Health inspection·December 12, 2024

The following reflects the findings of the California Department of Public Health during the investigation of Facility Reported Incident number CA00927296. Representing the Department. Class A Citation was written. Free of Accident Hazards/Supervision/Devices §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR § 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. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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. 22 CR §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 achieved. On 11/8/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a resident's fall in the facility. The facility (Skilled Nursing Facility-SNF) failed to provide a safe environment to prevent Resident 1 from falling. The facility failed to ensure: 1. Maintenance Worker (MW) 1 notified Resident 1 and the resident's roommate/s that the floor was wet after mopping Resident 1's room with a wet mop. 2. MW 1 placed a "wet floor" sign on the floor in Resident 1's room to alert Resident 1 that the floor was wet. 3. MW 1 supervised/monitored the wet floor and re-directed Resident 1 to avoid the wet floor. As a result, on 10/25/2024, Resident 1 slipped and fell, and suffered severe pain of 10 out of 10 (10/10- a numerical pain scale assessment tool where zero is no pain and 10 is severe pain) to the left knee treated with opioids (a class of drugs used to treat moderate to severe pain). Resident 1 was transferred to General Acute Care Hospital (GACH) 2 via 911 (a telephone number used to reach emergency medical, fire, and police services). GACH 2 diagnosed Resident 1 with a left femur fracture (broken thigh bone). On 10/29/2024, GACH 2 performed open reduction and internal fixation (ORIF - a type of surgery used to stabilize and repair broken bones, using screws, plates, sutures, or rods to hold the bone together and for healing) on Resident 1. A review of Resident 1's GACH 1 History & Physical (H&P), dated 10/6/2024, the H&P indicated Resident 1 presented to GACH 1 Emergency Department (ED - The department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) after having a mechanical fall at home (prior to admission to the facility. The H&P further indicated the resident was attempting to get out of bed, reached for a walker, tripped, and fell onto the left wrist with no injuries. A review of Resident 1's Admission Record, the Admission Record indicated the SNF originally admitted Resident 1, a 71 year old female, on 10/11/2024 and re-admitted the resident on 10/31/2024. The Admission Record indicated Resident 1's diagnoses included left femur fracture, left eye blindness, history of falling and history of healed traumatic fracture (occurs when significant or extreme force is applied to a bone). A review of Resident 1's Admission Assessment, dated 10/11/2024, the Admission Assessment indicated Resident 1 was admitted to the facility from GACH 1. The Admission Assessment further indicated Resident 1 was alert and oriented times four (person, place, time/date, and situation) with period of forgetfulness. The admission assessment indicated the resident was continent (the ability to voluntarily control) of bladder and bowel, generalized weakness, ambulated with assist, and was admitted for physical therapy (PT - treatment that uses physical activities and exercises to help improve movement, relieve pain, and strengthen muscles) and occupational therapy (OT -therapy that helps improve one's ability to perform everyday tasks, like eating and drinking). A review of Resident 1's Fall Risk Assessment dated 10/11/2024, the Fall Risk Assessment indicated Resident 1 scored 16 for risk for fall (the resident was at low risk for falls). The fall risk assessment indicated a score of 18 or more is high risk for falls. A review of Resident 1's Admission Rehabilitation Screening, dated 10/12/2024, the Admission Rehabilitation Screening indicated Resident 1 did not have any impairment (a significant difference or absence in a person's body structure or function or mental functioning) in functional range of motion (ROM -how far you can move a joint in any direction) to the lower extremities (hip, knee, ankle, and foot). A review of Resident 1's care plan titled, "At Risk for Falls/Injury," initiated on 10/14/2024, indicated Resident 1 was at risk for falls due to general weakness, history of falls, history of left ankle fracture, osteopenia (low bone density), and muscle weakness. The care plan goal was to reduce the risk of falls and injury to Resident 1. The care plan interventions indicated staff would visibly observe the resident frequently and provide resident with a safe and clutter-free environment. A review of Resident 1's Admission Minimum Data Set (MDS - a resident assessment tool), dated 10/15/2024, indicated Resident 1's cognition (ability to think, understand, and reason) was intact. The MDS also indicated Resident 1's vision was impaired, and the resident required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, showering, dressing, and personal hygiene. The MDS further indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with walking 10 feet. The MDS also indicated Resident 1 used a walker for mobility. A review of Resident 1's Change of Condition (COC- clinically important deviation from a patient's baseline) form, dated 10/25/2024 timed at 9:45 AM, the COC indicated Resident 1 was observed lying on the floor on the left side by housekeeping staff and the charge nurse. The COC also indicated the resident reported 6/10 pain level to the left leg and Resident 1 was transferred to a General Acute Care Hospital 2 (GACH 2). A review of Resident 1's Physician Order, dated 10/25/2024 timed at 10 AM, the Physician order indicated to transfer Resident 1 to GACH 2 via 911 for evaluation after a fall onto her left side with left leg pain. A review of Resident 1's GACH 2 Note, dated 10/25/24, the note indicated Resident 1 came into the ED after a fall onto the resident's left side and suffered severe knee pain. The ED notes indicated that from 10:44 AM to 3:03 PM, Resident 1 received fentanyl (an opioid pain medication) 50 micrograms (mcg-unit of measurement) intravenously (IV -inside a vein), Dilaudid (an opioid pain medication) 0.5 milligrams (mg-unit of measurement) IV, Toradol (a medication is used to treat moderately severe pain and inflammation [A normal part of the body's response to injury or infection]) 30 mg IV, and Morphine (an opioid pain medication) 4 mg IV for pain control. A review of Resident 1's GACH 2 H&P, dated 10/25/2024 timed at 10:55 AM, indicated Resident 1was transferred to GACH 2 ED after a ground level fall. GACH 2 H&P also indicated Resident 1 stated while at the facility, she got up to go to the bathroom, that someone had mopped the floor, and that Resident 1 did not realize that the floor was wet. GACH 2 H&P notes indicated Resident 1 slipped and crashed onto her left knee. GACH 2 H&P indicated Resident 1 experienced 9/10 pain to the left knee during left knee on palpation (touch). GACH 2 H&P further indicated the plan was for Resident 1 to have ORIF. A review of the Resident 1's GACH 2 Pelvis X-ray results, dated 10/25/2024, indicated Resident 1 had a left femur fracture. A review of Resident 1's GACH 2 Orthopedic (branch of medicine that focuses on the diagnosis and treatment of bones, muscles, and ligaments) Surgery Trauma (severe physical injury or damage)/General Consult Note, dated 10/26/2024, indicated, Resident 1 presented to GACH 2 with pain (pain level not indicated) in the left knee and thigh after falling to the ground on her the way to the bathroom at the facility earlier that morning. The orthopedic surgery trauma/general consult note indicated Resident 1 noted immediate pain to the left knee and thigh that was worse with movement. Resident 1 reported that the floor was wet, which caused the resident to slip and fall. The physician strongly recommended an ORIF surgery to treat the resident's left femur fracture. A review of Resident 1's GACH 2 Operative Note, dated 10/31/2024, GACH 2 Operative Note indicated Resident 1 had an ORIF surgery on 10/29/2024 to treat the resident's left femoral fracture. During an interview on 11/8/2024 at 8:38 AM, Resident 1 stated, "a couple of weeks ago, while walking out of the bathroom, I slipped because the floor was wet." Resident 1 stated no one notified Resident 1 that the floor was wet prior to entering the bathroom, that there was no wet floor sign on the floor, and that Resident 1 fell onto her knees and screamed in pain. Resident 1 stated the pain level at the time of the fall was 10/10. Resident 1 stated she was transferred to a GACH where she was told that her left thigh bone was broken. Resident 1 stated that currently, her pain level was 8/10 and that she could no longer ambulate and "I just stay in bed." During an interview on 11/8/2024 at 12:15 PM, Resident 2 (who is cognitively intact based on MDS dated 10/15/2024 and was Resident 1's roommate) stated Resident 2 did not see Resident 1 fall but "heard a loud boom" and heard Resident 1 scream out. Resident 2 stated the medication nurse left about five minutes prior to the fall because MW 1 was sweeping and mopping Resident 1's room with a wet mop. Resident 2 further stated MW 1 never notified Resident 2 that the floor was wet, and that Resident 2 did not see a "wet floor " sign posted/placed on the floor. During an interview on 11/8/2024 at 1:17 PM, the Director of Rehabilitation (DOR) stated prior to the fall on 10/25/2024, Resident 1 was able to walk with maximum assistance. The DOR stated maintenance usually places a wet floor sign down once they have mopped. The DOR stated that a wet floor is a fall risk for any person. The DOR further stated after the fall, Resident 1 was unable to walk because the resident is in a lot of pain. The DOR stated, "we premedicate (the administration of medication before a treatment or procedure to prepare the patient) her for pain before her therapy sessions." During an interview on 11/12/2024 at 9:54 AM, Treatment Nurse 1 stated staff are monitoring Resident 1's incision for swelling. During a concurrent observation, Resident 1 was lying in bed with head of bed up. Resident 1 was observed in a full leg immobilizing brace (a device that completely restricts movement in the leg) on her left leg with straps securing the brace closed from her upper thigh to her ankle. Resident 1 has 3 incisions along her lateral (situated at or on the side) left leg that is closed with Stryker's zip skin closure system (a non-invasive skin closure device). During an interview on 11/12/2024 at 12:14 PM, Licensed Vocational Nurse 1 (LVN 1) stated on 10/25/2024, LVN 1 exited Resident 1's room because MW 1 was sweeping the floor. LVN 1 stated MW 1 came out of Resident 1's room and stated, "your resident [Resident 1] is on the floor. LVN 1 stated LVN 1 found Resident 1 on floor and that the resident crying out in pain. LVN 1 stated Resident 1told LVN 1 that the floor was wet. LVN 1 stated LVN 1 could tell the floor was wet and that there was no "Wet Floor" sign posted. LVN 1 further stated, "maintenance must make residents and staff aware that the floor is wet. Maintenance is to tell us verbally and should place a sign on the floor." LVN 1 stated she asked MW 1, "where was your sign [wet floor sign]," and then MW 1 placed a sign down. LVN 1 further stated, MW 1, "should have placed a sign down and let the residents know the floor was wet because a wet floor is a fall hazard and that is just what happened." LVN 1 also stated Resident 1 was a fall risk because the resident already had problems with her leg before admission to the facility. During a phone interview on 11/12/2024 at 12:45 PM, MW 1 stated he started mopping Resident 1's room with a wet mop after Resident 1 went to the restroom and exited/left Resident 1's room after mopping the floor. MW 1 stated that Resident 1 fell after coming came out of the bathroom. MW 1 stated MW 1 did not tell Resident 1 or Resident 2 that the floor was wet, and MW 1 did not put down a wet floor sign and "I should have place the wet floor sign" MW 1 stated MW 1 knew that the floor was wet and a fall hazard. MW 1 stated MW 1 forgot to place the wet floor sign. MW 1 stated this was the first time in 37 years, MW 1 forgot to place the sign. MW1 also stated, "I feel really bad because she was really yelling in pain." During an interview on 11/12/2024 at 2:34 PM, the Administrator (ADM) stated, "I would say the wet floor promoted or assisted the fall." The ADM further stated ADM went to Resident 1's room at the time of the fall and observed that the floor was wet. During a review of the facility's policy and procedures (P&P) titled, "Falls and Fall Risk, Managing," revised 3/23, the P&P indicated "staff will identify 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." The P&P further indicated an environmental factor that contribute to the risk of falls included wet floors. During a review of the facility's P&P titled, "Housekeeping Cleaning Sanitizing, Disinfecting, & Sterilizing," undated, the P&P indicated "floor cleaning procedures are as follows: a. Vacuum or sweep floor thoroughly, paying close attention to corners and areas near or under furniture. b. Using a container of water with a detergent dash germicide added, wet mop one side of corridor or floor at a time, making sure that the first side is dry before mopping the other side. c. Obtain a fresh solution when water is dirty. d. Post a warning sign "WET FLOOR" on both ends of wet areas. The facility failed to provide a safe environment to prevent Resident 1 from falling The facility failed to ensure: 1. MW 1 notified Resident 1 and the resident's roommate/s that the floor was wet after mopping Resident 1's room with a wet mop. 2. MW 1 placed a "wet floor" sign on the floor in Resident 1's room to alert Resident 1 that the floor was wet. 3. MW 1 supervised/monitored the wet floor and re-directed Resident 1 to avoid the wet floor. As a result, on 10/25/2024, Resident 1 slipped and fell, and suffered severe pain of 10/10 to the left knee treated with opioids Resident 1 was transferred to GACH 2 via 911. GACH 2 diagnosed Resident 2 with a left femur fracture. On 10/29/2024, GACH 2 performed ORIF on Resident 1. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death