Health inspection·April 18, 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 72301. Patient Care Policies and Procedures. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated 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. On 3/11/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding resident safety and falls. As a result of the investigation, the CDPH determined the facility failed to implement the physician (MD) order dated 1/7/2024 to place bilateral floor mats on each side of the bed and a silent bed/chair alarm for Resident 1. These violations resulted in Resident 1 sustaining a fall resulting in a fracture of the right femoral neck of the hip. Resident 1 was transferred and admitted to the General Acute Care Hospital (GACH) on 2/24/2024. Resident 1 underwent a right hip hemiarthroplasty surgery on 2/26/2024 and discharged from GACH on 2/27/2024. A review of Resident 1's Admission Record (AR) indicated, the facility admitted Resident 1, a 77-year-old female, on 11/7/2023, and readmitted Resident 1 on 1/7/2024, with diagnoses that included muscle weakness, falls, abnormalities of gait, and mobility. A review of Resident 1's Order Summary Report (OSR) for February 2024 indicated, Resident 1 had an active MD order initiated on 1/7/2024, to place floor mats on each side of Resident 1's bed to prevent injury during a fall and a silent bed/chair alarm. A review of Resident 1's Fall Risk Evaluation (FRE) dated 1/8/2024, timed at 10:44 PM, indicated Resident 1 had a fall risk score of seven out of 10 due to Resident 1's history of 1-2 falls in the past 3 months, had balance problem while standing, and required the use of assistive devices such as a walker. A review of Resident 1's untitled Care Plan (CP) revised on 1/15/2024, indicated Resident 1 was at risk for falls related to gait/balance problems and had a history of falls. The CP indicated the goal was for Resident 1 to not sustain a serious injury. The approached interventions were for staff to anticipate and meet Resident 1's needs. A review of Resident 1's Minimum Data Set (MDS, a standardized comprehensive assessment and care screening tool) dated 1/25/2024, indicated Resident 1's cognitive abilities were intact. The MDS indicated Resident 1 required the use of a walker and required partial assistance with indoor ambulation. The MDS indicated Resident 1 required substantial assistance with toileting hygiene, and Resident 1 used a bed alarm, chair alarm, and floor mats daily. A review Resident 1's Post Fall Assessment (PFA) dated 2/24/2024, timed at 1:06 AM, indicated Resident 1's Physician (MD) 1 was notified regarding Resident 1's fall. A review of Resident 1's Interdisciplinary Team Conference (IDT) Record dated 2/26/2024, timed at 10:12 AM, indicated on 2/24/2024, at 12 AM, Resident 1 was yelling for help and Certified Nursing Assistant (CNA) 1 found Resident 1 on the floor. The IDT record indicated Resident 1 complained of pain (unrated) in the right leg when staff tried to assist Resident 1 back to bed. A review of Resident 1's Radiology Report dated 2/24/2024, timed at 11:15 AM, indicated Resident 1 had an acute right femoral neck fracture with mild displacement. A review of Resident 1's Situation, Background, Assessment, Recommendation Communication Form (SBAR) dated 2/24/2024, indicated Resident 1 was transferred to a GACH on 2/24/2024 at 1 PM after the X-ray result indicated an acute right femoral neck fracture. A review of Resident 1's GACH AR dated 2/24/2024, indicated Resident 1 was admitted to the GACH on 2/24/2024 at 8:16 PM. A review of Resident 1's Orthopedic Surgery Progress Note dated 2/27/2024, timed at 7:32 AM, indicated Resident 1 was post-operative day 1 for a right hip hemiarthroplasty. A review of Resident 1's Facility Transfer Checklist dated 2/27/2024, indicated Resident 1 was transferred from the GACH back to the facility on 2/27/2024 at 7 PM. During a concurrent observation of Resident 1 in Resident 1's room and an interview with Resident 1 on 3/11/2024 at 9:55 AM, Resident 1 was lying in bed with both legs elevated on a pillow. Resident 1 stated on 2/24/2024 (unable to recall exact time) Resident 1 got up and used Resident 1's front wheeled walker to use the restroom. Resident 1 stated Resident 1 lost her footing, fell straight onto the floor, and broke Resident 1's hip. Resident 1 stated Resident 1 was alone in the room during the fall. Resident 1 stated Resident 1 was calling for help while on the floor when staff arrived. Resident 1 stated there were no floor mats around the bed and no bed alarm was present when Resident 1 fell on 2/24/2024. Resident 1 stated, "I feel sad about the fall...now I have to start all over again." During an interview on 3/11/2024 at 11:42 AM, Licensed Vocational Nurse (LVN) 1 stated on 2/24/2024 at "around" 12 AM CNA 1 reported to her that Resident 1 was found on the floor. LVN 1 stated she notified MD 1 of Resident 1's fall and Resident 1's complaint of pain (unrated) in the right leg. LVN 1 stated MD 1 ordered an X-ray of the hips and Resident 1 was transferred to the GACH after the X-ray result indicated Resident 1 had a right hip fracture. During an interview on 3/11/2024 at 11:44 AM, CNA 1 stated on 2/24/2024 she heard yelling from Resident 1's room in the middle of the night (midnight) and she found Resident 1 sitting on the floor. CNA 1 stated Resident 1 was shaken up. During an interview on 3/11/2024 at 1:03 PM, CNA 1 stated she did not hear a bed alarm sound when Resident 1 was found sitting on the bare floor. CNA 1 stated she heard Resident 1 yelling for help and Resident 1 called out Resident 1's room number. During an interview on 3/11/2024 at 2:22 PM, LVN 1 stated there were no floor mats next to Resident 1's bed and no bed alarm was found on Resident 1's bed when Resident 1 fell on 2/24/2024. During a concurrent interview and record review on 3/11/2024 at 2:57 PM, Registered Nurse (RN) 1 reviewed Resident 1's OSR dated 1/7/2024. The OSR indicated Resident 1 had an active MD order dated 1/7/2024 for placement of floor mats on each side of Resident 1's bed to prevent injury and a silent bed/chair alarm. RN 1 stated she did not realize both orders (floor mats and silent bed/chair alarm) were active. RN 1 stated from 1/7/2024 to 2/27/2024 the physician ordered floor mats and silent bed/chair alarm but the floor mats, and silent bed alarm were not in place for Resident 1. A review of the facility's policy and procedure (P&P) titled, "Silent Pad Alarms," dated 1/4/2024, indicated the pad alarm was a pressure pad device ordered by a physician that emitted an audible alert at a remote monitoring unit when triggered by movement. The P&P indicated the facility ensured that silent bed and wheelchair pad alarms were in place, in proper working order, and activated the monitoring unit at the nurses’ desk. A review of the facility's undated P&P titled, "Fall Management Program," indicated falls and related injuries were the most frequent adverse occurrence in Skilled Nursing Facilities. The P&P indicated there were many interventions that can help prevent injury and may also reduce the number of falls. The P&P indicated nursing staff must have the knowledge and skill to manage falls and reduce injury. The facility failed to implement the MD order dated 1/7/2024 to place bilateral floor mats on each side of the bed and a silent bed/chair alarm for Resident 1. These violations resulted in Resident 1 sustaining a fall resulting in a fracture of the right femoral neck of the hip. Resident 1 was transferred and admitted to the GACH on 2/24/2024. Resident 1 underwent a right hip hemiarthroplasty on 2/26/2024 and discharged from GACH on 2/27/2024. The above violation 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.