Health inspection·September 19, 2024

F689 Code of Federal Regulations, Title 42, Section 483.25 (d) Accidents. The facility must ensure that – §483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. 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. California Code of Regulations, Title 22, Section 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 8/7/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding quality of care and safety/falls. CDPH determined the facility failed to provide care and services to prevent a fall for Resident 1 who was assessed as high risk for fall by failing to: 1. Implement the interventions documented in Resident 1’s Minimum Data Set (MDS), which indicated Resident 1 needed supervision or touching cues/contact guard assistance, and supervision while walking in the resident’s room and using the bathroom. 2. Follow Resident 1's care plan interventions such as providing supervision to Resident 1 during toilet use, transfer, walking in the room as indicated in Resident 1's Care Plans titled, "Activities of Daily Living " and "Fall Risk." As a result of the investigation, on 8/3/2024, at or around 9 AM, Resident 1 fell in the bathroom, experienced pain on the left shoulder, and was transferred to General Acute Care Hospital (GACH) 1 via Emergency Transportation for further evaluation. At GACH 1, Resident 1 was found to have a left humeral (upper arm bone) neck impacted fracture (occurs when the broken ends of the bone are jammed together by force of the injury) and the greater tuberosity (bony bump at top of humerus) had mildly displaced fracture fragment (occurs when a broken bone moves enough to create a gap around the fracture, and the pieces of the bone are no longer aligned). A review of Resident 1's Admission Record indicated the facility admitted Resident 1, a 76-year-old female on 5/27/2021 and readmitted on 5/16/2022, with diagnoses that included type 2 diabetes mellitus with diabetic chronic kidney disease, dementia, and epilepsy. A review of Resident 1's Fall Risk Assessment dated 11/27/2023 indicated Resident 1 was assessed as high risk for falls due to intermittent confusion, currently taking three - four medications and had one - two predisposing disease condition. A review of Resident 1's MDS dated 5/21/2024, indicated Resident 1 had moderately impaired cognition. The MDS indicated Resident 1 required supervision or touching assistance for toilet transfer and when walking at least 10 feet in a room, corridor, or similar space. A review of Resident 1's Care Plan titled, "Fall Risk," dated 5/21/2024 indicated Resident 1 was at risk for fall related to depression secondary to dementia, use of anti-depressants and poor safety awareness. The CP interventions included for staff to encourage Resident 1 to call for assistance as needed, assist Resident 1's Activities of Daily Living (ADL) as needed, and conduct frequent visual checks of Resident 1. A review of Resident 1's Care Plan titled, "ADL," dated 5/21/2024 indicated Resident 1 had ADL deficit related to dementia and depression. The Care Plan indicated Resident 1 required supervision with toilet use, transfer, walking in the room and walking in the corridor. The Care Plan interventions included for staff to assist Resident 1 with ADL as needed and to monitor Resident 1 for ADL needs. A review of Resident 1's History and Physical Examination dated 8/1/2024 indicated Resident 1 did not have the capacity to understand and make decisions due to dementia. A review of Resident 1's Situation-Background-Assessment-Recommendation Summary (SBAR) for Providers dated 8/3/2024 and timed at 9:30 AM indicated on 8/3/2024, the Charge Nurse/Registered Nurse 1 (RN1) was alerted by a scream and found Resident 1 lying on the floor. Resident 1 complained of left shoulder pain. The SBAR indicated Resident 1 refused to get up due to shoulder pain. The SBAR indicated Resident 1 did not use the call light for assistance. The SBAR indicated Resident 1's Primary Care Provider/Medical Doctor (MD) 1 recommended sending Resident 1 to GACH 1. The SBAR indicated Resident 1 was transferred to GACH 1 on 8/3/2024 at 9:30 AM via emergency services. A review of Resident 1's Physician Order, dated 8/3/2024, indicated to send Resident 1 to GACH 1 for status post fall on 8/3/2024. A review of Resident 1's GACH 1 Radiology Report of the left humerus dated 8/3/2024 at 10:08 AM indicated Resident 1 sustained a left humeral neck impacted fracture, the greater tuberosity had mildly displaced fracture fragment, and there was diffused osteopenia. During an interview on 8/7/2024 at 1:30 PM, RN 1 stated Resident 1 had an unwitnessed fall on 8/3/2024 at "around" 9 AM. RN 1 stated RN 1 found Resident 1 on the bathroom floor after Resident 1 walked to the bathroom unsupervised. RN 1 stated, Resident 1 could walk independently and did not need supervision with walking. RN 1 stated Resident 1 only needed redirection "at times" due to confusion from dementia. During a concurrent observation of Resident 1 in Resident 1's room and interview with Resident 1 on 8/7/2024 at 3:37 PM, Resident 1 was awake, lying in bed, using a blue arm sling on the left arm. Upon interview, Resident 1 stated her left arm was injured from playing football with doctors. Resident 1 stated she had no concerns. Resident 1 did not answer additional questions. During an interview on 8/7/2024 at 3:49 PM, LVN 2 stated LVN 2 took care of Resident 1 before the fall on 8/3/2024. LVN 2 stated Resident 1 would ambulate to the bathroom independently without the need for supervision. LVN 2 stated LVN 2 was unaware Resident 1 required supervision during ADL. During a concurrent interview and record review on 8/9/2024 at 9:54 AM with MDS Nurse 1 (MDS 1), Resident 1's MDS dated 5/21/2024 was reviewed. The MDS under Section "GG – Functional Abilities and Goals" indicated Resident 1 needed supervision or touching assistance for ambulation and supervision for toileting transfer. MDS 1 stated, based on the MDS (dated 5/21/2024), Resident 1 required a staff member to be present when Resident 1 walked or used the bathroom for safety. MDS 1 stated Resident 1's fall could have been prevented if staff supervision had been provided. During an interview on 8/9/2024 at 10:46 AM, MDS Nurse 2 (MDS 2), stated, MDS 2 completed Resident 1's MDS dated 5/21/2024. MDS 2 stated when Resident 1 walked to the restroom, a staff member needed to be present to watch and supervise Resident 1. MDS 2 stated, supervision meant a staff member needed to be with Resident 1 and provided "constant visual checks." During an interview on 8/9/2024 at 1:16 PM, CNA 1 stated she was the assigned CNA for Resident 1 during the fall on 8/3/2024. CNA 1 stated Resident 1 did not require assistance or supervision to walk to the bathroom/restroom or inside the room. CNA 1 stated when Resident 1 fell, CNA 1 was in the dining room monitoring other residents. During an interview on 8/9/2024 at 2:27 PM, the Lead Licensed Vocational Nurse (Lead LVN), stated Resident 1 was not always alert and "would be confused at times". Lead LVN stated Resident 1 needed supervision in the room and bathroom. Lead LVN stated when Resident 1's MDS assessments and care plans interventions for fall prevention and ADLs were not followed, it resulted in serious harm and injury to Resident 1. A review of the facility's Policy and Procedure (P&P) titled, "Falls and Fall Risk, Managing," revised 12/2007 indicated "based on previous evaluations and current data, the staff identifies interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling." A review of the facility's P&P titled, "Safety and Supervision of Residents," revised 7/2017, indicated "resident safety, supervision, and assistance to prevent accidents were facility-wide priorities." The P&P indicated, "the care team targeted interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices." The P&P indicated, "implementing interventions to reduce accident risks and hazards included communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, and ensuring that interventions were implemented." The P&P indicated, "resident supervision was a core component of the systems approach to safety. The type and frequency of supervision may vary among residents and over time for the same residents." A review of the facility's P&P titled, "Care Plans - Comprehensive," revised 9/2010 indicated "for policy implementation, the facility develops and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain." A review of the facility's P&P titled, "ADL Supporting," revised 3/2018 indicated "appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility and elimination." The P&P indicated, "a resident's ability to perform ADLs will be measured using clinical tools, including the MDS." The facility failed to provide care and services to prevent a fall for Resident 1 who was assessed as high risk for fall by failing to: 1. Implement the interventions documented in Resident 1’s MDS, which indicated that Resident 1 needed supervision or touching cues/contact guard assistance, and supervision to while walking in the resident’s room and using the bathroom. 2. Follow Resident 1's care plan interventions such as providing supervision to Resident 1 during toilet use, transfer, walking in the room as indicated in Resident 1's Care Plans titled, "Activities of Daily Living " and "Fall Risk." As a result of the investigation, on 8/3/2024, at or around 9 AM, Resident 1 fell in the bathroom, experienced pain on the left shoulder, and was transferred to GACH 1 via Emergency Transportation for further evaluation. At GACH 1, Resident 1 was found to have a left humeral neck impacted fracture and the greater tuberosity had mildly displaced fracture fragment. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.