) parasagittal (situated alongside of or adjacent to) subdural hematoma (SDH), 15mm acute (of sudden onset) L tentorial (a tent-shaped duplicated fold) SDH, 8mm acute L hemispheric (relating to, or involving one of the two parts of the brain) SDH, trace left middle cranial fossa (a depression, commonly it refers to bones) subarachnoid hemorrha