Health inspection·March 28, 2025

§483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights § 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. § 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 2/10/2025 at 12:30 p.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint allegation regarding a resident fall. CDPH determined the facility did not implement interventions to prevent Resident 1, who was assessed as a risk for falls with poor safety awareness, from falling and sustaining an injury. The facility failed to: 1. Ensure Resident 1's untitled care plan, dated 7/5/2024, identifying the resident as a fall risk, had specific interventions used and carried out to prevent the resident from falls and injuries. 2. Ensure the untitled care plan, dated 7/5/2024, identifying Resident 1 as a fall risk, was reviewed and revised after the resident's fall on 8/20/2024, to have specific interventions, including visual checks every two hours or adding 1:1 sitter, to safeguard the resident from future falls and injuries. 3. Ensure staff took precautions (unspecified) to prevent Resident 1's falls as indicated in the untitled care plan, dated 7/8/2024, for anticoagulant (blood thinner) therapy. 4. Ensure staff followed the facility's policy and procedure (P/P) titled "Fall Management System" dated 12/2023, which indicated "residents with high risk factors identified on the fall risk evaluation will have an individualized care plan developed that includes measurable objectives and timeframes." These deficient practices resulted in Resident 1's unwitnessed fall on 10/24/2024, and sustaining injuries leading to the resident's transfer to a General Acute Care Hospital (GACH)'s Intensive Care Unit (ICU) where Resident 1 was diagnosed with an 8.0 millimeter (mm) subdural (one of the tissue layers of the brain) hematoma (a collection of blood after a head injury) and an acute hyperextension (forceful extension of a joint beyond its normal limits) fracture in the spine that involves a triangular fragment of bone of the C6 (bone located at the base of the neck) vertebral body (bone in the neck). While at the GACH, Resident 1 was intubated (a tube inserted into a person's mouth or nose, then into their windpipe to help deliver oxygen to the body) and subsequently had a tracheostomy (a surgical opening through the neck into the windpipe to allow air to fill the lungs). On 11/12/2024, Resident 1 had a burr (a small, rotating cutting tool used by surgeons and dentists to remove or reshape bone) hole evacuation (a surgical procedure that involves drilling small holes in the skull to drain blood or excess fluid) for the treatment of the subdural hematoma. On 12/9/2024 Resident 1 underwent cervical (the neck) bone to thoracic (chest) bone fusion (the process of combining two or more things into one) and decompression (to release pressure) surgery. A review of Resident 1's Admission Record indicated Resident 1, an 86- year-old male, was admitted to the facility on 7/5/2024 with diagnoses including atrial fibrillation ([A-Fib], irregular heartbeat), repeated falls, dementia (a progressive state of decline in mental abilities), and traumatic subdural hemorrhage (secondary to a fall pre-admission). A review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool) dated 10/25/2024 indicated Resident 1 was moderately independent (some difficulty in new situations) in daily decision making and required partial/moderate assistance (helper does less than half the effort) in completing activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). A review of Resident 1's Physician Order dated 7/5/2024 indicated to administer Apixaban (medication to thin the blood and prevent clots) 5.0 milligrams ([mg] a unit of measurement of mass) one tablet by mouth two times a day for A-Fib. A review of Resident 1's untitled care plan dated 7/5/2024 indicated Resident 1 was a high risk for falls related to recurrent falls and getting up unassisted despite encouragement not to do so. The care plan indicated the interventions included reviewing information on past falls, determining causes of the falls, and removing any potential causes if possible. A review of Resident 1's untitled care plan dated 7/8/2024 indicated Resident 1 was on anticoagulant therapy related to A-Fib and was at risk for bruising (skin discoloration from damaged, leaking blood vessels underneath the skin), bleeding, and related complications. The care plan's interventions included resident/family/caregiver teaching to include avoiding activities that could result in injury and to take precautions to avoid falls. A review of Resident 1's Change in Condition (COC) dated 8/20/2024 and timed at 10:17 a.m., indicated Resident 1 had fallen out of his wheelchair when he was trying to get to his bed, the resident stood up and slid from the wheelchair. A review of Resident 1's Fall Risk evaluation dated 8/20/2024 indicated Resident 1 was a high risk for falls. A review of Resident 1's Fall Committee Interdisciplinary Team ([IDT] a group of health care professionals from different disciplines who work together to provide care) note dated 8/21/2024 indicated the root cause of Resident 1's fall on 8/20/2024 was due to Resident 1 initiating self-transfer and not asking for assistance. A review of Resident 1's Physical Therapy (PT) Discharge Summary dated 8/29/2024 indicated Resident 1 required supervision or touching assistance during transfers and ambulation. The PT Discharge Summary indicated Resident 1 required ongoing cueing due to poor safety awareness. A review of Resident 1's Fall Committee IDT note dated 9/18/2024 (28 days from the fall on 8/20/2024) indicated a recommendation to remove Resident 1 from the Fall Committee on this date (9/18/2024). The note indicated there were no incidents of Resident 1's fall or injury, and interventions (unspecified) were effective at this time. A review of Resident 1's COC dated 10/24/2024 and timed at 11:30 p.m., indicated Resident 1 had experienced a fall which resulted in swelling on the left side of his forehead and upper left eyelid. A review of Resident 1's Physician Order dated 10/24/2024 indicated to transfer Resident 1 to the GACH for further evaluation and treatment. A review of the Paramedic (emergency medical response team) Report Sheet dated 10/24/2024 indicated Resident 1 sustained an unwitnessed fall and had a one-inch laceration to the left side of his forehead. A review of Resident 1's Fall Committee IDT note dated 10/25/2024 and timed at 9:34 a.m., indicated that Licensed Vocational Nurse 2 (LVN 2) heard an unfamiliar sound coming from Resident 1's room, and then found Resident 1 lying on the floor by the bedside table near the bed. The Fall Committee IDT note indicated Resident 1 reported to LVN 2 that he (imagined) he heard his daughter calling him and he was going to meet her when he stood up from the bed. The Fall Committee IDT note indicated on 10/24/2024 Resident 1 was transferred to the GACH for further evaluation due to Resident 1 being on anticoagulant medication. The Fall Committee IDT note indicated the IDT team concluded Resident 1 tried to get out of bed unassisted, lost his balance, and fell on the floor. A review of Resident 1's Emergency Department (ED) Physician Notes dated 10/25/2024 and timed at 10:25 a.m. indicated Resident 1 had an acute (sudden onset) subdural hematoma, and was admitted to the ICU, where he received Kcentra (a medication that reverses the effects of a blood thinning medication in adults with acute major bleeding) for urgent reversal of Apixaban effects. A review of Resident 1's Computerized Tomography Scan (CT of the spine dated 10/25/2024 indicated Resident 1 had "an acute hyperextension fracture of the C6 vertebral body." A review of Resident 1's CT scan of the head dated 10/25/2024 indicated an 8.0 mm acute subdural hematoma. A review of Resident 1's Operative Report dated 12/9/2024 indicated Resident 1 had Cervical bone to Thoracic bone fusion and decompression surgery. A review of Resident 1's GACH's Discharge Summary dated 12/23/2024 indicated Resident 1 had a burr hole evacuation on 11/12/2024 for treatment of the subdural hematoma. During an interview on 2/11/2025 at 2:00 a.m., Certified Nursing Assistant (CNA) 1 stated for residents, who were high risk for falls and were attempting to get out of bed unassisted, she would check on them every two hours, or "sit close to their room, and keep an eye on them." During an interview on 2/11/2025 at 2:03 a.m., LVN 1 stated a resident (in general), who was high risk for falls, required frequent monitoring every two hours. LVN 1 stated for residents, who were getting out of bed unassisted, she would assign a 1:1 sitter (a person provides constant supervision) because the resident needs constant redirection and monitoring. During an interview on 2/11/2025 at 12:52 p.m., PT 1 stated Resident 1 required contact guard (lightly touching the resident to help with balance or stability) during ambulation due to Resident 1's poor safety awareness. During an interview on 2/11/2025 at 1:42 p.m., Registered Nurse 1 (RN 1) stated Resident 1 was a high risk for falls. RN 1 stated residents, who had dementia and were high fall risks, required reminders to use the call light to call for assistance, rounding (checking on the resident) and monitoring at least every two hours to ensure their safety. During an interview on 2/11/2025 at 2:07 p.m., the Director of Nursing (DON)stated when a resident (in general) is admitted to the facility, upon admission a fall risk assessment is completed and if needed, a care plan related to falls is created. The DON stated when a resident (general) sustains a fall, a rehabilitation screening is completed, the root cause of the fall is investigated and discussed with the IDT team, and the resident's care plan is updated. During an interview on 2/11/2025 at 2:10 p.m. the DON stated, for Resident 1 frequent monitoring and visual checks every two hours should have been added to the care plan and implemented. The DON stated that if Resident 1 was frequently monitored, it could have decreased his chances of falling. The DON stated Resident 1 did not have but would have benefited from having a 1:1 sitter assigned to him. A review of the facility's policy and procedure (P/P) titled "Fall Management System" dated 12/2023, the P/P indicated residents with risk factors identified on the fall risk evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. The P/P indicated the care plan interventions will be developed to prevent falls by addressing risk factors and will consider the particular elements of the evaluation that put the resident at risk. The P/P indicated after a resident sustains a fall, the resident's care plan will be updated. The facility failed to: 1. Ensure Resident 1's untitled care plan, dated 7/5/2024, identifying the resident as a fall risk, had specific interventions used and carried out to prevent the resident from falls and injuries. 2. Ensure the untitled care plan, dated 7/5/2024, identifying Resident 1 as a fall risk, was reviewed and revised after the resident's fall on 8/20/2024, to have specific interventions, including visual checks every two hours and/or 1:1 sitters, to safeguard the resident from future falls and injuries. 3. Ensure staff took precautions (unspecified) to prevent Resident 1's falls as indicated in the untitled care plan dated 7/8/2024, for anticoagulant (blood thinner) therapy. 4. Ensure staff followed the facility's P/P titled "Fall Management System" dated 12/2023, which indicated "residents with high risk factors identified on the fall risk evaluation will have an individualized care plan developed that includes measurable objectives and timeframes." These deficient practices resulted in Resident 1's unwitnessed fall on 10/24/2024, and sustaining injuries leading to the resident's transfer to a GACH's ICU where Resident 1 was diagnosed with an 8.0 mm subdural hematoma and an acute hyperextension fracture in the spine that involves a triangular fragment of bone of the C6 vertebral body. While at the GACH Resident 1 was intubated and subsequently had a tracheostomy. On 11/12/2024 Resident 1 had a burr hole evacuation for the treatment of the subdural hematoma. On 12/9/2024 Resident 1 underwent cervical bone to thoracic bone fusion and decompression surgery. These violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result. 2