Health inspection·July 10, 2024

California Code of Regulations, Title 22, Section 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. Code of Federal Regulations, Title 42, Section 483.25(d) Accident, §483.25(d) Accidents. The facility must ensure that – §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. F689 The facility failed to prevent Patient 1, who was a high risk for falls, history of seizures (a sudden, uncontrolled burst of electrical activity in the brain, which can cause changes in behavior, movements, feelings and levels of consciousness) that needed two persons moderate assistance for transferring, from falling and sustaining injuries by failed to: 1. Develop a care plan and place Patient 1 on seizure monitoring and seizure precautions, upon admission to the facility on 3/2/24, that included the use of seizure pads and floor mats as indicated in the facility's policy and procedures titled "Seizure Precautions" and "Fall Management Program," and bilateral side rails up, in accordance with the physician's order on 3/2/24. 2 . Conduct an IDT(Interdisciplinary Team)-Falls Committee meeting within 72 hours when Patient 1 had a fall and sustained physical injuries from the fall and update the patient's care plan interventions, on 3/7/24 and 3/18/24, to prevent further falls that can result to an injury, in accordance with the facility's policy and procedure titled "Fall Management Program." As a result, Patient 1 sustained a laceration (skin wound) on the left eyebrow after the fall on 3/7/24 and a small skin tear to the right lateral top side of the "pinky finger (little finger)" after the fall on 3/18/24. In addition, Patient 1 was found on the floor bleeding from the head with seizure activity and foaming of the mouth, as witnessed by Certified Nurse Assistant (CNA) 1 for three to five seconds. Patient 1 was transferred to the general acute care hospital (GACH 3) via 911 emergency services for head injury evaluation and surgical incisions to the head. In GACH 3, Patient 1 experienced trauma to the posterior (located behind or toward the back) scalp requiring laceration repair by skin staples (a surgical procedure to close an open wound) on the scalp that measured 5 centimeters (cm- unit of measurement) long. A review of Patient 1's GACH 1 records, titled "History and Physical (H&P)," dated 1/24/24 timed at 9:25 a.m., and GACH 1 "Progress Notes," dated 2/14/24 timed at 12:35 p.m., indicated Patient 1 had a history of head injury (due to an assault), cardiac arrest (a condition when the heart stops beating suddenly), and seizure. A review of Patient 1's facility record titled, "Admission Record" indicated Patient 1, a 60 years old male, was admitted to the facility from GACH 1 on 3/2/24 and readmitted on 5/8/24 with diagnosis that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), anoxic brain damage (caused by a complete lack of oxygen to the brain, with symptoms that included problems with thinking and focus, seizures, muscle wasting (a weakening, and loss of muscle caused by disease or lack of use) and atrophy (progressive decline of a body part), difficulty walking, and injury of the head. A review of Patient 1's facility records, titled "Order Summary Report," for March 2024, indicated a physician order dated 3/2/24, that indicated the patient may have bilateral side rails up as enabler to assist with bed mobility, transfers, and repositioning. A review of Patient 1's record titled, "Fall Risk Assessment," dated 3/3/24 timed at 9:09 a.m., indicated Patient 1 was at high risk for falling due to impaired gait (difficulty rising from chair, uses chair arms to get up, bounces to rise; keeps head down when walking, watches the ground; grasps furniture, person, or aid when ambulating; cannot walk unassisted). A review of Patient 1's facility "Care plan," dated 3/3/24 indicated, Patient 1 was at risk for falls and/or injuries related to balance deficit, cognitive impairment (a condition when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), and history of falls. The care plan interventions indicated to attach call light within reach and encourage patient to use it, developing an activity program to refocus patient, educate/remind patient to ask for assistance, frequent visual checks, keep bed in low position, keep patient up in wheelchair in a supervised area, and postural devices as needed. A review of Patient 1's facility "Care plan," dated 3/7/24 and revised on 3/8/24 indicated, Patient 1 had an actual fall on 3/7/24 and sustained a left eyebrow laceration with poor balance and unsteady gait. The care plan interventions included to continue interventions on the “At risk for fall plan” to determine and address the causative factors of the fall, neuro-checks, and physical therapy consult. A review of Patient 1's "Progress Notes New," dated 3/7/24 timed at 2:26 p.m. indicated Patient 1 had an unwitnessed fall around 8:40 a.m. Patient 1 was found on the floor in the Activity Room, which resulted in laceration on left eyebrow and a transfer to GACH 2. A review of Patient 1's "Order Summary Report," for the month of March, 2024 indicated, Patient 1 had a physician order on 3/7/24 to be transferred to GACH 2 via ambulance for further evaluation and treatment. A review of Patient 1's GACH 2 records titled "Physician H&P," dated 3/8/24 at 7:50 a.m. indicated Patient 1 was referred to urgent care for evaluation from the facility for evaluation of a head injury that the patient sustained when he had unwitnessed fall on 3/7/24. The patient was admitted to GACH 2 for syncope (fainting or passing out), laceration from fall, and bradycardia (abnormal low heart rate). The GACH 2 Physician H&P indicated Patient 1 was bleeding from the left eyebrow. The GACH 2 Physician H&P indicated "[Patient 1] had a history of unstable gait that could have led to the fall, but it is possible the patient (Patient 1) may have had a syncopal episode (fainting or passing out). A review of Patient 1's facility record, titled "Progress Notes New," dated 3/13/24 timed at 6:54 p.m., indicated the patient was readmitted back from the facility in stable condition. A review of Patient 1's facility record indicated the "Minimum Data Set" (MDS- a comprehensive assessment and screening tool) dated 3/17/24, the MDS indicated, Patient 1's cognitive skills for daily decision making was severe impairment (difficulty with or unable to make decisions, learn, remember things). The MDS indicated Patient 1 needed moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limb, but provides less than half the effort) to transfer to and from a bed to a chair/wheelchair, and walk at least ten (10) feet in a room, corridor, or similar space. The MDS indicated due to medical conditions or safety concerns, walking 50 feet with two turns had not been attempted for Patient 1. The MDS under "Fall History," indicated Patient 1 had an episode of fall within the last month of the MDS assessment date of 3/17/24. A review of Patient 1's facility records, titled "Progress Notes New," dated 3/18/24 at 3:20 p.m. indicated Patient 1 had another unwitnessed fall when the patient was found lying on the right side on 3/18/24 timed at 2:40 p.m. The Progress Note indicated Patient 1's fall on 3/18/24 resulted in a small skin tear noted to the “right Lateral top side of the pinky finger”. Fall assessment done. A review of Patient 1's facility record indicated a Physician Order, dated 5/2/24 at 5:06 p.m. indicated Patient 1 had an order to be transferred out via 911 emergency services to GACH 3 related to status post (an event that a person experienced previously) unwitnessed fall with seizure activity. A review of Patient 1's facility records, titled "Progress Notes New," dated 5/2/24 timed at 5:12 p.m. indicated Patient 1 had an unwitnessed fall at 4:50 p.m. when he was found on the floor bleeding from the head with seizure activity noted from three to five seconds. The Progress Note indicated Patient 1 was transferred to GACH 3 via 911 emergency services on 5/2/24. A review of Patient 1's GACH 3 Emergency Department (ED) Notes dated 5/2/24 timed at 7:20 p.m., indicated Patient 1 was "Unable to recall what happened, where he lives but knows he's in the hospital... Patient complains of left hip/leg knee pain, appears uncomfortable. Moving back in fourth in bed [sic]... Patient requires frequent redirection to lay still but forgets and rolls around in bed..." A review of Patient 1's GACH 3 records, titled "Trauma Surgery History and Physical," dated 5/2/24 at 6:56 p.m. indicated Patient 1 arrived at the GACH 1 ED, status post witnessed seizure and fall. The GACH 3 record indicated, "The Patient 1 was found on the ground in a convalescent home following an unwitnessed event that was described as seizure-like. The event lasted for approximately 3-5 seconds and involved the patient foaming at the mouth. The patient was reportedly altered during the entirety of the event. Staples applied to posterior scalp laceration..." A review of Patient 1's GACH 3 records, titled "Laceration Repair Procedure Note," dated 5/2/24 timed at 7:06 p.m. indicated, Patient 1 was admitted for trauma to the posterior scalp, which required laceration repair by skin staples on the scalp measuring 5 cm long. A review of Patient 1's GACH 3 records, titled "Computed Tomography [CT] (uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) Brain without contrast," dated 5/2/24 indicated critical finding of "Small focus of acute posttraumatic subarachnoid hemorrhage (bleeding in the brain) in the left medial frontal region (area just behind the forehead)." A review of Patient 1's GACH 3 records, titled "Neurology Consult Note," dated 5/3/24 at 10:16 a.m. indicated "Patient had a scalp laceration for which he received staples." A review of Patient 1's facility records, titled "Progress Notes New," dated 5/8/24 timed at 7:57 p.m., indicated the patient was readmitted back to the facility from GACH 3 with diagnosis of head injury. A review of Patient 1's facility records, titled "Skin Observation Checks," dated 5/9/24 indicated Patient 1 had surgical incision with four (4) staples in the back of the head, which measured at 4 x 0.1 centimeters (a unit of length). During an interview on 5/17/24 at 11 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated Patient 1 was known in the facility to be high risk for falls due to forgetfulness and confusion. CNA 1 stated, on 5/2/24, at around 4 p.m., CNA 1 helped Patient 1 back to bed after sat on the wheelchair located on the right side of the patient’s bed. CNA 1 stated, while helping CNA 2 with another patient in a different room, CNA 1 heard a sound that sounded like somebody had fallen. CNA 1 stated Patient 1 was found on the floor on the right side if the bed, with the patient's head bleeding. CNA 1 stated, that on 5/2/24, CNA 1 observed that there was no floor mat on the right side of Patient 1's bed and the side rails on both sides were down. When asked if CNA 1 had put the side rails of the bed up, after placing the patient back to bed. CNA 1 stated, she could not recall. CNA 1 stated Patient 1 was not strong enough to put the bed side rails down by himself if the side rails were up. CNA 1 stated, she believed that Patient 1 was trying to go to the bathroom, which was located toward the right side of the bed because going to the bathroom was what Patient 1 frequently requested. CNA 1 stated that Patient 1's stronger side was on the right side where he usually gets up from the bed. CNA 1 stated Patient 1 had a fallen a few times in the facility before and needed assistance with walking because the patient was unsteady. During an interview on 5/17/24 at 11:40 a.m. with CNA 2, CNA 2 stated she was the first one that saw Patient 1 on the floor, on 5/2/24 at around 4:45 to 4:50 p.m. CNA 2 stated, Patient 1 was in bed when she asked CNA 1 for help in another room around 4:30 p.m. CNA 2 stated, while CNA 1 was helping CNA 2 with one of her assigned patients, they heard "a boom sound" so CNA 2 went to check each patient's rooms until she went to Patient 1's room and found him lying face up on the floor bleeding from his head. CNA 2 stated the area that they (CNA 1 and 2) were assigned had a lot of patients that were high risk for falls. CNA 2 stated, Patient 1 should be on one-to-one monitoring because Patient 1 was very "unpredictable, forgetful, confused and not compliant with nurse's recommendation to call for help before getting up on his own." During an interview on 5/17/24 at 12:15 p.m. with Registered Nurse (RN) 1, RN 1 stated on 5/2/24 in the afternoon, she heard a commotion and went to Patient 1's room. RN 1 stated she saw Patient 1 on the floor with a lot of blood, and there was no floor mat on the right side where Patient 1 was lying. RN 1 stated, Patient 1 was a high fall risk because of his unsteady balance. RN 1 stated, Patient 1 was known for forgetfulness and never listened to the nurse's reminder to call for help before getting up. RN 1 stated, there should be a non-compliance care plan for Patient 1 because he had fallen in the facility before. RN 1 stated Patient 1 had a history of seizures so there should also be seizure care plan initiated upon admission for Patient 1. During an interview on 5/17/24 at 12:47 p.m. with LVN 1, LVN 1 stated she was called by CNA 1 and CNA 2 on 5/2/24 and asked for help. LVN 1 stated, when she came, Patient 1 was observed lying on the floor on the right side of the bed facing up. LVN 1 stated, there was one floor mat that was placed on the left side of Patient 1's bed but Patient 1 fell on the right side of the bed where there was no floor mat. LVN 1 stated, "blood was everywhere," and Patient 1 was "Shaking really bad for three to five seconds." LVN 1 stated, Patient 1 did not have any bed side rails up and was not on one-to-one monitoring. LVN 1 stated, Patient 1 had history of falls in the facility prior to the fall on 5/2/24 and was restless, non-compliant when nurses asked him to call before getting up. LVN 1 stated, she did not know if the physician was made aware of Patient 1's noncompliance. During an interview on 5/17/24 at 1:06 p.m. with the Director of Nurses (DON), the DON stated, on 5/2/24 at around 5 p.m., he responded to a call for assistance in Patient 1's room. The DON stated, Patient 1 was lying on the floor and his head was bleeding. The DON stated, Patient 1 was having seizures and foaming from his mouth for about three to five seconds. The DON stated, there was no floor mat on the side that Patient 1 fell in, and the side rails were not up. The DON stated, he did not know for sure if the seizure triggered Patient 1's fall or his noncompliant behavior of getting out of bed unassisted triggered the fall. The DON stated, for fall risk patients, interventions should be initiated that included frequent monitoring, and use of the floor mats. On 5/17/24 at 2:45 p.m., during a concurrent record review of Patient 1's "Nursing Admission Assessment," dated 3/2/24 timed at 8:29 p.m., and interview with the Infection Prevention Nurse (IPN), Patient 1's diagnoses included "localization related idiopathic epilepsy [partial seizures that originate from a localized region of the brain that process and register incoming sensory information (data received through our senses such as sight, smell, touch, taste, and hearing) and make possible the conscious awareness of the world] and epileptic syndrome." The IPN stated, the term was the same as seizure. The IPN stated, if the patient was admitted with history of seizure, a care plan for seizure monitoring and intervention should be