Health inspection·December 18, 2023

Free of Accident Hazards/Supervision/Devices 42 CFR §483.25 Quality of Care (d) Accidents. The facility must ensure that- (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. 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. The Department received a complaint on 10/24/23 regarding Resident 1 falling. On 10/31/23 an unannounced investigation was conducted to investigate the allegation. The facility failed to: 1.Ensure Certified Nurse Assistant (CNA) 2 monitored and supervised Resident 1 after Resident 1 was agitated and medicated with Lorazepam (medication used to treat anxiety), to prevent the resident from falling.  As a result, Resident 1 fell from a wheelchair and sustained a subdural hematoma (buildup of blood on the surface of the brain), subarachnoid hemorrhage (bleeding in the space that surrounds the brain), compression fracture (small breaks or cracks in the vertebrae [the bones that make up your spinal column]) of the fourth lumbar vertebra (backbone), right eleventh rib fracture, and right temporal bone (base of the skull) fracture, that required surgical intervention at a general acute care hospital (GACH) A review of Residents 1’s Face Sheet (admission record), indicated Resident 1 was a 74-year-old male admitted to the facility on 9/20/2022 and readmitted on 9/8/2023. Resident 1’s diagnoses included generalized muscle weakness, Alzheimer’s disease (affects memory, thinking and behavior), and anxiety (feelings of tension, worried thoughts). A review of Resident 1’s History and Physical (H/P) dated 4/6/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s care plan titled, “Resident is noted with restlessness and anxiety,” dated 7/9/2023, indicated to ensure safety measures were in place, to monitor Resident 1 for behaviors. A review of Resident 1’s Fall Risk Assessment dated 7/9/2023, indicated Resident 1 had a score of 55. A score of 45 and higher indicated a high risk for falls. A review of Resident 1's Minimum Data Set ([MDS] a standardized care assessment and care screening tool) dated 7/20/2022, indicated Resident 1 usually had the ability to understand and be understood by others. The MDS indicated Resident 1 required a two-person physical assist for bed mobility, transfers, dressing, eating, personal hygiene and total dependence for locomotion (moving from place to place), and toilet use. The MDS indicated Resident 1’s balance was not steady during transitions and walking and was only able to stabilize with staff assistance. A review of Resident 1’s care plan titled, “At risk for falls and injuries,” dated 7/21/2023, indicated apply/monitor tab alarm when in bed or up in wheelchair to alert staff due to resident attempting to get up/out of bed/(wheelchair) unassisted. A review of Resident 1’s Verification of Incident Investigation report dated 9/1/2023 at 10:22 p.m., on 9/1/2023, Resident 1 was restless and made multiple attempts to get out of bed. The report indicated a CNA (CNA 2) placed Resident 1 in a wheelchair. The report indicated Resident 1 received Lorazepam at 10:14 p.m. The report indicated the CNA left Resident 1 in the hallway outside another residents’ room to answer a resident’s call light. The report indicated a nurse at the nursing station heard a thud (a dull, heavy sound, such as that made by an object falling to the ground) at 10:22 p.m., looked over, and Resident 1 was on the floor while the resident’s legs were still positioned in the wheelchair. A review of Resident 1’s GACH History and Physical (H&P) report dated 9/1/23 disclosed Resident 1 was admitted to the facility with a bilateral and chronic subdural hematoma. A review of Resident 1’s Interdisciplinary Team ([IDT] group of different disciplines working together towards a common goal for residents) Post Fall Follow Up dated 9/12/2023, indicated on 9/1/2023, Resident 1 attempted to stand up unassisted from a wheelchair and fell. The report indicated Resident 1 was transferred to the GACH for further evaluation and returned to the facility on 9/8/2023. The report also indicated Resident 1 was unable to recall the fall incident nor state what happened. On 11/7/2023 at 10:23 a.m., during an interview, LVN 2 stated Resident 1 was agitated the evening of 9/1/2023) and she (LVN 2) administered Lorazepam1 milligram (mg, unit of measurement), to calm the resident down because the resident was restless and trying to get out of bed multiple times. LVN 2 stated Resident 2 fell 10 minutes after he received Lorazepam. LVN 2 stated CNA 2 was assigned to monitor Resident 1 continuously (1:1). LVN 2 stated she was sitting at the nurse’s station when Resident 1 fell but was not monitoring the resident. LVN 2 stated CNA 2 should have asked LVN 2 to watch Resident 1 while CNA 2 went to answer another resident’s call light to prevent Resident 1 from falling. LVN 2 stated Resident 1 should have not been left unattended. On 11/07/2023 at 11:54 a.m., during an interview, CNA 2 stated he was told by the previous shift nurses’ staff he had to always stay with Resident 1 because of the resident’s high risk for falls. CNA 2 stated he did not inform anyone he was going into a resident’s room to respond to a call light because there was no one available. CNA 2 stated everyone (facility staff) was doing their rounds at that time, she left Resident 1 in unattended. On 11/8/2023 at 12:40 a.m., during an interview, the Director of Nursing (DON), the DON stated it was not a good decision for CNA 2 to leave Resident 1 without supervision because that caused Resident 1 to fall. The DON stated Resident 1 needed continuous monitoring and staff did not need a physician’s order for one-to-one (1:1) monitoring. The DON stated staff were supposed to continuously monitor Resident 1, to prevent the resident from falling. A review of the facility’s policy and procedure (P&P), titled “Fall Prevention,” revised 11/8/2023, indicated for Resident’s with identified fall risk factors upon admission, the facility will implement, “universal safety interventions” in response to risk, which may include, but not limited to providing supervision and physical assistance in accordance with assessed needs. The facility failed to: 1.Ensure CNA 2 monitored and supervised Resident 1 after Resident 1 was agitated and medicated with Lorazepam to prevent the resident from falling.  As a result, Resident 1 fell from a wheelchair and sustained a subdural hematoma, subarachnoid hemorrhage, compression fracture of the fourth lumbar vertebra, right eleventh rib fracture, and right temporal bone fracture, that required surgical intervention at a general acute care hospital. This violation 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.