Health inspection·September 6, 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 § 72313 Nursing Service--Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. 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 prevent a fall and injury for Resident 1, who was identified as high risk for falls. The facility failed to: 1. Provide treatment as prescribed in the physician’s orders, which indicated for Resident 1 to have bilateral bedside mats (a safety pad placed on the floor beside the bed to prevent injuries resulting from falls). 2. Identify care needs, develop, and update Resident 1’s care plan to include an intervention of placing bilateral bedside mats at Resident 1’s bedside to prevent injuries to Resident 1 who was at high risk for falling. 3. Ensure that Resident’s environment was free of accident hazards and failed to provide devices to prevent accidents when Resident 1 was given a bed without bedside mats. 4. Implement its policies and procedures entitled "Falls and Fall Risk, managing" and "Care Plan, Comprehensive Person-Centered”. As a result, on 7/22/2024 at 8:01 p.m., Resident 1 fell on the floor and required immediate transfer to General Acute Care Hospital 1 (GACH 1). Resident 1 was diagnosed with a left intertrochanteric fracture (a type of hip fracture that occurs in the upper part of the femur) and underwent a left hip open reduction and internal fixation (a surgical procedure to treat broken bones by realigning the bones and securing them in place with hardware). A review of Resident 1’s Admission Record indicated Resident 1 was a 78-year-old male admitted to the facility on 7/1/2024 with a medical history including traumatic subdural hemorrhage (a serious condition that occurs when blood collects beneath the outermost membrane surrounding the brain) without loss of consciousness, history of falling, and difficulty in walking. A review of Resident 1’s Minimum Data Set (MDS- a standardized care screening tool), dated July 8, 2024, indicated Resident 1’s cognition was severely impaired. The MDS indicated Resident 1 was dependent on staff for oral hygiene, toileting, upper dressing, lower dressing, and personal hygiene. The MDS indicated Resident 1 had a history of falls prior to admission to the facility. A review of Resident 1’s Fall Risk Assessment, dated 7/1/2024, indicated the resident was a high risk for falls due to the following: 1. Resident 1 had one to two falls during the last 90 days; 2. Resident 1 with moderately impaired (limited) vision; 3. Resident 1 ambulated with problems and with devices (gait was unsteady, slow, lurching [make an abrupt, unsteady, uncontrolled movement or series of movements]); 4. Resident 1 was dependent and incontinent (having no voluntary control over urination or defecation); and 5. Resident 1’s cognitive status changed in the last 90 days. A review of Resident 1’s Order Summary Report, dated 7/1/2024, indicated an order for Resident 1 to have bilateral bedside mats and a low bed for safety and fall precaution. A review of Resident 1’s care plan (CP), dated 7/2/2024, indicated the resident was at risk for unavoidable falls due to history of falls, status post subdural hematoma (type of bleeding near the brain that can happen after a head injury), status post craniotomy (a surgical procedure that involves making a hole in the skull), dementia (memory loss), impaired cognition, unable to communicate needs, unable to stop a fall require dependent assist with transfers, toileting, and seizures. The goal indicated to minimize complications related to fall to extent possible. The interventions included to anticipate and meet resident’s needs, educate, and remind the resident to call for assistance with all transfers. In addition, the interventions included for staff to keep the resident’s bed in low position with breaks locked and to keep personal items frequently within reach and supervise view as much as possible. Resident 1’s care plan for 7/2/2024 did not include an intervention to provide Resident 1 with bilateral bedside mats as ordered by the physician. A review of Resident 1’s Change of Condition report, dated 7/22/2024 at 8:01 p.m., indicated Resident 1 had a fall. Certified Nurse Assistant (CNA 1) reported to Licensed Vocational Nurse (LVN 1) that Resident 1 was observed on the floor. Registered Nurse 1 (RN 1) found Resident 1 lying supine (lying on the back). Resident 1 was unable to explain what happened. The report indicated a head-to-toe assessment (a health evaluation that examines a patient’s physical condition from head to toe) was completed and the resident expressed having left hip pain by grimacing. The physician was notified and placed an order to send Resident 1 to "higher level of care." A review of Resident 1’s GACH Emergency Department (ED) Notes, dated 7/22/2024, indicated Resident 1 was brought in by emergency medical services with a history of weakness, GERD (Gastroesophageal [relating to or involving the stomach and esophagus] reflux disease), hypertension, epilepsy, presenting after a fall that occurred just prior to arrival, resulting in injury to the left hip. The notes indicated the fall was unwitnessed, and the resident was unsure how it occurred. Resident 1 was found on the ground in front of his bed by nursing staff. The level of pain was moderate. The notes indicated Resident 1 had a fracture of the hip that required admission to the hospital for surgical repair. A review of Resident 1’s GACH Operative Report, dated 7/22/2024, indicated Resident 1 had a left hip intertrochanteric fracture. Resident 1 underwent a left hip open reduction and internal fixation. A review of Resident 1’s care plan, revised on 7/23/2024, indicated Resident 1 had an unwitnessed fall, and the resident was provided with a soft touch call light (a soft touch pad or call switch enables individuals with limited movement to summon help). Resident 1’s care plan for 7/23/2024 did not include an intervention to provide Resident 1 with bilateral bedside mats as ordered by the physician. A review of Resident 1’s Interdisciplinary Notes, dated 7/23/2024, indicated on 7/22/2024 at approximately 8:01 p.m., Resident 1 was found lying on the floor in his room next to Resident 1’s bed. The notes indicated upon Registered Nurse (unidentified) interview and post fall assessment; Resident 1 was unable to state what happened. Resident 1 had pain in the left hip and leg. The notes indicated the resident had a physician order to transfer to the hospital for further evaluation. During an interview on 7/31/2024 at 10:00 a.m., the Director of Nurses (DON) stated, not all residents who are a fall risk need to have bilateral bedside mats. The DON stated, she did not know Resident 1 had an order for bilateral bedside mats. The DON stated, the bedside mats should have been incorporated into the Resident 1’s plan of care since the physician had placed an order for the resident to have bedside mats. During an interview on 7/31/2024 at 12:00 p.m., CNA 1 stated on 7/22/2024 (she did not remember the time), she observed Resident 1 on the floor next to Resident 1’s bed. CNA 1 stated she went to get help and Resident 1 was very confused. CNA 1 stated Resident 1 complained of pain (level of pain not indicated) on the left hip and was transferred to the hospital. CNA 1 stated Resident 1 did not have bedside mats. During an interview on 7/31/2024 at 4:00 p.m., Licensed Vocational Nurse (LVN 1) stated she was notified by RN 1 that Resident 1 was found on the floor by Resident 1’s bed on 7/22/2024 (did not indicate time). LVN 1 stated she went to help the resident, and she asked the resident what happened. LVN 1 stated Resident 1 was confused and could not tell her exactly what happened. LVN 1 stated she placed a pillow under Resident 1’s head. LVN 1 stated Resident 1 did not have the bilateral bedside mats in place at the time of the fall and was not aware of the physician’s order to have bilateral bedside mats. LVN 1 stated, when there was an order from the doctor (for bilateral floor mats), then the order should have been carried out by placing bilateral bedside mats and incorporated in Resident 1’s care plan. LVN 1 stated the purpose of the bilateral floor mats is to prevent injuries in the event the resident fell. A review of the facility’s Policy and Procedure (P&P) titled, "Falls and Fall Risk, managing," dated March 2018, indicated based on previous evaluations and current data, the staff will identify the interventions related to the resident’s specific risks and causes to try to prevent the resident from falling and to try to minimize complication from falling. The P&P indicated facility’s staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. A record review of the facility’s P&P titled, "Care Plan, Comprehensive Person-Centered," dated March 2022, indicated a comprehensive, person-centered care plan should include measurable objectives and timetables to meet resident’s physical, psychosocial, and functional needs. The facility failed to prevent a fall and injury for Resident 1, who was identified as high risk for falls. The facility failed to: 1. Provide treatment as prescribed in the physician’s orders, which indicated for Resident 1 to have bilateral bedside mats. 2. Identify care needs, develop, and update Resident 1’s care plan to include an intervention of placing bilateral bedside mats at Resident 1’s bedside to prevent injuries to Resident 1 who was at high risk for falling. 3. Ensure that Resident’s environment was free of accident hazards and failed to provide devices to prevent accidents when Resident 1 was given a bed without bedside mats. 4. Implement its policies and procedures entitled "Falls and Fall Risk, managing" and "Care Plan, Comprehensive Person-Centered”. As a result, on 7/22/2024 at 8:01 p.m., Resident 1 fell on the floor and required immediate transfer to GACH 1. Resident 1 was diagnosed with a left intertrochanteric fracture and underwent a left hip open reduction and internal fixation. 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 to Resident 1.