Health inspection·March 6, 2024

42 CFR §483.25 Accidents. The facility must ensure that: (d)(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. 42 CFR §483.21(b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights set forth at § 483.10(c)(2) and § 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment 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 1/8/2024, the California Department of Public Health (CDPH) received a facility-reported incident indicating Resident 1 was found on the floor in the hallway with hematoma (clotted blood within tissues) on her forehead. On 1/22/2024, at 11:30 a.m., the CDPH conducted an unannounced visit at the facility to investigate Resident 1's fall incident with injury. The facility failed to: 1. Provide supervision and prevent accident hazards, as indicated in Resident 1's care plan titled "At risk for fall/injury," which indicated staff will assist Resident 1 with transfer and ambulation as needed (PRN) and provide visual monitoring every hour. 2. Follow its policy and procedure (P/P) titled "Safety and Supervision of Residents," which indicated the facility will ensure residents were safe, supervised and assisted to prevent accidents. As a result, Resident 1 fell, sustained facial trauma (injury) and a left arm fracture (broken bone) which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment. Findings: A review of Resident 1's admission record, dated 1/22/2024 indicated Resident 1, a 101-year-old female, was originally admitted to the facility on 10/26/2018 and readmitted on 1/12/2024. Resident 1's diagnoses included parkinsonism (a brain condition that causes slow movement, stiffness, and tremors), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and osteoarthritis (a wearing down of the protective tissue at the ends of bones, causing pain and stiffness). A review of Resident 1's History and Physical (H&P) dated 1/14/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 11/1/2023, indicated Resident 1 sometimes understood others and was usually understood. The MDS indicated Resident 1 required moderate assistance from staff for activities of daily living (ADL) such as eating, oral hygiene, and personal hygiene. The MDS indicated Resident 1 required maximum assistance from staff for lower body dressing. The MDS indicated Resident 1 was dependent on staff for toileting, and showering. The MDS indicated Resident 1 was dependent on staff for transferring from a chair to a bed and to the toilet. The MDS indicated Resident 1 required staff's assistance in wheeling her wheelchair for 50 feet with two turns and wheeling 150 feet. A review of Resident 1's fall risk assessment dated 5/16/2023, indicated Resident 1 was a high risk for falls. A review of Resident 1's fall risk evaluation, dated 11/6/2023 indicated Resident 1 was a high risk for falls. A review of Resident 1's care plan titled, "At risk for fall/injury," dated 11/2023, indicated staff will assist Resident 1 with transfer and ambulation as needed (PRN), and visual monitoring every hour. A review of Resident 1's care plan titled, "The resident has impaired cognitive function, impaired thought process related to dementia," dated 12/10/2023, indicated staff will supervise Resident 1 as needed. A review of Resident 1's visual check monitoring sheet did not indicate Resident 1 was monitored every hour in 2024, as indicated in Resident 1's care plan. A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR) Fall report, dated 1/7/2024, indicated on 1/7/2024, Resident 1 was found on the floor, face down, in front of her wheelchair. The SBAR indicated Resident 1 was in the hallway by her room, waiting to be transferred to bed. The SBAR indicated Resident 1 had a pain level of 6/10 (moderate pain) and swelling to her left elbow and forehead. The SBAR indicated Resident 1's Physician ordered the resident to be transferred to an emergency room (ER) for further evaluation. A review of Resident 1's physician's order dated 1/7/2024, at 1:32 p.m. indicated Resident 1 was to be transferred to the GACH ER. A review of Resident 1's GACH radiology report dated 1/7/2024 indicated Resident 1 had multiple right rib fractures, most likely old, maxillofacial (jaw and face) with soft tissue swelling, left supracondylar (a round part at the end of a bone) fracture and dislocation (separation of bones). A review of Resident 1's GACH's, H &P, dated 1/8/2024 indicated Resident 1 fell from a wheelchair and sustained a left forehead, periorbital (surrounding the eye), left elbow bruising with deformity (abnormal shape). A review of Resident 1's GACH Discharge Summary, dated 1/11/2024 indicated Resident 1's admitting diagnoses included a fall with facial trauma and bilateral orbital ecchymosis (bruises), left elbow fracture and multiple rib fractures (possibly old findings). The discharge summary indicated Resident 1 had a left shoulder brace in place and due to her age, the resident was not a candidate for surgery because the risks outweighed the benefits. During an interview with Registered Nurse (RN 1) on 1/22/2024, at 3:30 p.m., RN 1 stated on 1/7/2024, while at the nurses' station, a Certified Nurse Assistant (CNA) notified him that Resident 1 fell. RN 1 stated it was an unwitnessed fall which occurred after a CNA (name unknown) left Resident 1 in her wheelchair, outside the resident's room, unattended. RN 1 stated the CNA should not have left Resident 1 in the hallway unattended. RN 1 stated the CNA should have notified another staff to monitor Resident 1 for safety. During an interview with Licensed Vocational Nurse (LVN 1) on 1/23/2024, at 2:45 p.m., LVN 1 stated on 1/7/2024, she (LVN1) observed Resident 1 outside her room in a wheelchair when the resident fell. LVN 1 stated she did not know who left Resident 1 outside her room, unsupervised, after lunch. LVN 1 stated Resident 1 was at risk for falls and should not have been left unsupervised. During a concurrent interview and record review on 1/23/2024, at 3:55 p.m., with the Director of Nursing (DON) Resident 1's fall risk assessment was reviewed. The DON stated Resident 1 was at risk for falls. The DON stated Resident 1's fall interventions included visual checks and monitoring. The DON stated, Resident 1 fell after a CNA left the resident in the wheelchair, unsupervised in the hallway. The DON stated there was no staff monitoring or supervising Resident at the time of the fall. During a phone interview with CNA 1 on 2/1/2024 at 12:19 p.m., CNA 1 stated she saw Resident 1 on the floor face down, when she was walking down the hall. CNA 1 stated there were no other CNAs around when Resident 1 fell because it happened after lunch time. CNA 1 stated CNAs were busy taking residents back to their rooms. CNA 1 stated staff were not supposed to leave any residents in the hallway. During an interview with LVN 1 on 2/1/2024 at 3:42 p.m., LVN 1 stated Resident 1 was in the hallway in front of her room when Resident 1 fell. LVN 1 stated it was hard to see the resident in the hallway if the staff were inside the nurse's station. LVN 1 stated if staff could not see Resident 1 in the hallway, the resident was not supervised and could fall. LVN 1 stated Resident 1's fall could have been prevented if the resident was supervised and monitored. During a concurrent interview and record review on 2/1/2024 at 4:11 p.m., with RN 2, Resident 1's fall risk care plan was reviewed. RN 2 stated interventions for the fall risk care plan included visual monitoring every hour. RN 2 stated visual monitoring meant making rounds every hour and seeing where the residents were. RN 2 stated the facility had just switched from paper to electronic charting and she was not sure where the visual monitoring for Resident 1 was documented. During a concurrent interview and record review on 2/1/2024 at 4:40 p.m., of Resident 1's Visual Checks Monitoring Sheet dated 8/2022, with the medical records (MR), the visual check monitoring sheet was reviewed. The MR stated the last visual check monitoring sheet for Resident 1 was from 8/2022 and was unable to find documentation visual monitoring was done every hour in the electronic records. During a phone interview with LVN 1 on 2/2/2024 at 9:35 a.m., LVN 1 stated she observed a CNA push Resident 1 in her wheelchair while she (LVN 1) was gathering another resident's supply. LVN 1 stated, she observed Resident 1 sitting in the hallway outside her room but did not see any staff with Resident 1. LVN 1 stated Resident 1 had an unwitnessed fall in the hallway, because there was no one monitoring or keeping an eye on Resident 1. LVN 1 stated she did not tell any other staff to keep an eye on Resident 1. LVN 1 stated if anyone was at the nurses' station, it would have been difficult to see Resident 1. A review of the facility's P&P titled, "Safety and Supervision of Residents," dated 7/2017, indicated the facility's priority was to ensure resident safety, supervision, and assistance to prevent accidents. The P&P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P&P indicated implementing interventions to reduce accident risks and hazards shall include communicating specific interventions to relevant staff and assigning responsibility for carrying out interventions. The facility failed to: 1. Provide supervision and prevent accident hazards, as indicated in Resident 1's care plan titled "At risk for fall/injury," which indicated staff will assist Resident 1, with transfer and ambulation as needed and provide visual monitoring every hour. 2. Follow its P/P titled "Safety and Supervision of Residents," which indicated the facility will ensure residents were safe, supervised and assisted to prevent accidents. As a result, Resident 1 fell and sustained facial trauma and a left arm fracture which required hospitalization in a GACH for evaluation and treatment. These 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.