Health inspection·December 11, 2024

§483.21(b)(1) Comprehensive Care Plans 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. §72311(a)(2) 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. §72523(a) 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 10/15/2024, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) regarding verbal abuse between a staff and a resident and on 10/17/2024 the CDPH received a complaint with allegations concerning the facility's unsanitary physical environment and resident care. On 10/29/2024, the CDPH conducted an unannounced visit to investigate the FRI and complaint allegations. While investigating the FRI and complaint allegations, which were unsubstantiated, the CDPH was made aware of an unrelated incident regarding a resident (Resident 4) who was found on the floor with a head injury. Upon investigation the CDPH determined Resident 4, who was at risk for falls and who had a history of getting out of bed unassisted, was not monitored to prevent him from falling and sustaining a head injury. The facility failed to: 1. Ensure the nursing staff followed interventions, per Resident's 4's Care Plan titled, "Risk for Falls" dated 7/1/2024, to reduce Resident 4's risk for falls by increasing the frequency of monitoring rounds. 2. Ensure the nursing staff, who provided care to Resident 4, were made aware of what the time frame was for "frequent monitoring" for Resident 4 who was assessed at risk for falls and who had a history of getting out of bed unassisted. 3. Follow their Policy and Procedure (P/P), titled, "Fall Prevention Program" dated 12/2023, that indicated to provide additional interventions as directed by the resident's assessment, including but not limited to increased frequency of rounds. This resulted in Resident 4 getting up from his bed unassisted without staff knowledge to go to the bathroom, where he was found on the floor with a head injury. This had the potential to result in Resident 1's continued behavior of getting up unassisted without staff knowledge, and possibly leading to more serious injuries including death. A review of Resident 4's Admission Record (Face Sheet), indicated Resident 4, an 84 year-old male, was admitted to the facility on 7/1/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), difficulty walking, lack of coordination, and muscle weakness. A review of Resident 4's Minimum Data Set ([MDS] resident assessment tool) dated 10/9/2024, indicated Resident 4's cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 4 required maximal assistance (helper does more than half the effort) for toileting, hygiene and showering, and moderate assistance (helper does less than half the effort) for dressing, personal hygiene, and walking. A review of Resident 4's Fall Risk Assessment dated 10/7/2024, indicated Resident 4 was at risk for falls due to intermittent (occurring at irregular intervals, not continuous) confusion, requiring assistance with elimination (using the toilet), balance, gait (how a person walks) problems, currently taking more than three medications, and disease predisposition (a condition where a person has an increased chance of developing a disease due to genetic or environmental factors). A review of Resident 4's Care Plan titled, "Risk for Falls" dated 7/1/2024, indicated Resident 4 was at risk for falls. The Care Plan's goal indicated to reduce Resident 4's risk for falls with interventions that included meeting Resident 4's needs and to follow the facility's Fall Protocol (policy), which indicated to increase the frequency of rounds. A review of Resident 4's Nurses Progress Notes dated 10/29/2024 and timed at 2:40 p.m., indicated Resident 4 was found in his bathroom on the floor next to the sink, with bleeding on the back of his head, a laceration measuring 1.1 x 1.4 centimeters ([cm] a unit of measurement) and swelling. The Nurses Progress Notes indicated Resident 4 stated he slipped and hit his head on the sink. A review of Resident 4's Care Plan titled, "Unwitnessed Fall" dated 10/29/2024, indicated Resident 4 had an unwitnessed fall on 10/29/2024. The Care Plan indicated the goal was for Resident 4 to have no fall incidents. The care plan interventions included frequent visual checks every two hours. During a concurrent observation and interview on 10/30/2024 at 9:30 a.m., Resident 4 was observed lying in bed, with a hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) on the back of his head that was approximately 2.5 x 2.5 cm in length/width, and it was raised approximately 1.0 cm. Resident 4's hematoma had a light blue and yellow discoloration and in the middle of it were three wound closure strips (tape strips used to close small wounds) with a small amount of blood. Resident 4 stated he hit his head and was unable to recall any details surrounding his fall and subsequent head injury. During an interview on 10/30/2024 at 9:35 a.m., Resident 5 stated Resident 4 fell yesterday (10/29/2024) because nursing staff took a long time to come in and help him (Resident 4) to the restroom. During an interview on 10/30/2024 at 10:45 a.m., Licensed Vocational Nurse 1 (LVN 1), stated Resident 4 had a known behavior of trying to get out of his wheelchair without assistance due to his forgetfulness and he needed to be instructed periodically not to stand up without assistance. During an interview on 10/31/2024 at 10:19 a.m., Certified Nursing Assistant 1 (CNA 1), stated the day Resident 4 fell (10/29/2024) she was making her final rounds around 2:45 p.m. and was informed by the Housekeeper (HS 1) that Resident 4 was on the floor in the bathroom. CNA 1 stated she went to the bathroom and saw Resident 4 sitting on the bathroom floor next to the sink. CNA 1 stated she last saw Resident 4 at 2 p.m., in bed in his room, prior to his fall at 2:45 p.m. CNA 1 stated she usually checked on Resident 4 every one to two hours during her shift when she was assigned to him. CNA 1 stated Resident 4 was very demanding and had a history of trying to get out of bed without assistance. CNA 1 stated they (the nursing staff) do not document when they monitor Resident 4. During an interview on 10/31/2024 at 10:55 a.m., LVN 2 stated residents, who were at risk for falls, required frequent visual checks at least once every two hours. During an interview on 10/31/2024 at 11:09 a.m., Registered Nurse (RN 1) stated all residents should be checked at least once every two hours but more frequently if they were confused. RN 1 stated she had not been instructed regarding what the time frame was for frequent visual checks, but she believed it would be reasonable to check on a confused resident, who had a behavior of trying to get out of bed, every 15 to 30 minutes, or to assign someone to monitor them one to one. During an interview on 10/31/2024 at 11:53 a.m., the Director of Nursing (DON), stated frequent visual checks meant once every two hours for all residents, including residents who were confused or who were at risk for falls. The DON stated she was not aware that Resident 4 had a history of trying to get out of bed without assistance prior to his fall on 10/29/2024, but even if he had a history of trying to get out of bed unassisted, monitoring him every two hours was reasonable. The DON stated they do not put a time frame for frequent monitoring of residents in the care plan because it would not be realistic for nurses to monitor residents on a schedule unless the resident had a sitter (a patient companion who was responsible for sitting with and monitoring the welfare of patients who cannot be left alone). The DON stated she was not aware that their policy "Fall Prevention Program" indicated interventions must include increased frequency of rounds for residents at risk for falls. The DON stated that an increased frequency of rounds would mean more than once every two hours. During an interview on 10/31/2024 at 1:48 p.m., CNA 1 stated she did not inform anyone that Resident 4 had a history of trying to get out of bed without assistance because she assumed everyone already knew. During an interview on 10/31/2024 at 2:23 p.m., the DON stated the facility does not document when they visually check on a resident because if the nurses could not check on a resident timely, the nurses would be out of compliance with Federal and State regulations. During a review of facility's P&P, titled "Fall Prevention Program" dated 12/2023, the P&P indicated under "At Risk Protocols" to provide additional interventions as directed by the resident's assessment, including but not limited to increased frequency of rounds. The facility failed to: 1. Ensure the nursing staff followed interventions, per Resident's 4's Care Plan titled, "Risk for Falls" dated 7/1/2024, to reduce Resident 4's risk for falls by increasing the frequency of monitoring rounds. 2. Ensure the nursing staff, who provided care to Resident 4, were made aware of what the time frame was for "frequent monitoring" for Resident 4 who was assessed at risk for falls and who had a history of getting out of bed unassisted. 3. Follow their P/P, titled, "Fall Prevention Program" dated 12/2023, that indicated to provide additional interventions as directed by the resident's assessment, including but not limited to increased frequency of rounds. This resulted in Resident 4 getting up from his bed unassisted without staff knowledge, to go to the bathroom, where he was found on the floor with a head injury. This had the potential to result in Resident 1's continued behavior of getting up unassisted, without staff knowledge, and possibly leading to more serious injuries including death. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 4.