Health inspection·February 28, 2025

F689 §483.25(d) Accidents. The facility must ensure that – (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 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 1/14/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint allegation regarding quality of care. The facility failed to ensure Resident 1, who was assessed as high risk for falls was free from falls and injury in accordance with Resident 1's care plan by failing to: 1. Ensure Resident 1, who was identified as a high fall risk, was not left unattended by Physical Therapist (PT) 1 (a health professional trained to evaluate and treat residents who have conditions or injuries that limit their ability to move and to physical activities) during a physical therapy (is a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) session on 1/5/2025. 2. Ensure Resident 1's fall mat (a soft, foam-based mat that reduces the impact of a fall and helps prevent injuries) was placed back on the floor before PT 1 left Resident 1's room. 3. Ensure Resident 1's bed alarm (a device that contains sensors that trigger an alarm when a person tries to get out of bed) was placed between Resident 1 and Resident 1's mattress. As a result, on 1/5/2025, at 1:20 p.m., Resident 1 fell from the bed. Resident 1 was transferred to a General Acute Care Hospital (GACH) 1 on 1/5/2025, and was diagnosed with scalp hematoma (a collection of blood that pools outside of a blood vessel [a tube through which the blood circulates in the body], usually caused by an injury or surgery) and scalp laceration (a cut on the head that occurs when the skin and underlying tissues are torn by blunt force or an injury). A record review of Resident 1's Admission Record indicated the facility admitted the 73-year-old Resident 1 on 3/12/2024, with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side (the side of the body that is not used as much or is not as much effective as the same side on the other side of the body), benign prostatic hyperplasia (BPH - a condition that occurs when the prostate gland [a gland in the male reproductive system] enlarges, potentially slowing or blocking the urine stream), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). A record review of Resident 1's Care Plan on falls, created on 3/12/2024, indicated Resident 1 was at risk for falls due to Resident 1's left side weakness. The Care Plan Intervention indicated the use of a bed alarm, to keep Resident 1 within supervised view, and to implement safety devices as ordered such as bilateral (having two sides or affecting both sides) raised safety floor mats. A record review of Resident 1's Physician Order dated 3/12/2024, indicated to apply a bed alarm when Resident 1 was in bed. Resident 1's Physician Order indicated to monitor for placement and function of the bed alarm. A record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/1/2024, indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were severely impaired. The MDS indicated Resident 1 had functional limitation in range of motion (ROM - extent of movement of a joint) on one side of both the upper extremity (shoulder, elbow, wrist, and hand) and the lower extremity (hip, knee, ankle, and foot). The MDS indicated Resident 1 required maximal assistance (helper lifts or holds trunk [part of the body to which the head, arms and legs connect] or limbs and provides more than half the effort) on rolling to the left or the right side. The MDS indicated Resident 1 was dependent on facility staff with lying to sitting on the side of the bed activity. The MDS indicated Resident 1's sit-to-stand activity was not attempted due to medical condition or safety concerns. The Bladder (a hollow organ that stores urine) and Bowel (a long tube-shaped organ that carries solid waste from the stomach out of the body) section of the MDS indicated Resident 1 had an indwelling urinary catheter (a flexible plastic tube [a catheter] inserted into the bladder to provide continuous urinary drainage). A review of Resident 1's Fall Risk Observation and Assessment dated 12/13/2024, indicated Resident 1 had a total score of 20. A total score of 16 to 42 represents a high risk for falls. A record review of Resident 1's Change in Condition (COC - when there is a sudden and significant change from a resident's health) Evaluation form dated 1/5/2025, indicated that on 1/5/2025, at around 1:20 p.m., PT 1 was inside Resident 1's room. PT 1 placed a knee brace (a medical device that stabilizes and supports the knee joint) on Resident 1's right leg and then stepped out of Resident 1's room. The COC Evaluation form indicated Licensed Vocational Nurse (LVN) 2 heard Resident 1 screaming. LVN 2 and PT 1 went inside Resident 1's room and saw Resident 1 lying on the floor, bleeding (amount not specified) from the head. Resident 1's physician was notified and ordered Resident 1 to be sent to GACH 1. A record review of Resident 1's Interdisciplinary Team (IDT, a team of healthcare professionals from different professional disciplines who work together to address and manage the needs of the resident) Fall Progress Notes dated 1/6/2025, indicated Resident 1 had an unwitnessed fall from his bed on 1/5/2025. Resident 1 was found lying on the floor, bleeding (amount not specified) from his head and was sent to GACH 1 for further evaluation and treatment. The IDT Fall Progress Notes indicated Resident 1 returned to the facility on 1/6/2025. A record review of Resident 1's GACH 1 Emergency Department (ED- a hospital facility that treats patients with severe injuries or illnesses that require immediate care) Physician Note dated 1/5/2025, indicated Resident 1 had a four (4) feet (ft - unit of measure) fall from the bed and sustained a laceration to the forehead with bruising to the face. The Physical Exam section indicated Resident 1 had hematoma to the left forehead (part of the face above the eyebrows) with laceration on the lateral (away from the middle of the body) left eyebrow. Resident 1's lateral left eyebrow had two steri-strip (a type of wound closure tape) on it. A record review of Resident 1's GACH 1 computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the head dated 1/5/2025, indicated Resident 1 had a large hematoma and contusion (a bruise or injury to the soft tissue caused by a direct blow or impact) to the left frontal (forehead) scalp extending over the left periorbital region (the area around the eyes). During a concurrent observation and interview on 1/14/2025, at 11:51 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 1 was observed with a large, round, protruding, bluish black hematoma on the left forehead. Resident 1 was also observed with a dry, scabbed (covered with a dry, crusty layer that forms over a cut or wound during healing) laceration on the left eyebrow. Resident 1's bed alarm was observed on the floor under Resident 1's bed. LVN 1 stated Resident 1 was a fall risk. LVN 1 stated the bed alarm was used to alert facility staff that Resident 1 was trying to get out of bed. LVN 1 stated the bed alarm should have been placed between Resident 1 and Resident 1's mattress. LVN 1 stated the facility staff will not be alerted if not properly placed, and Resident 1 had the potential to fall. During a telephone interview on 1/14/2025, at 4:15 p.m., PT 1 stated that on 1/5/2025, at around 1:20 p.m., he (PT 1) provided physical therapy to Resident 1 and applied the knee brace on Resident 1's right leg. PT 1 stated he removed Resident 1's fall mat from Resident 1's bedside during the physical therapy session for easy access to Resident 1. PT 1 stated he then left Resident 1's room to inform LVN 2 about Resident 1's knee brace. PT 1 stated that on 1/5/2025, Resident 1's privacy curtain was closed, and Resident 1 was out of his (PT 1) sight. PT 1 stated he then heard Resident 1 yelling. PT 1 stated he returned to Resident 1's room with LVN 2 and saw Resident 1 lying on the floor on the right side of Resident 1's bed. PT 1 stated Resident 1 had bleeding on the left forehead. PT 1 stated he did not return Resident 1's fall mat beside Resident 1's bed because he was not done with Resident 1's physical therapy session. PT 1 stated Resident 1's fall mat should have been placed back beside Resident 1's bed before leaving Resident 1's bedside. PT 1 stated Resident 1's fall risk interventions were not implemented which resulted in Resident 1's fall and injury. During an interview on 1/14/2025, at 4:30 p.m., the Director of Nursing (DON) stated Resident 1 had a fall on 1/5/2025 and sustained a head injury. The DON stated Resident 1's bed alarm should have been between Resident 1 and the mattress. The DON stated fall interventions for Resident 1 that included the fall mats and bed alarm should have been in place to prevent Resident 1's fall and resulting injury. The DON stated the facility failed to follow the fall interventions in accordance with Resident 1's fall care plan such as to implement safety devices (fall mats and bed alarm) as ordered. A record review of the facility's policy and procedure (PnP) titled, "Fall Prevention and Management Program," last reviewed in 11/22/2024, indicated that a licensed nurse assess all residents on admission, quarterly, and after each fall related incident to identify risk factors for fall and initiate a plan of care for residents. The PnP indicated residents assessed as high risk for falls will be given interventions of safety floor mats at bedside, and alarm in bed and in wheelchair. A record review of the facility's PnP titled, "Managing Falls and Fall Risk," last reviewed in 11/22/2024, indicated that based on previous evaluations and current data, staff will identify interventions related to a resident's specific risks and causes to prevent the resident from falling and to try to minimize complications from falling. The PnP indicated staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. The PnP indicated position-change alarms (any physical or electronic device such as bed alarms that monitors resident movement and alerts the staff when movement is detected) will not be used as the primary or sole intervention to prevent falls. The PnP indicated the use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. The facility failed to ensure Resident 1, who was assessed as high risk for falls was free from falls and injury in accordance with Resident 1's care plan by failing to: 1. Ensure Resident 1, who was identified as a high fall risk, was not left unattended by PT 1 during a physical therapy session on 1/5/2025. 2. Ensure Resident 1's fall mat was placed back on the floor before PT 1 left Resident 1's room. 3. Ensure Resident 1's bed alarm was placed between Resident 1 and Resident 1's mattress. As a result, on 1/5/2025, at 1:20 p.m., Resident 1 fell four feet from the bed onto the floor. Resident 1 was transferred to GACH 1 on 1/5/2025 and was diagnosed with scalp hematoma and scalp laceration. 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.