Health inspection·March 4, 2025

F744, Code of Federal Regulations, Title 42, Section §483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. California Code of Regulations, Title 22, Section §72311 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. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B)Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. §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 1/21/2025 at 8:55 am, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility for an annual recertification survey. As a result of the investigation, the Department determined the facility failed to ensure Resident 92, who had a diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life) and history of falling, received care and services to prevent a fall by failing to: a. Ensure Registered Nurse 1 (RN 1) notified Resident 92's physician/medical doctor (MD 1) regarding Resident 92's increased agitation and confusion when Resident 92 attempted to stand up unassisted from Resident 92's wheelchair (WC) multiple times on 1/20/2025 as indicated in the facility's policy and procedure (P&P) titled, "Change in Resident Condition." b. Ensure Certified Nurse Assistant 5 (CNA 5) did not wheel/take Resident 92 to Resident 92's room, placed Resident 92 in bed and left Resident 92 in Resident 92's bed, unsupervised, on 1/20/2025, when Resident 92 was agitated and confused. As a result of these failures, on 1/20/2025, at 4:30 PM, Resident 92 fell out of Resident 92's bed. Resident 92 sustained a laceration, bruising on Resident 92's right eyebrow, and abrasions on both knees. The facility transferred Resident 92 to the General Acute Care Hospital 1's (GACH 1) Emergency Department (ED) via emergency services by calling 911 (phone number used to contact emergency services in the event of a medical emergency). A review of Resident 92's Admission Record (AR) indicated Resident 92 was a 68-year-old female and the resident was admitted on 1/16/2025 with diagnosis that included Alzheimer's Disease, and psychosis. A review of Resident 92's Progress Notes (PN), dated 1/16/2025, timed at 3:10 PM, indicated Resident 92 was alert and had some forgetfulness. The PN indicated Resident 92's gait was unsteady, and Resident 92 had poor balance. A review of Resident 92's PN, dated 1/16/2025, timed at 9:34 PM, indicated Resident 92 was confused, needed full assistance with activities of daily living, and was at risk for falls. A review of Resident 92's Baseline Care Plan (BCP), signed on 1/17/2025 by RN 1, indicated Resident 92 was unable to be oriented due to Dementia. A review of Resident 92's CP for alteration in cognitive function related to AD and Dementia, initiated on 1/17/2025, the CP's interventions indicated to provide reorientation, and redirection as needed to Resident 92. A review of Resident 92's CP for at risk for falls related to impaired cognition, lack of safety awareness, and poor communication/comprehension, initiated on 1/17/2025, the CP's goal indicated to decrease the risk of falls and minimize injuries from falls. The CP's interventions indicated to remind Resident 92 not to get up without assistance. A review of Resident 92's PN, dated 1/20/2025, timed at 6:40 PM, indicated on 1/20/2025 at 4 PM, Resident 1 was placed in Resident 92's bed. The PN indicated Resident 92 had episodes of getting out of bed unassisted. The PN indicated at 4:30 PM, Resident 1 was found on the floor next to Resident 92's bed in a prone. The PN indicated Resident 1 was confused, disoriented, and had a laceration on Resident 1's right eyebrow that measured 5.2 centimeters in length by 0.3 cm in width by 0.1 cm in depth, and abrasions on both knees. The PN indicated (on 1/20/2025), at 4:35 PM, 911 was called due to Resident 1 sustaining a head injury. A review of Resident 92's Situation, Background, Assessment and Recommendation Communication Form (SBAR, a communication tool that helps teams share information about the condition of a resident), dated 1/20/2025, indicated Resident 92 was found on the floor and Resident 92 had a laceration on the right eyebrow and abrasions on both knees. A review of Resident 92's GACH 1 History and Physical (H&P), dated 1/20/2025, timed at 6:40 PM, indicated Resident 92 had a history of Dementia. The H&P indicated Resident 92 presented to the ED due to an unwitnessed fall. The H&P indicated Resident 92 had a laceration on the right eye with contusions, abrasions on both knees, and a contusion on the right knee. During an observation on 1/21/2025, at 12:10 PM, Resident 92 was sitting on a WC in the dining room and eating lunch. Resident 92's right eye had light gray skin discoloration around the eye. There was swelling under the right eye, and a laceration on the right side of the eye that measured 4 cm, three steri strips covered the laceration. During an interview with Certified Nursing Assistant (CNA) 3 on 1/22/2025 at 11:23 AM, CNA 3 stated CNA 3 was assigned to care for Resident 92 on 1/20/2025 during the AM shift (7 AM to 3 PM). CNA 3 stated, on 1/20/2025 during the AM shift, Resident 92 was trying to get up from Resident 92's WC multiple times and was, "more confused." CNA 3 stated when Resident 92 was left by herself, Resident 92 attempted to get up from the [WC]. CNA 3 stated, "The moment you turn your back she will get up." CNA 3 stated Resident 3 was at risk for falls. CNA 3 stated to ensure safety and constant supervision for Resident 92, CNA 3 wheeled/took Resident 92 to the nurse's station and informed RN 1 and LVN 3 of Resident 92's increased confusion. During an interview with RN 1 on 1/22/2025 at 11:48 AM, RN 1 stated upon admission (1/16/2025), Resident 92 was non-verbal and did not attempt to get out of bed/WC. RN 1 stated on 1/20/2025, during the AM shift, Resident 92 was placed at the nurse's station for constant monitoring because Resident 92 "consistently attempted to stand up, mumbled, and spoke to herself." RN 1 stated, "She (Resident 92) would just stand up." RN 1 stated, she (RN 1) did not tell the physician (MD 1) about the changes in Resident 1's condition. RN 1 stated, on 1/20/2024, during shift change, RN 1 endorsed to LVN 6 that Resident 92 attempted to stand up from the WC multiple times and was placed in the nurse's station for constant monitoring. RN 1 stated RN 1 would have continued to monitor Resident 92. RN 1 stated RN 1 would not have placed Resident 92 back in bed and left Resident 92 unsupervised. During a concurrent interview with LVN 3 on 1/23/2025, at 10:54 AM, LVN 3 stated (on 1/20/2025) during the AM shift, Resident 92 was placed in the nurse's station for constant monitoring due to Resident 92's constant attempts to stand up from the WC unassisted. LVN 3 stated during shift change report (on 1/20/2025), LVN 3 reported to LVN 6 that Resident 92 had attempted multiple times to get out of Resident 92's WC and reported Resident 92 needed constant supervision. During an interview with LVN 6, on 1/23/2025, at 3:12 PM, LVN 6 stated on 1/20/2025, at 3 PM, LVN 6 stated while Resident 92 was sitting at the nursing station, Resident 92 attempted to get up from the WC. LVN 6 stated LVN 3 and RN 1 informed LVN 6 that Resident 92 attempted to get up from Resident 92's WC multiple times during the AM shift, and Resident 92 needed to be placed in the nurse's station for constant monitoring. LVN 6 stated after 3 PM, CNA 5 wheeled/took Resident 92 to Resident 92's room located "at the end of the hallway, five to six rooms " away from the nursing station and CNA 5 placed Resident 92 in Resident 92's bed. LVN 6 stated, "I thought CNA 5 was watching her [Resident 92]." LVN 6 stated at 4:30 PM, LVN 6 walked inside Resident 92's room and Resident 92's bed was empty. LVN 6 stated LVN 6 found Resident 92 on the floor, face toward the floor. LVN 6 stated LVN 6 saw blood on the floor and Resident 92 had a "long and big" laceration with active bleeding on the right side of Resident 92's eye and abrasions on both knees. Resident 92 was very confused, disoriented, and unable to state any pain. LVN 6 stated, "I needed to make sure there is visual checks on [Resident 92] at all times." LVN 6 stated, Resident 92 should have been constantly monitored for the Resident 92's safety. During an interview with Certified Nurse Assistant 5 (CNA 5) on 1/23/2025, at 3:53 PM, CNA 5 stated Resident 92's "mind did not follow directions." CNA 5 stated during shift change (on 1/20/2024, at 3 PM), CNA 3 endorsed to CNA 5 that Resident 92 was placed at the nurse's station for constant monitoring due to Resident 92's agitation and confusion. CNA 5 stated from 3 PM to 4 PM, Resident 92 was at the nurse's station being monitored by LVN 6. CNA 5 stated at around 4 PM, CNA 5 informed LVN 6 that CNA 5 would take Resident 92 back to Resident 92's room and "put her (Resident 92) back to bed, to rest before dinner." CNA 5 stated LVN 6 did not say to not take Resident 92 to Resident 92's room. CNA 5 stated CNA 5 placed Resident 92 in Resident 92's bed and CNA 5 left Resident 92's room to care for other residents [leaving Resident 92 unsupervised]. During an interview and concurrent record review with the Director of Nursing (DON) on 1/24/2025, at 8:55 AM, the DON stated on 1/20/2025, CNA 5 should not have taken Resident 92 back to Resident 92's room and left Resident 92 unsupervised when Resident 92 had an increase in confusion and was attempting to get up [from the bed/ WC] multiple times. The DON stated Resident 92 needed constant monitoring during the day shift and more than likely Resident 92 required constant monitoring during the evening shift (3 PM to 7 AM) because Resident 92 could fall. The DON stated RN 1 needed to call and notify MD 1 to make MD 1 aware when Resident 92 had a COC such as increased in confusion and started to get up, unassisted, from the WC. During a telephone interview with MD 1 on 1/24/2025, at 4:23 PM, MD 1 stated MD 1 was not aware of Resident 92's mentation change/COC or the fall that occurred on 1/20/2025. MD 1 stated MD 1 should have been made aware for MD 1 to give [appropriate] orders. MD 1 stated MD 1 should have been notified upon Resident 92's change in behavior, trying to get out of bed/WC [unassisted], for MD 1 to evaluate Resident 1 and write new order and for the facility to implement safety measures to prevent falls. MD 1 stated MD 1 would write an order for 1:1 supervision (one staff supervising one resident) as intervention for Resident 1's COC. A review the facility's P&P titled, "Dementia, Caring of Residents," revised 1/2015 (most updated), indicated "Residents who exhibited new or worsening behavioral or psychological symptoms (affecting, or arising in the mind; related to the mental and emotional state of a person) of dementia (BPSD) should have an evaluation by the physician in order to identify and address treatable [conditions] that may be contributing to behaviors." The P&P indicated "Individualized approaches to care utilizing a consistent process that focuses on a resident's individual needs and tries to understand behavior as a form of communication may help to reduce behavioral expressions of distress in some residents." A review of the facility's P&P titled, "Change in Resident Condition," revised 11/2016 (most updated), indicated "Changes in a resident condition will be communicated to the physician timely." The P&P indicated "Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior, will be communicated to the physician ..." The P&P indicated "The nurse in charge is responsible for notification of physician prior to the end of the assigned shift when a change in a resident's condition is noted." A review of the facility's P&P titled, "Falls Prevention and Management Program," revised on 12/14/2022 (most updated), indicated "Staff, in conjunction with the attending physician... will properly assess a resident's risk for falling, provide accurate interventions to minimize that risk and try to prevent a resident from falling." The P&P indicated "Interventions for fall prevention included, frequent (often, occurring or done on many occasions) observation of the resident, especially following admission, to learn their habits and to accommodate needs: assign a resident's room near the nurse's station, strategies for residents with dementia and those who have recurrent falls." As a result of the investigation, the Department determined the facility failed to ensure Resident 92, who had a diagnosis of dementia and history of falling, received care and services to prevent a fall by failing to: a. Ensure RN 1 notified MD 1 regarding Resident 92's increased agitation and confusion when Resident 92 attempted to stand up unassisted from Resident 92's WC multiple times on 1/20/2025 as indicated in the facility's P&P titled, "Change in Resident Condition." b. Ensure CNA 5 did not wheel/take Resident 92 to Resident 92's room, placed Resident 92 in bed and left Resident 92 in Resident 92's bed, unsupervised, on 1/20/2025, when Resident 92 was agitated and confused. As a result of these failures, on 1/20/2025, at 4:30 PM, Resident 92 fell out of Resident 92's bed. Resident 92 sustained a laceration, bruising on Resident 92's right eyebrow, and abrasions on both knees. The facility transferred Resident 92 to GACH 1’s ED via emergency services by calling 911. The above violations had a direct or immediate relationship to the health, safety, or security of Resident 92.