Health inspection·January 22, 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 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. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. § 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 12/18/2024 the California Department of Health (CDPH) received a complaint alleging that the facility was not self-reporting multiple falls, that occur because the facility was understaffed and that a resident (Resident 2) was found on the floor in the bathroom bleeding with a large cut to her face. Resident 2 had an unwitnessed fall and sustained a skin tear and discoloration to her face. On 12/31/2024 the CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation, the CDPH determined Resident 2 fell on 11/15/2024 and sustained and injury to her head. The facility failed to: 1. Ensure Resident 2's care plans were revised after Resident 2 had previous falls on 2/10/2024 and 7/14/2024. 2. Ensure the facility followed their policy and procedures (P/P), titled, "Falls and Fall Risk, Managing" revised 3/ 2022, "Safety and Supervision of Residents" revised 7/2022, and "Care Plans, Comprehensive Person- Centered" revised 3/2022 that indicated to identify interventions related to the resident's specific risks and causes, based on previous evaluation and current data, to prevent the resident from falling and to minimize complications from falling, to identify any specific risk for individual residents and shall provide individualized, resident- centered approach to safety for each resident ensuring the interventions are implemented correctly and consistently, evaluated for its effectiveness and modified/ replaced as needed, and to develop a comprehensive and person-centered care plan to meet the residents' physical, psychosocial and functional needs. As a result of these deficient practices, Resident 2 sustained a skin tear and discoloration to the left temporal (the area behind the temples and ears) area of her head following a third fall on 11/15/2024. A review of Resident 2's Admission Record (Face Sheet) indicated Resident 2, a 95 year old female, was admitted to the facility on 1/9/2024 with a diagnosis including metabolic encephalopathy (a condition of the brain that can causes confusion, memory loss or loss of consciousness), unspecified dementia (a condition of loss of mental functioning such as thinking, remembering and reasoning that interferes with a person's daily life and activities) and end stage renal disease ([ESRD] a condition in which the kidneys stop working and are not able to remove wastes and extra water from the body). A review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 4/15/2024, indicated Resident 2's cognition (a problem with a person's ability to think, learn, remember, use judgement, and make decisions) was severely impaired and she required a two person assist to complete her activities of daily living ([ADL] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and a one person assist for repositioning in bed and transfers from chair to bed, bed to chair, and walking. A review of Resident 2's untitled Care Plan, dated 1/10/2024, indicated Resident 2 was at risk for falls due to poor safety awareness, unsteady gait, balance problem, poor endurance and getting out of bed without calling for assistance. The Care Plan's goal was for Resident 2 to be free from injuries related to falls. The Care Plan's interventions included conducting rounds/checks on Resident 2 every two hours and as needed, remind Resident 2 to call for assistance, provide cueing and supervision as needed, and reinforce safety awareness. A review of Resident 2's SBAR ([Situation, Background, Assessment, Recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) and Change of Condition (COC) Charting and Skilled Documentation dated 2/11/2024 and timed at 12 p.m., indicated Resident 2 had discoloration and pain (pain level not specified) on her right shoulder. The SBAR and COC indicated Resident 2's physician ordered a STAT (a medical term that means now or immediately) Xray (a procedure that takes pictures of the areas inside the body) of Resident 2's right shoulder. A review of Resident 2's right shoulder Xray, dated 2/11/2024, indicated Resident 2 had a questionable fracture (a complete or partial break in a bone) of the right scapula (shoulder). A review of Resident 2's SBAR dated 2/12/2024 at 12:25 p.m., (following the Director of Nursing [DON]'s investigation of the injury to Resident 2's shoulder discovered on 2/11/2024) indicated Resident 2 had a witnessed fall in her room on 2/10/2024 at 10:35 p.m. A review of a subsequent Resident 2's right shoulder Xray done on 2/12/2024, indicated Resident 2 had osteopenia (a condition that occurs when the bone has lost its density [thickness] which could make the bones weaker and increase the risk of bone fractures) but no fracture of her shoulder. A review of Resident 2's Morse Fall Risk Assessment dated 4/15/2024 and timed at 11:03 a.m., indicated Resident 2 was assessed as high risk for falls with a score of 55 (a score of 45 and higher means Hi risk for fall). A review of Resident 2's clinical record, indicated there was no revision to Resident 2's care plan following her fall on 2/10/2024 to evaluate if the current intervention were effective or not and to consider new intervention. A review of Resident 2's SBAR dated 7/14/2024 at 5:23 p.m., indicated Resident 2 had an unwitnessed fall inside her room and was found in a sitting position on the floor in front of her wheelchair. The SBAR indicated Resident 2 had a pain level of four (an 11 eleven-point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain) to her left buttock. The SBAR indicated Resident 2 was up in her wheelchair thirty minutes before a nursing staff found her sitting on the floor in front of her wheelchair in her room. The SBAR indicated Resident 2 was assessed to be high risk for falls with a score of 75 (a score of 45 and higher means high risk for falls). A review of Resident 2's Interdisciplinary Team ([IDT] a group of medical professionals from different disciplines who work together to help residents achieve their goals) Falls Progress Notes dated 7/15/2024 and timed at 9:18 a.m., indicated Resident 2 complained of pain following an unwitnessed fall on 7/14/2024 at 5:23 p.m. when Resident 2 tried to get up from a wheelchair without assistance. The IDT Falls Progress Notes indicated Resident 2 had impaired cognition, poor safety awareness and a gait/balance deficit and the facility's current safety/preventive measures were to anticipate and meet Resident 2's needs, place Resident 2's bed at lowest position, and to check on Resident 2 regularly. The IDT Falls Progress Notes indicated the new/revised safety interventions for Resident 2 was for the facility staff to increase visual checks, encourage Resident 2 to ask for assistance and to closely monitor Resident 2. A review of Resident 2's clinical record, indicated there was no revision to Resident 2's Care Plan following her unwitnessed fall on 7/15/2024 to evaluate current intervention for the effectiveness and to have new interventions in place. A review of Resident 2's SBAR dated 11/15/2024 and timed at 12:50 p.m., indicated Resident 2 had an unwitnessed fall inside her room's bathroom sitting next to the toilet. The SBAR indicated Resident 2 sustained a skin tear and discoloration to the left temporal area of her head. During an interview on 1/2/2025 at 12:34 p.m., Restorative Nursing Assistant (RNA) 1 stated Resident 2 needed constant cueing, a front wheel walker ([FWW] an aid that provides stability and balance while walking) to assist her to walk and one person to assist her with ambulation. RNA 1 stated Resident 2 had a slow and unsteady gait, was forgetful and was at risk for falls. During a telephone interview on 1/2/2025 at 6 p.m., the Director of Rehabilitation Services (DORS) stated during the IDT meeting conducted on 7/15/2024 following Resident 2's fall on 7/14/2024, it was decided that visual checks and close monitoring should be increased because Resident 2 often had episodes of confusion, impulsivity (the tendency to act without thinking), and attempts to perform tasks that were beyond her capabilities. During an interview and record review on 1/2/2025 at 6:51 p.m., the DON stated and confirmed Resident 2's Care Plan interventions on fall precautions had not been revised to ensure effective interventions were in place. The DON confirmed during an IDT meetings conducted on 7/15/2024, the plan was to increase visual checks and close monitoring of Resident 2 due to Resident 2's of occasional episodes of confusion/forgetfulness and attempts to perform tasks by herself which were beyond her capabilities. The DON stated the nursing staff took turns monitoring Resident 2 and conducting hourly visual checks, however, there was no documentation of those interventions and efforts. The DON stated Resident 2 had three fall incidents in the facility because Resident 2 was not able to fully understand the staff instructions on safety precautions and Resident 2 tried to perform tasks beyond her capabilities. The DON stated Resident 2's Care Plans' interventions should have been revised and updated based on Resident 2's COC, fall risk assessments and IDT meetings to ensure appropriate care was provided to prevent Resident 2 from continued falls which could harm Resident 2. A review of the facility's P/P titled, "Falls and Fall Risk, Managing" revised 3/ 2022, indicated the facility must identify interventions related to the resident's specific risks and causes, based on previous evaluation and current data, to prevent the resident from falling and to minimize complications from falling. The P/P indicated the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors or falls for each resident at risk or with history of falls. A review of the facility's P/P titled, "Safety and Supervision of Residents" revised 7/2022, indicated the facility shall strive to supervise and attend to the residents to ensure their safety. The P/P indicated the facility, and its IDT will perform assessments and observations to identify any specific risk for individual residents and shall provide individualized, resident- centered approach to safety for each resident ensuring the interventions are implemented correctly and consistently, evaluated for its effectiveness, and modified/ replaced as needed. A review of the facility's P/P titled, "Care Plans, Comprehensive Person- Centered" revised 3/2022, indicated the facility provides a comprehensive and person-centered care plan to meet the residents' physical, psychosocial and functional needs and must be developed and implemented for each resident. The P/P indicated the facility's interdisciplinary team (IDT) in conjunction with the resident and his/her responsible party must develop and implement the comprehensive, person-centered care plan and should reflect the recognized standard of practice for the resident's problem areas and conditions, the resident's stated goals, strengths, problem areas and conditions and the care plan interventions chosen based on careful consideration of the resident's problem areas and their causes. The P/P indicated the assessments of the residents are ongoing and the care plan are revised based on the information of the resident and their changes of condition. The facility failed to: 1. Ensure Resident 2's care plans were revised after Resident 2 had previous falls on 2/10/2024 and 7/14/2024. 2. Ensure the facility followed their policy and procedures (P/P), titled, "Falls and Fall Risk, Managing" revised 3/ 2022, "Safety and Supervision of Residents" revised 7/2022, and "Care Plans, Comprehensive Person- Centered" revised 3/2022 that indicated to identify interventions related to the resident's specific risks and causes, based on previous evaluation and current data, to prevent the resident from falling and to minimize complications from falling, to identify any specific risk for individual residents and shall provide individualized, resident- centered approach to safety for each resident ensuring the interventions are implemented correctly and consistently, evaluated for its effectiveness and modified/ replaced as needed, and to develop a comprehensive and person-centered care plan to meet the residents' physical, psychosocial and functional needs. As a result of these deficient practices, Resident 2 sustained a skin tear and discoloration to the left temporal (the area behind the temples and ears) area of her head following a third fall on 11/15/2024. These violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result, or a substantial probability of death or serious physical harm would result to Resident 2.