Health inspection·December 26, 2024

F689 §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: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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 11/12/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident about a resident fall. The facility failed to prevent a fall and injury for Resident 1, who was identified as a high fall risk, with unsteady standing and walking balance, and needed supervision to prevent falls and injuries. The facility failed to: a. Provide an assistive device for safe ambulation (the ability to walk from one place to another safely or move around independently). b. Implement the facility's policy and procedure (P&P) titled, "Falling Star Program," by failing to ensure Resident 1's name was printed on a brightly colored paper (yellow) by the door outside of Resident 1's room to ensure that staff is aware Resident 1 is a high risk for falls. As a result, on 10/29/2024 at 7:08 a.m., Resident 1 fell while walking towards the bathroom unassisted and without a walker. Resident 1 sustained a laceration (a deep cut or tear in the skin) at the back of the head and required transfer to General Acute Care Hospital 1 (GACH 1) on 10/29/2024 at 7:36 a.m. where Resident 1 was diagnosed with closed displaced intertrochanteric fracture of left femur (the upper part of the thigh bone was broken, and the broken pieces were not aligned, without any open wounds on the skin around the break). Resident 1 underwent left femur (thigh bone) intramedullary nailing (IM nailing - a surgical procedure that involves inserting a metal rod into the center of a broken bone to stabilize and aid in healing) at GACH 1. A review of Resident 1's Admission Record indicated the facility admitted the 91-year-old female resident on 1/31/2023 with diagnoses including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), and generalized muscle weakness. A review of Resident 1's History and Physical, dated 2/24/2024 indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/2/2024 indicated Resident 1's cognitive (the ability of the brain to think and reason) skills for daily decision making was moderately impaired. The MDS indicated Resident 1 required a walker and wheelchair for mobility (the ability to move freely). The MDS indicated Resident 1 required moderate assistance with toileting and personal hygiene. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or steadying as resident completes activity) while walking at least 10 feet (ft. - unit of measure), while walking 50 ft. with two turns and when walking 150 ft. A review of Resident 1’s Fall Risk Assessment dated 10/2/2024 indicated Resident 1 had a total score of 22 (a total score above 10 represents a high risk for falls). The Fall Risk Assessment indicated Resident 1 had intermittent confusion (a medical condition that involves a sudden or worsening change in mental state), balance problem while standing and while walking, decreased muscular coordination, unsteady gait (a manner of walking) when walking through the doorway, unstable when making turns and requires use of assistive device. A review of Resident 1's Weekly Summary, dated 10/11/2024, the Weekly Summary under the functional status section indicated the resident (Resident 1) required assistance when walking. The Weekly Summary under the Special Treatment/ Procedures/ Programs section indicated Resident 1 required contact guard assist (CGA - a light touch or contact is made to help steady the body and help with balance), use of a front wheel walker (a device designed for people who are unstable to walk, has two wheels in front of the walker) and use of a walking belt (a device used to help safely transfer a person from a bed to a wheelchair, and assist with walking, sitting and standing) when walking 175 ft. to 200 ft. daily. The Weekly Summary further indicated to monitor Resident 1's balance for steadiness (refers to stability and balance while walking) during transitions (change from one position, step, or movement to another) and walking and to provide assistance to Resident 1. A review of Resident 1's Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) Progress Notes, dated 10/29/2024, timed at 7:40 a.m. indicated on 10/29/2024 at 7:08 a.m., Restorative Nursing Assistant 1 (RNA 1) informed LVN 1 that Resident 1 was found on the floor, next to Resident 1's bed, inside the resident's room. LVN 1 documented she (LVN 1) observed Resident 1 lying supine (lying on the back with the face and body facing up) on the floor with a small amount (exact amount not specified) of blood at the back of Resident 1's head. The RN/LVN Progress Notes indicated LVN 1 applied pressure on the small laceration at the back of Resident 1's head. LVN 1 documented Resident 1 was not able to move the left lower extremity (hip, thigh, knee, leg, ankle, and foot) and complained of left hip pain. The RN/LVN Progress Notes indicated Resident 1 stated the fall happened while walking on the way to the bathroom. The RN/LVN Progress Notes indicated at 7:36 a.m. (on 10/29/2024), Resident 1 was transferred to GACH 1. A review of Resident 1's Physician Order Sheet, dated 10/29/2024, indicated Attending Physician 1 (MD 1) ordered to transfer Resident 1 to GACH 1 via 911 (a phone number to contact the emergency services) after a fall for further evaluation. A review of Resident 1’s Post Fall Summary and Intervention form dated 10/29/2024 indicated Resident 1 had a fall on 10/29/2024 at 7:08 a.m. inside Resident 1's room. The Post Fall Summary form indicated the cause of Resident 1's fall were unsteady gait (when a person is having trouble with their balance of the way they walk), poor judgment, non-compliant (inability or unwillingness to follow a prescribed treatment plan), and dementia. A review of Resident 1's Paramedics' (trained personnel that provides emergency medical care to people who are injured or ill) Patient Care Report, dated 10/29/2024, indicated the paramedics, who were on scene (at the facility) at 7:26 a.m. (on 10/29/2024), found Resident 1 lying supine on the ground and complained of left hip pain. The Patient Care Report under the narrative section indicated Resident 1 had a small abrasion (scrape on the skin) on the top of the head and had a possible left leg shortening with outward rotation and tender (painful) to touch. During an interview on 11/12/2024 at 10:40 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she (CNA 1) observed Resident 1 use a walker at times. CNA 1 stated Resident 1 was observed unstable when walking to the bathroom independently without a walker. CNA 1 stated residents that were identified as a high fall risk had their names on the residents' room doors highlighted (colored) in yellow. CNA 1 stated Resident 1 was not identified as a fall risk because the resident's name on the room door was not highlighted in yellow. During an interview on 11/12/2024 at 10:52 a.m. with CNA 2, CNA 2 stated Resident 1 required assistance with walking to the bathroom and was unstable when walking without a walker. CNA 2 stated Resident 1 did not have a yellow highlighted name outside Resident 1's room. CNA 2 stated that on 10/29/2024 she (CNA 2) observed Resident 1 lying on the floor by the resident bed's foot part with the Resident 1's head towards the door and the towards the bathroom. CNA 2 stated Resident 1 wanted to go to the bathroom. CNA 2 stated Resident 1 did not have a walker in the room. During an interview on 11/12/2024 at 1:44 p.m. with Registered Nurse 2 (RN 2), RN 2 stated she (RN 2) did not see an assistive device or walker inside Resident 1's room. During a concurrent interview and record review on 11/12/2024 at 2:50 p.m., with the Director of Rehabilitation (DOR), Resident 1's Physical Therapy (PT) Discharge Summary, dated 3/16/2024 was reviewed. The PT Discharge Summary dated 3/16/2024 indicated Resident 1 had a treatment diagnosis of unspecified abnormalities of gait and mobility (a diagnosis used when a resident has abnormal gait or mobility that does not fit into other categories). The DOR stated Resident 1's treatment diagnosis indicated the resident's gait was compromised and warranted therapy at the time of Resident 1's evaluation. During a concurrent interview and record review on 11/12/2024 at 2:56 p.m. with the Director of Nursing (DON), the DON stated Resident 1's balance was not stable and stated Resident 1 was a fall risk. The DON stated Resident 1's strength and mobility was declining, and the resident was not safe to ambulate (walk) without assistance. Resident 1's Care Plan on ambulation, initiated on 10/3/2024 was reviewed. The DON stated Resident 1 required CGA on ambulation due to unsteady gait and balance. The Care Plan Intervention indicated to assist Resident 1 to ambulate 175 ft. to 200 ft. daily with CGA and with the use of a front wheel walker. A review of Resident 1's Care Plan on falls, initiated on 2/13/2023, indicated the resident was at risk for falls. The Care Plan Intervention indicated to remind Resident 1 to follow fall precaution and to ambulate with walker and with staff assistance. The DON stated Resident 1's name should have been highlighted in yellow (by the door outside Resident 1's room) to indicate Resident 1 was a high fall risk. The DON stated that on 10/29/2024, Resident 1 sustained a laceration on the head and a left femur fracture from a fall. The DON stated the walker should have been available for Resident 1's use. The DON stated the facility failed to provide Resident 1 with a walker as indicated on Resident 1's fall care plan. The DON stated the facility failed to ensure Resident 1's name (by the door outside Resident 1's room) was in yellow identifying Resident 1 as a high risk for fall. A 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 pelvis (the bony structure between the lower stomach and upper thighs that connects the spine to the legs), dated 10/29/2024 indicated Resident 1 had angulated (tilts at an angle) and impacted (the broken ends of the bone were jammed together by the force of the injury) intertrochanteric fracture of the proximal (closer to the center of the body or to the point of attachment to the body) left femur. A review of Resident 1's undated GACH 1 clinical record (provided by the facility), indicated on 10/29/2024 Resident 1 was admitted to GACH 1 after a fall resulting to the resident's left hip pain. The clinical records indicated Resident 1 had a fall and sustained a closed displaced intertrochanteric fracture of the left femur and traumatic (a sudden and severe physical injury that requires immediate medical attention) left intertrochanteric fracture. The clinical records indicated Resident 1 underwent a left femur IM nailing. A review of the current facility-provided P&P titled, "Fall Management Program," last reviewed in 1/29/2024, indicated the facility to provide the highest quality care in the safest environment for the residents in the facility. The P&P indicated the facility strived to prevent resident falls through meaningful assessments, interventions, education, and reevaluation. The Universal Fall Prevention Measures for all Residents section indicated to reassess resident's mobility status daily and encourage use of assistive devices such as walker or wheeled walker, as appropriate. A review of the current facility-provided P&P titled, "Falling Star Program," last reviewed in 1/29/2024, indicated the facility will ensure that staff was aware of residents who were at high risk for falls. The P&P indicated the resident's name will be printed on brightly colored paper by the door outside of resident's room. The facility failed to prevent a fall and injury for Resident 1, who was identified as a high fall risk, with unsteady standing and walking balance, and needed supervision to prevent falls and injuries. The facility failed to: a. Provide an assistive device for safe ambulation. b. Implement the facility's P&P titled, "Falling Star Program," by failing to ensure Resident 1's name was printed on a brightly colored paper (yellow) by the door outside of Resident 1's room to ensure that staff is aware Resident 1 is a high risk for falls. As a result, on 10/29/2024 at 7:08 a.m., Resident 1 fell while walking towards the bathroom unassisted and without a walker. Resident 1 sustained a laceration at the back of the head and required transfer to GACH 1 on 10/29/2024 at 7:36 a.m. where Resident 1 was diagnosed with closed displaced intertrochanteric fracture of left femur and underwent left femur IM nailing. 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.