Other·January 26, 2024

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 12/11/2023 at 8 a.m., the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a facility reported incident regarding quality of care and treatment. As a result of the investigation, the Department determined the facility failed to provide nursing services, adequate supervision to prevent accidents, and follow the internal policies and procedures necessary to prevent a fall for Resident 1, who had a history of multiple falls, by failing to: Ensure Resident 1's silent bed alarm system was plugged into the electrical outlet and functioning on 11/24/2023. This deficient practice resulted in Resident 1 falling on 11/24/23. Resident 1 got up from Resident 1's bed unnoticed/unaware by staff, fell from Resident 1's bed. Resident 1 required transfer to a General Acute Care Hospital (GACH) via Emergency Medical Services (EMS). Resident 1 was diagnosed with a fracture of the pelvis. A review of Resident 1's Admission Record indicated the facility admitted an 89-year-old male on 7/21/23 and was readmitted on 9/6/23 with diagnoses including dementia, unspecified fall, lack of coordination, abnormalities of gait, and difficulty in walking. A review of Resident 1’s physician order, dated 9/6/23, indicated for Resident 1 to have a silent bed alarm. A review of Resident 1's Care Plan (CP) for Actual Fall, dated 10/26/23, indicated Resident 1 had a fall on 10/24/23, and the nursing interventions including for Resident 1 to have a silent bed and chair alarms. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/1/23, indicated Resident 1 was severely impaired in cognitive skills. The MDS indicated Resident 1 required substantial/maximal assistance from staff for toileting and bathing, and Resident 1 required the use of bed and chair alarms. The MDS indicated Resident 1 had fallen at the facility three times (dates were not indicated). A review of Resident 1's CP titled, "Unwitnessed Fall on 11/20/23," dated 11/21/23, indicated nursing interventions including for Resident 1 to have a bed alarm and continue with fall safety precautions. A review of Resident 1's Progress Notes, indicated on 11/24/23 at 9 p.m. Registered Nurse (RN) 1 heard Resident 1 from the Nurses' Station and RN 1 rushed over to Resident 1's room and saw Resident 1 lying on the floor. The note indicated Resident 1 complained of pain in the hip and the head. The note indicated Emergency services were notified and the paramedics took Resident 1 to the GACH. A review of Resident 1's Post fall Assessment, dated 11/24/23, indicated Resident 1 fell on 11/24/23 at 9 p.m. The assessment indicated Resident 1's bed alarm did not sound at the Nurses' Station. A review of Resident 1's “Emergency Department (ED) Note Physician”, dated 11/24/23, indicated Resident 1 presented to the GACH emergency room on 11/24/23. The note indicated Resident 1 was brought in by paramedics via EMS from the facility due to right hip pain after sustaining a fall. The note indicated Resident 1 was admitted to the GACH for hip pain after a fall. A review of Resident 1's Computed Tomography (CT scan, a diagnostic imaging exam), dated 11/25/23, the CT result showed Resident 1 had fracture of the pelvis. A review of Resident 1's Consultation Notes, dated 11/25/23, indicated Resident 1 complained of pelvic pain. The note indicated the orthopedic surgeon diagnosed Resident 1 with fracture of the pelvis. The note indicated that Resident 1 would need surgery if he was not able to do physical therapy and walk with good pain control. During an interview on 12/11/23 at 9:42 a.m., the Director of Nursing (DON) stated Resident 1 fell in Resident 1's room on 11/24/23. The DON stated Resident 1 was sent to GACH after Resident 1 fell and would not be returning to the facility. During an interview on 12/11/23 at 10:16 a.m., Certified Nursing Assistant (CNA) 1 stated Resident 1 would try to get up on his own. CNA 1 stated Resident 1 had fallen multiple times while at the facility (unable to recall the dates). During an interview on 12/11/23 at 11:16 a.m. Licensed Vocational Nurse (LVN) 1 stated LVN 1 saw Resident 1 asleep in bed before Resident 1 fell on 11/24/23. LVN 1 stated Resident 1 had a bed alarm in place. LVN 1 stated the bed alarm would sound at the Nurses' Station when Resident 1 moved around. LVN 1 stated it was the facility practice for the Registered Nurse Supervisor to sit at the Nurses' Station to monitor the alarm system. During an interview on 12/11/23 at 1:50 p.m. RN 1 stated Resident 1 fell from Resident 1's bed on 11/24/23. RN 1 stated Resident 1's bed alarm did not sound at the Nurses' Station. RN 1 stated RN 1 did not think Resident 1 would have fallen if the alarm had sounded at the Nurses' Station. RN 1 stated RN 1 checked the alarm system after Resident 1 fell and discovered the alarm module/system at the Nurses' Station was not plugged into the electrical outlet. RN 1 stated the alarm module/system must be plugged into the electrical outlet for the alarms to sound at the Nurse's Station. RN 1 stated Resident 1 tried to get up [out of bed] often because Resident 1 was very confused. During a concurrent observation and interview on 12/12/23 at 12:28 p.m. with LVN 3, the facility's Wireless Central Monitoring Unit (alarm module) was observed sitting on top of the counter and located next to a computer in the Nurse's Station. LVN 3 stated the alarm module would sound when residents got up from their beds or wheelchairs. LVN 3 stated if the alarm module was not plugged into the electrical outlet, the alarm would not sound, and residents could fall and hurt themselves without staff noticing. During a concurrent interview and record review on 12/12/23 at 1:10 p.m. with the DON, the facility's policy, and procedure (P&P) titled, "Falls Management Program," dated 1/16/14 was reviewed. The P&P indicated, the primary goal of the program was to implement measures that will help reduce fall frequency and injury severity. The P&P indicated, interventions were predicated on residents needs and their unique intrinsic factors and directed toward the resident's fall risk indicators. The P&P indicated for potential or actual falls related to confusion, the facility should consider, the use of bed and chair alarms that the resident cannot remove. The DON stated the purpose of the facility's Falls Prevention Program was to identify residents who were at high risk of falling and assist in preventing falls by implementing safety interventions. The DON stated the purpose of the interventions was to prevent falls and mitigate injuries from falls. The DON stated for Resident 1, the facility had safety interventions including bed alarm and a wheelchair alarm. The DON stated the alarms alerted the staff when Resident 1 needed assistance and was getting out of bed or out of the wheelchair. The DON stated when the alarm module at the Nurses' Station was not plugged in the electrical outlet (was not working), then staff were not alerted when Resident 1 attempted to get up unassisted. The DON stated Resident 1 could fall if he got out of bed unassisted. During an interview on 12/13/23 at 10:00 a.m. with the Administrator (ADM) regarding how often nursing staff (in general) needed to check the bed/wheelchair alarm system for its functioning, the ADM stated the facility did not have a P&P for bed/wheelchair alarms. As a result of the investigation, the Department determined the facility failed to provide nursing services to prevent a fall for Resident 1, who had a history of multiple falls, by failing to: Ensure Resident 1's silent bed alarm system was plugged into the electrical outlet. As a result of this failure, on 11/24/23, Resident 1 got up from Resident 1's bed unnoticed/unaware by staff, fell from Resident 1's bed and sustained pelvis fracture. Resident 1 required transfer to a GACH via EMS. The above violations jointly, separately, or in any combination, 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.