Health inspection·September 13, 2024

42 CFR §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: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (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. 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 8/1/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate an allegation of a resident fall. The facility failed to ensure residents receive the necessary care based on the assessed individual needs to prevent accidents and minimize injuries for Resident 1, who was identified as a high fall risk. The facility failed to: 1. Ensure Resident 1 was provided visual supervision, in accordance with the facility’s policies titled, "Free of Accident Hazards / Supervision / Devices" and “Fall Management Program,” while sitting on a Geri-chair (a padded reclining chair that was designed to help older adults with limited mobility) in the hallway. The System Approach section of the policy on "Free of Accident Hazards / Supervision / Devices" indicated implementation of individualized, resident centered interventions, including adequate supervision and assistive devices, to reduce individual risks related to hazards in the environment. The policy titled, “Fall Management Program,” indicated, “Facilities are obligated to provide adequate supervision to prevent accidents.” 2. Review and revise Resident 1's care plan interventions on risk for falls, created on 4/13/2023, that were person-centered and were individualized based on the resident's risks, physical, and mental conditions. As a result, on 7/14/2024 at 7:45 p.m., Resident 1 fell out of the Geri-chair in the hallway and sustained a right femur fracture (a break in the thighbone), acute (severe or sudden onset) nondisplaced fracture (the bone cracks or breaks but retains its proper alignment) of the right inferior and superior pubic ramus (pelvic bones), and an acute mildly comminuted (a bone that is broken in at least two pieces) and mildly displaced fracture (the ends of the bone had come out of alignment) of the left inferior pubic ramus. Resident 1 also sustained blunt head injury (caused by an external force strong enough to move the brain within the skull) and hematoma (an area of blood that collects outside of the larger blood vessels) of the face. A review of Resident 1's Admission Record indicated the facility admitted the 87-year-old female resident on 4/12/2023 with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), muscle weakness, and essential hypertension. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 4/16/2024, indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills was moderately impaired. The MDS indicated Resident 1 required moderate assistance (helper lifts, holds, or supports trunk or limbs but provides less than half the effort) to roll left and right. The MDS indicated Resident 1's assessment on lying to sitting, sit to stand, and chair/bed-to-chair transfer were not attempted because of the resident's medical condition or safety concerns. A review of Resident 1's Fall Risk Evaluation, dated 4/18/2024, indicated the resident had a total score of ten. A score of ten or greater represented high risk for falls. The fall risk evaluation indicated a prevention protocol should be initiated immediately and documented on the care plan and reviewed at least quarterly and with Change of Condition (COC). A review of Resident 1's COC Form, dated 6/22/2024, indicated the resident had an unwitnessed fall. Resident 1 was seen lying on the floor and sustained a skin tear on the right elbow. The COC indicated Resident 1 was agitated and wanted to throw herself off the bed. The COC indicated the family was notified and consents were acquired for a pad alarm (a device placed under a high fall risk resident on the bed or on a chair to alert the caregivers), an extra mattress on the floor, and to put the resident's bed against the wall. The COC indicated Ativan 0.5 milligrams (mg - unit of measurement) twice a day, as needed for anxiety (the feeling of fear, dread or uneasiness that may occur as a reaction to stress) was ordered. A review of Resident 1's Fall Risk Evaluation, dated 6/22/2024, indicated the resident had a total score of 12. A score of ten or greater represented high risk for falls. The fall risk evaluation indicated a prevention protocol should be initiated immediately and documented on the care plan and reviewed at least quarterly and with COC. A review of Resident 1's Physician Orders, dated 6/22/2024, indicated an order for a pad alarm (a pressure-sensitive pad placed under the mattress or seat cushion that triggers an audible alarm when a resident attempts to rise off the pad) on bed. A review of Resident 1's Physician Orders, dated 6/22/2024, indicated an order for lorazepam (also known as Ativan, a medication used to manage anxiety disorders) 0.5 milligrams (mg - unit of measurement) for verbalization of feeling nervous. A review of Resident 1's Care Plan on actual fall, dated 6/22/2024, indicated the resident had a fall secondary to poor balance. The Care Plan interventions included to place the bed against the wall, place a mattress on the floor, encourage Resident 1 to use bell to call for assistance, and to keep the call light (a device used to call for assistance from the facility staff) within reach at all times. The Care Plan did not include Resident 1's pad alarm in accordance with the physician’s order on 6/22/2024. A review of Resident 1's COC Form, dated 7/14/2024, indicated the resident was found on the floor beside Resident 1's chair. The COC indicated Resident 1 sustained a small bump on the head without bleeding and Emergency Medical Services (EMS) were notified. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) for further evaluation. A review of Resident 1's Post Fall Evaluation/Interdisciplinary Team (IDT) Review, dated 7/14/2024, indicated the resident was observed on the floor at 7:45 p.m., beside the resident's Geri-chair. The IDT Review indicated Resident 1 sustained a bump on the head. The IDT Review indicated Resident 1 had hallucination of being killed. A review of Resident 1's GACH 1 History and Physical (H&P) Reports, dated 7/14/2024 at 9:03 p.m., indicated the resident was admitted to the emergency department due to a fall. The Physical Exam section indicated Resident 1 had a deformity of the right leg consistent with fracture. The Assessment / Plan section indicated Resident 1 sustained a fall, blunt head injury, and hematoma. A review of Resident 1's GACH 1 Discharge Instructions, dated 7/16/2024, indicated the resident's diagnoses included fall, blunt head trauma, and hematoma of the face. The Imaging section indicated a computed tomography (CT - a diagnostic imaging procedure that used a combination of x-ray [the use of electromagnetic energy beams to produce images of internal tissues, bones, and organs] and computer technology to produce images of the inside of the body) scan of the brain/head without contrast (a dye or other substance that helps show abnormal areas inside the body) was done at 8:42 p.m. on 7/14/2024. The CT scan impression indicated Resident 1 had mild to moderate bi-frontoparietal scalp (both forehead and upper back wall of the head bones) hematoma or contusion (an injury that resulted from a direct blow or impact in which the skin is not broken) at the vertex (top of the head). The CT scan of the pelvis without contrast indicated Resident 1 had a right femur fracture, acute nondisplaced fracture of the right inferior and superior pubic ramus, and an acute mildly comminuted and mildly displaced fracture of the left inferior pubic ramus. During an interview and concurrent record review on 7/30/2024 at 11:42 a.m., Registered Nurse 1 (RN 1) stated that Resident 1 was agitated and anxious. RN 1 stated that Resident 1 was unable to walk and had a high risk for falls. Resident 1's Care Plan on risk for falls, initiated on 4/13/2023 and last revised on 2/9/2024, was reviewed with RN 1 and indicated the resident was at risk for falls secondary to gait and balance problems and muscle weakness. The Care Plan had a goal to minimize risk of injury from falls. The Care Plan Interventions included to educate the resident /family/caregivers about safety reminders and what to do if a fall occurs. During a telephone interview on 7/31/2024 at 6:10 p.m., CNA 4 stated on 7/14/2024, CNA 4 went on her lunch break and informed LVN 2 and CNA 6 that Resident 1 was on a Geri-chair in the hallway across from the resident's room. During a telephone interview on 7/31/2024 at 6:22 p.m., LVN 2 stated on 7/14/2024, CNA 4 went on a lunch break and informed her that Resident 1 was on a Geri-chair in the hallway. LVN 2 stated she was at nurse station 2 and could not see Resident 1 from the nurse station. CNA 6 found Resident 1 on the floor at the hallway. LVN 2 stated CNA 6 made her aware and saw Resident 1 lying facing the left side on the floor beside the Geri-chair. LVN 2 stated Resident 1 complained of pain on the head. LVN 2 stated Resident 1’s Attending Physician (MD 1) was made aware. LVN 2 stated that EMS was called, and Resident 1 was brought to GACH 1. During an interview on 8/1/2024 at 10:40 a.m., CNA 6 stated on 7/14/2024 at 7:40 p.m., she went to the kitchen to return a resident's food tray and informed LVN 2, who was at nurse station 2, that Resident 1 was on sitting on a Geri-chair in the hallway. CNA 6 stated Resident 1 was on a Geri-chair in the hallway for closer supervision because of the resident's daily attempt to jump out of the bed. CNA 6 stated she returned to the hallway and found Resident 1 on the floor with the resident's hand on the head. CNA 6 stated Resident 1's fall could be prevented if there was someone visually watching the resident. CNA 6 stated Resident 1 was on a Geri-chair without a pad alarm or a mattress on the floor. During an interview on 8/1/2024 at 12:44 p.m., the Assistant Director of Nursing (ADON) stated Resident 1 was a fall risk, had impulsive behavior, and had made attempts of getting out of bed. The ADON stated Resident 1 was placed on a Geri-chair in the hallway for more visual monitoring. The ADON stated the pad alarm and mattress were not provided for Resident 1 while on the Geri-chair. Resident 1's Care Plan on risk for falls, dated 6/22/2024, was reviewed with the ADON indicated the resident did not have the pad alarm and Geri-chair as part of the Care Plan interventions. The ADON stated that care plans should be individualized to meet the resident's need. The ADON stated the facility failed to include the use of Geri-chair, pad alarm, and visual monitoring in Resident 1's Care Plan interventions. Resident 1's facility provided GACH 1 records were reviewed with the ADON and indicated the resident sustained an acute right hip fracture and left pubic fracture. The ADON stated the facility failed to ensure Resident 1 was monitored and visually supervised to prevent resident falls. A review of the facility's policy and procedure titled, "Fall Management Program," dated 11/2017 and last reviewed on 10/26/2024, indicated the facility strives to provide each resident with adequate supervision and assistance devices to minimize the risks associated with falls and to provide an environment which remains as free from accident hazards as possible. The policy defined fall as unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force. The policy indicated the facility nursing staff and/or the interdisciplinary team shall update the resident's plan of care accordingly to reduce the risk of further occurrences of a fall and/or to reduce the risk for significant injury related to falling. The policy indicated, “Supervision / Adequate Supervision: An intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents.” A review of the facility's policy and procedure titled, "Free of Accident Hazards / Supervision / Devices," dated 3/2018 and last reviewed on 10/26/2023, indicated the intent to provide guidelines for facility staff to manage residents at risk for avoidable accidents. The System Approach section indicated implementation of individualized, resident centered interventions, including adequate supervision and assistive devices, to reduce individual risks related to hazards in the environment. A review of the facility's policy and procedure titled, "Develop - Implement Comprehensive Care Plans," dated 2/2018 and last reviewed on 10/26/2023, indicated the facility develops a person-centered comprehensive care plans that are culturally competent and trauma-informed, developed, and implemented to meet the preferences and goals and address the resident's medical, physical, mental, and psychosocial needs. The policy indicated the facility must establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining their highest practicable quality of life. The facility failed to ensure residents receive the necessary care based on the assessed individual needs to prevent accidents and minimize injuries for Resident 1, who was identified as a high fall risk. The facility failed to: 1. Ensure Resident 1 was provided visual supervision, in accordance with the facility’s policies titled, "Free of Accident Hazards / Supervision / Devices" and “Fall Management Program,” while sitting on a Geri-chair (a padded reclining chair that was designed to help older adults with limited mobility) in the hallway. The System Approach section of the policy on "Free of Accident Hazards / Supervision / Devices" indicated implementation of individualized, resident centered interventions, including adequate supervision and assistive devices, to reduce individual risks related to hazards in the environment. The policy titled, “Fall Management Program,” indicated, “Facilities are obligated to provide adequate supervision to prevent accidents.” 2. Review and revise Resident 1's care plan interventions on risk for falls, created on 4/13/2023, that were person-centered and were individualized based on the resident's risks, physical, and mental conditions. As a result, on 7/14/2024 at 7:45 p.m., Resident 1 fell out of the Geri-chair in the hallway and sustained a right femur fracture, acute nondisplaced fracture of the right inferior and superior pubic ramus, and an acute mildly comminuted and mildly displaced fracture of the left inferior pubic ramus. Resident 1 also sustained blunt head injury and hematoma of the face. The above violations jointly, separately, or in any combination, presented either immin