Health inspection·May 28, 2024

F744, 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. Title 22, Section 72523 (a) 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. Title 22, Section 72311 Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient’s needs with input, as necessary, from health professionals involved in the care of the patient. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient’s condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 4/15/2024 at 8:50 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 Resident 1 sustaining a fall at the facility. As a result of the investigation, the Department determined the facility failed to ensure Resident 1 who had a diagnosis of dementia, was assessed at high risk for falls, elopement, and received care and services to mitigate risk of a fall by failing to: 1. Implement Resident 1's Care Plan (CP) interventions related to repetitive wandering behavior and attempts to leave the facility unattended. 2. Update Resident 1's CP interventions titled, "Cognitive Loss/Dementia," and "Activities," when Certified Nurse Assistant (CNA 2) recognized that Resident 1 needed a one-to-one supervision (one staff supervising one resident), and when the Social Services Director (SSD) recognized that Resident 1 made frequent elopement attempts and stated the facility was fearful that Resident 1 might leave the facility without staff noticing. As a result of these failures, on 3/29/2024, Resident 1 fell while running toward the front lobby to leave the facility. Resident 1 sustained a left distal radius fracture and right humerus fracture. The facility transferred Resident 1 to the General Acute Care Hospital (GACH) where Resident 1 received a cast on Resident 1's left arm and a sling on Resident 1's right arm. A review of Resident 1's "Admission Record," (AR) indicated the facility admitted Resident 1, a 79-year-old female to the facility on 2/6/2024 with diagnoses that included dementia, muscle weakness, and encephalopathy (brain disease that alters brain function or structure). A review of Resident 1's "Falls Risk Assessment," (FA) dated 2/6/2024, indicated Resident 1 had a total score of 11 (a score of 10 or more indicated high risk for falls). The FA indicated Resident 1 was a high risk for falls related to Resident 1’s gait and balance problems, needed assistant from staff with toileting and received multiple medications. A review of Resident 1's "Minimum Data Set," (MDS, a resident assessment and care screening tool) dated 2/12/2024, indicated Resident 1 was moderately impaired with cognitive skills. The MDS indicated Resident 1 required substantial/ maximal assistance with eating and personal hygiene. A review of Resident 1's CP, titled "Cognitive Loss/Dementia," due to Resident 1 had impaired cognition related to Dementia which resulted in repetitive wandering, dated 3/8/2024, indicated Resident 1 walked aimlessly along hallways towards the front lobby, unassisted and without sense of direction. The CP's goal indicated Resident 1's safety would be maintained daily, and Resident 1 would fulfill the need to walk about in safety without distracting others. The CP's intervention indicated for staff to provide Resident 1 regular opportunities to go outdoors with supervision and assist the resident as needed. A review of Resident 1's "Elopement Risk Assessment," (EA) dated 3/11/2024, indicated Resident 1's total score was a 29 (a score of 10 or more indicated at risk for elopement). The EA indicated Resident 1 was at high risk for elopement due to Resident 1’s multiple attempts to leave the facility (elope), and because Resident 1 stated a desire to get out of the facility but did not know where to go. A review of Resident 1's CP titled, "Activities," related to Resident 1’s attempt to leave the facility unattended, dated 3/25/2024, indicated a goal that Resident 1 would not try to leave the facility unattended. The CP's intervention indicated Resident 1 would walk two to three times a week. A review of Resident 1's Interdisciplinary (IDT) Notes, dated 3/29/2024, indicated Resident 1 was sent to the GACH after sustaining a fall and the hospital Registered Nurse (RN) reported to the facility that Resident 1 had a left distal radius fracture and right humerus fracture. The IDT notes indicated Resident 1 returned to the facility the same day (3/29/24) with a sling on Resident 1's right arm and cast on Resident 1's left arm. A review of Resident 1's Fall Situation, Background, Assessment and Recommendation (SBAR,), dated 3/30/2024, timed at 8:08 a.m., late entry for 3/29/2024, indicated Resident 1 suffered a witnessed fall to the floor. The SBAR indicated Resident 1 was at the facility, found flat on the resident's back, and Resident 1 was transferred to the emergency room (GACH) for further evaluation. The SBAR indicated Resident 1 was taken to the nurse's station for close monitoring, and Resident 1 kept getting up and going to other resident's rooms. The SBAR indicated re-direction did not work and Resident 1 was seen by staff running down the main hall around 9:30 a.m. and at 9:35 a.m., Resident 1 had an unwitnessed fall. The SBAR indicated Resident 1 had a knot on top of Resident 1's right temple and Resident 1 mentioned she had pain (unrated) on the right shoulder shooting down to Resident 1's arm. The SBAR indicated Resident 1 had swelling on the right arm and right wrist. During a concurrent observation and interview on 4/15/2024 at 9:30 a.m., Resident 1 had a sling on the right arm and a cast on the left wrist/arm. Resident 1 could not remember the day, month, or year. Resident 1 was confused and stated [the day of the fall (3/29/24)] Resident 1 was running with Resident 1's daughter at the park and Resident 1 fell. During an interview on 4/15/2024 at 10:18 a.m. Licensed Vocational Nurse (LVN) 1 stated the interventions implemented for Resident 1 included frequent visual checks every one to two hours due to Resident 1's high risk for elopement and falls. During an interview on 4/15/2024 at 10:27 a.m. the Activities Coordinator (AC), stated prior to Resident 1's fall (3/29/2024), Resident 1 was always saying, "I have to go, I have to go," and tried to leave the facility. The AC stated, before the fall, Resident 1 used to walk up and down the hallways all the time. During an interview on 4/15/2024 at 11:48 a.m. Certified Nursing Assistant (CNA) 2, stated prior to Resident 1's fall (3/29/24), Resident 1 was known to be very confused and known to wander. CNA 2 stated despite attempts at keeping Resident 1 near the nursing station, it was difficult to monitor (watch) Resident 1 when the staff were busy with other tasks. CNA 2 stated the morning when Resident 1 fell, Resident 1 had verbalized wanting to leave the facility and tried wandering toward the front lobby. CNA 2 stated no staff was specifically designated to watch Resident 1 when the Resident 1 was at the nursing station. CNA 2 stated a staff should be at the nursing station watching the resident. CNA 2 stated Resident 1 wandered frequently, and it ultimately led to Resident 1 falling and sustaining a fracture on Resident 1's arm. CNA 2 stated CNA 2 reported to a charge nurse (unable to identify to whom or when it was reported) that Resident 1 required one to one staff monitoring because Resident 1 had unpredictable behavior when some days, Resident 1 sat and did nothing and other days, Resident 1 walked around the facility and tried to leave. During an interview on 4/15/2024 at 2:36 p.m. the Director of Nursing (DON) stated on the day Resident 1 fell (3/29/2024, unable to recall the time), Resident 1 was sitting down in the hallway with other residents. The DON stated a resident (unidentified) yelled out, "she's running," and CNA 3 came around the nurse's station and saw Resident 1 running down the hall toward the front lobby and CNA 3 started running after Resident 1. The DON stated she saw the Administrator (ADM) get up, run to the front lobby and she followed the ADM. The DON stated, she saw Resident 1 was on the floor of the front lobby, rolled on Resident 1's back. The DON stated interventions that were implemented for Resident 1 who was a high fall risk included frequent rounds (visual checks). The DON stated frequent rounds meant monitoring Resident 1 more frequently than every two hours. The DON stated prior to Resident 1's fall on 3/29/2024, Resident 1 was taken outside for walks only when someone had time because this [activity] was not a regular part of Resident 1's care. During an interview on 4/15/2024 at 4:33 p.m. the Social Services Director (SSD) stated the SSD had contacted Resident 1's family prior to Resident 1's fall (2/26/24) due to the SSD recognized Resident 1 made frequent elopement attempts and stated the facility was fearful Resident 1 might leave the facility without staff noticing. During a concurrent interview and review of Resident 1’s CPs on 4/15/2024 at 4:50 p.m. with the DON, Resident 1's CP titled, "Cognitive Loss/Dementia,” dated 3/8/2024 and CP titled, "Activities," dated 3/25/24 were reviewed. The DON stated there were no documentations that indicated Resident 1's CP interventions such as to provide Resident 1 with opportunities to go outdoor and walk two to three times per week were implemented by facility's staff for Resident 1. A review of the facility's policy and procedure (P&P) titled, "Safety and Supervision of Residents," dated 7/2017 indicated "implementing interventions to reduce accident risks and hazards shall include ensuring that the interventions are implemented and documented." A review of the facility's P&P titled, "Dementia - Clinical Protocol," dated 11/2018, indicated "the IDT will identify a resident-centered care plan to maximize remaining function and quality of life, direct care staff will support the resident in initiating and completing activities and tasks of daily living." The P&P indicated "the staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician, the IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia." The P&P indicated "the IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise." As a result of the investigation, the Department determined the facility failed to ensure Resident 1 who had a diagnosis of dementia, was assessed at high risk for falls, and elopement received care and services to prevent a fall by failing to: 1. Implement Resident 1's CP interventions related to repetitive wandering behavior and attempts to leave the facility unattended. 2. Update Resident 1's CP interventions titled, "Cognitive Loss/Dementia," and "Activities," when CNA 2 recognized that Resident 1 needed a one-to-one supervision, and when the SSD recognized that Resident 1 made frequent elopement attempts and stated the facility was fearful that Resident 1 might leave the facility without staff noticing. As a result of these failures, on 3/29/2024, Resident 1 fell while running toward the front lobby and attempting to leave the facility. Resident 1 sustained a left distal radius fracture and right humerus fracture. The facility transferred Resident 1 to the GACH where Resident 1 received a cast on Resident 1's left arm and a sling on Resident 1's right arm. 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.