Other·June 14, 2024

F689 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §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(a)(1)(C)(2) 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: (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. 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 4/15/2024 the California Department of Public Health (CDPH), received a facility reported incident (FRI) that a resident (Resident 1) fell and sustained an injury. On 4/29/2024, at 8 a.m., an unannounced visit was conducted at the facility to investigate the FRI. Upon investigation, CDPH determined, Resident 1 who was assessed as a high risk for falls and was totally dependent on staff for activities of daily living ([ADL] task such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating) fell out of bed, sustained injuries, and was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment. The facility failed to: 1. Ensure Resident 1's bed was maintained in the lowest position, as care planned, to minimize and/or prevent injuries during a fall. 2. Place floor mats (high impact foam pads which are placed adjacent to the bed on the floor to help reduce the impact from falls and help prevent injuries) on the floor adjacent to Resident 1's bed, as care planned, to minimize and/or prevent injuries during falls. 3. Ensure licensed nurses followed the facility's policy and procedure (P/P), titled "Fall Management System," indicating the facility is to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. These deficient practices resulted in Resident 1 falling from her bed (4/11/2024), which was in a high position, landing on the floor without floor mats in and sustaining a non-displaced (when a bone cracks in only one place and does not move to change alignment) left intertrochanteric fracture (a hip fracture), a bump on her forehead and an abrasion on her left arm. On 4/12/2024 Resident 1 was transferred to a GACH for evaluation and treatment. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1, a 78 year-old female was initially admitted to the facility on 5/2/2012 and readmitted on 12/11/2023 with a diagnoses of generalized muscle weakness. A review of Resident 1's Minimum Data Set ([MDS]) a standardized assessment and care screening tool), dated 12/14/2023, indicated Resident 1's cognitive skills (thinking process) for daily decision-making were severely impaired. The MDS indicated Resident 1 was totally dependent (when a helper does all of the effort to assist the resident and the resident does not of the effort to assist themselves) on staff for ADLs. The MDS indicated Resident 1 had a functional limitations in range of motion ([ROM] the distance and direction a joint can move to its full potential) to both sides of her lower extremities (legs). A review of Resident 1's Fall Risk Evaluation, dated 3/22/2024 indicated a fall risk score of 13. A score of 13 and above indicated a high risk for falls. A review of Resident 1's Care Plan, dated 12/14/2023, indicated Resident 1 was at risk for falls and fall related injuries due to impaired ADLs. The Care Plan's goal indicated Resident 1 would be free from falls through the review date of 7/19/2024. The Care Plan's interventions were to have floor mats at Resident 1's bedside and to keep Resident 1's bed in the lowest position. A review of Resident 1's Change of Condition (COC) dated 4/11/2024 and timed at 11:15 p.m., indicated a Certified Nurse Assistant (CNA 2) heard a thud and found Resident 1 on the floor in a prone (lying on the stomach) position. Resident 1 was noted with a bump on her forehead and an abrasion on her left arm. A review of Resident 1's Physician's Orders dated 4/11/2024, indicated to transfer Resident 1 to a GACH for further evaluation and treatment as indicated, status post (after) an unwitnessed fall. A review of the GACH's Emergency Document - MD, dated 4/12/2024 and timed at 12:03 a.m., indicated Resident 1 had a hematoma (a bruise) above her left eyebrow and pain to her left hip. A review of Resident 1's X-ray report dated 4/12/2024 and timed at 1:03 a.m., indicated Resident 1 had a probable nondisplaced left intertrochanteric fracture. During an interview on 4/29/2024 at 4:41 p.m., and a subsequent interview on 5/1/2024 at 4:49 p.m., CNA 1 stated, on 4/11/2024 at approximately 10:30 p.m., she was called to Resident 1's room. CNA 1 stated she observed Resident 1 on the floor in a prone position and there was no floor mat on the ground. During an interview on 4/29/2024 at 5:18 p.m., CNA 2 stated, on 4/11/2024, between 10:15 p.m., and 10:30 p.m., she heard Resident 1 crying in her room. CNA 2 stated she went to check on Resident 1 and found the resident lying on a low air loss mattress (a type of medical mattress designed to reduce pressure on the skin, which helps prevent pressure ulcers or bed sores) on her right side and soiled. CNA 2 stated she went to the bathroom to get supplies to clean and change Resident 1, when she heard a loud thud. CNA 2 stated, she went to check Resident 1 and found her on the floor next to her bed on her stomach. CNA 2 stated Resident 1's mattress and bed were at bedside table height (approximately 30 inches to 36 inches high), and she did not recall if a floor mat was on the floor. CNA 2 stated the best way to prevent a fall was to have two people assisting with Resident 1's care. During an interview on 4/30/2024 at 3:57 p.m., Licensed Vocational Nurse 1 (LVN 1) stated on 4/11/2024 at approximately 10:40 p.m., she was called to Resident 1's room, when she entered Resident 1's room, she saw Resident 1 on the floor and observed Registered Nurse 1 (RN 1) assessing Resident 1. LVN 1 stated Resident 1's bed had to be placed in the lowest position in order to transfer Resident 1 back to the bed. During an interview on 4/30/2024 at 4:19 p.m., RN 1 stated she was called to Resident 1's room by CNA 1 and CNA 2 at approximately 10:50 p.m. RN 1 stated when she went to the room, she found Resident 1 on the floor. RN 1 stated Resident 1 had a bump on her forehead and complained of discomfort. During an interview on 5/2/2024 at 4:26 p.m., the Director of Nursing (DON) stated Resident 1's bed should have been in the lowest position along with floor mats on the floor next to Resident 1's bed and two staff members providing care. The DON stated two staff should be present to help prevent falls and the floor mats should have been on the floor next to Resident 1's bed to lessen the chance of injury if Resident 1 fell out of bed. A review of the facility's P/P, titled "Fall Management System," revised 1/2024, the P/P indicated the facility is to provide an environment that remains as free of accident hazards as possible. The P/P indicated to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The facility failed to: 1. Ensure Resident 1's bed was maintained in the lowest position, as care planned, to minimize and/or prevent injuries during a fall. 2. Place floor mats on the floor adjacent to Resident 1's bed, as care planned, to minimize and/or prevent injuries during falls. 3. Ensure licensed nurses followed the facility's P/P, titled "Fall Management System," indicating the facility is to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. These deficient practices resulted in Resident 1 falling from her bed (4/11/2024), which was in a high position, landing on the floor without floor mats in and sustaining a non-displaced left intertrochanteric fracture (a hip fracture), a bump on her forehead and an abrasion on her left arm. On 4/12/2024 Resident 1 was transferred to 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 to Resident 1.