Health inspection·November 8, 2023

§ 72541 Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 9/13/2023, the California Department of Public (CDPH) received a complaint with allegations of Resident 1 safety/fall. On 9/27/2023 the CDPH conducted an unannounced visit at the facility The facility failed to: 1. Ensure CDPH was notified of Resident 1's fall with injury. 2. Ensure the facility staff followed the facility's policy and procedure (P/P) titled, "Unusual Occurrence" and reported to CDPH Resident 1's fall with injury. This failure resulted in the delay of CDPH investigation of Resident 1 fall and sustaining a laceration at the back of the head. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 77-year-old- female was admitted to the facility on 8/21/2023 with diagnoses including essential hypertension (high blood pressure), cardiomegaly (enlargement of the heart) and chronic obstructive pulmonary disease ([COPD]-a progressive disease that makes it hard to breath). A review of Resident 1's Transfer Order dated 08/21/2023 and timed at 10:38 p.m., indicated Resident 1 was transferred to GACH (general acute care hospital) due to fall incident that resulted in laceration at the back of the head. During an interview on 09/27/2023 at 2:45 p.m. the Minimum Data Set Assistant (MDSA) stated Resident 1 was admitted in the facility on 8/21/2023 at 9:40 pm. Resident 1 was transferred to GACH on 8/21/2023 at 10:38 pm. due to Resident 1's fall on 8/21/2023 at around 10:40 pm (two hours post admission to the facility) that resulted in lacerations at the back of her head that required hospitalization. MDSA stated Resident 1's fall with injury should have been reported to the CDPH but was not. During an interview on 09/27/2023 at 3:08 p.m., the facility's Administrator (ADM) stated Resident 1's fall incident was not reported to CDPH and there was no documentation of the fall incident in Resident 1's clinical record. During a telephone interview on 09/28/2023 at 11:07 a.m., Certified Nursing Assistant (CNA 2) stated Resident 1 was alert and able to follow instructions. CNA 2 stated she was removing extra bed linens from Resident 1's bed. CNA 2 stated she was standing behind Resident 1, on the right side of Resident 1's bed. CNA 2 instructed Resident 1 to turned to her left side. Resident 1 swung her right leg and extended her leg over the edge of the bed, rolled off the bed and hit her head on the corner of the bedside dresser as she was falling. CNA 2 stated Resident 1 was bleeding from the back of her head. A review of the facility's policy and procedure (P&P) titled "Unusual Occurrence" dated 7/2007 indicated, the unusual occurrence shall be reported by the facility within 24 hours either by telephone or in writing to the Department. The facility failed to: 1. Ensure CDPH was notified of Resident 1's fall with injury. 2. Ensure the facility staff followed the facility's P/P "Unusual Occurrence" and reported to CDPH Resident 1's fall with injury. This failure resulted in the delay of CDPH investigation of Resident 1 fall and sustaining a laceration at the back of the head. This violation presented a direct or immediate relationship to the health, safety, security, or welfare of the residents.