Health inspection·January 5, 2024

42 CFR § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. §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: (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 CCR § 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 11/20/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the investigation of a facility reported incident. The facility failed to ensure care and supervision to prevent falls for Resident 1, who was diagnosed with dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and had abnormalities of gait (a person’s manner of walking) and mobility by failing to: 1.Correctly assess Resident 1 as indicated on the Fall Risk Assessment and identify Resident 1 was at high risk for falls. 2. Develop a care plan for Resident 1’s non-compliance with the front wheel walker and the resident’s refusal of staff assistance with ambulation. As a result, on 11/7/2023, Resident 1 fell and sustained a hematoma (an abnormal collection of blood outside of the blood vessel) to the head, and a femoral neck fracture (broken upper thigh bone). A review of the Admission Record indicated the facility admitted Resident 1 on 6/22/2020 and re-admitted the resident on 11/15/2023 with diagnoses including encephalopathy (brain dysfunction that can appear as confusion, memory loss, personality changes and/or coma in the most severe form), dementia, heart failure, rhabdomyolysis (a condition in which damaged muscle breaks down rapidly), adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability), abnormalities of gait and mobility, and lack of coordination. A review of the History and Physical (H&P) dated 4/6/2023, indicated Resident 1 did not have the capacity to understand and make decisions due to the reason of Alzheimer’s (the most common type of dementia, a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). The H&P further indicated Resident 1 had a history of Alzheimer’s, gait disorder, and poor memory. A review of the Physician’s Order dated 4/28/2023, indicated Resident 1 could ambulate (walk) using a front wheel walker (FWW) ad lib (as desired) around the facility as tolerated. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 10/27/2023, indicated Resident 1 had moderately impaired cognition (decisions poor; cues/supervision required), had impaired vision, and had delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated Resident 1 had no impairment to the upper/lower extremities and utilized a walker and required partial/moderate assistance for showering/bathing, and required supervision or touching assistance for personal hygiene, putting on/taking off footwear, lower body dressing, and upper body dressing. The MDS indicated Resident 1 required set up or clean up assistance for toileting, oral hygiene, eating, rolling left and right, sitting to lying, lying to sitting on the side of the bed, toilet transfer, walking 10 feet, walking 50 feet with two turns, and walking 150 feet. The MD further indicated Resident 1 was continent of bowel and bladder. According to a review the Interdisciplinary Plan of Care Review Form dated 7/27/2023, Resident 1 was provided safety education to continue use of the FWW when ambulating. The Interdisciplinary Plan of Care Review Form indicated Resident 1 was explained the risk of fall/injury if their gait had imbalance and of the non-compliance of using a FWW. The Plan of Care Review form indicated Resident 1 understood the risk and benefits of preventing falls. A review of the Care Plan initiated on 7/31/2023, indicated Resident 1 was at risk for falls related to the disease processes of lack of coordination, dementia, and abnormalities of gait and mobility. The care plan indicated the goals for Resident 1 to be free of falls, free of minor injury, and to not sustain serious injury through the review date. The care plan interventions indicated to anticipate and meet Resident 1’s needs, to be sure the resident’s call light was within reach, and to encourage the resident to use it for assistance as needed. The care plan interventions indicated Resident 1 needed prompt response to all requests for assistance, needed to be evaluated for and supplied appropriate adaptive equipment or devices as needed; to re-evaluate as needed for continued appropriateness; and to ensure least restrictive devices. The care plan interventions indicated Resident 1 needed a safe environment with even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, the bed in low position at night, a front wheel walker, a wheelchair or side rails as ordered, had rails on walls, personal items within reach, and bilateral upper side rails. A review of the Fall Risk Assessment dated 10/21/2023, indicated Resident 1 had a fall risk score of 8 (a total score above 10 represents a high risk for falls). The Fall Risk Assessment indicated Resident 1 had intermittent confusion or poor safety awareness, no falls in the past three months, was ambulatory, had adequate vision (with or without glasses), had a balance problem while standing, had a balance problem while walking, required the use of an assistive device, no noted drop of systolic blood pressure (top number) between lying and standing, took 1-2 medications currently and/or within the last seven days, and had no predisposing disease present (from the list of hypotension, vertigo (dizziness), cerebral vascular accident [CVA], Parkinson’s disease, loss of limb, seizure, arthritis, osteoporosis, or fractures). The Fall Risk Assessment did not indicate whether Resident 1 was low or moderate risk for falls. A review of the Interdisciplinary Plan of Care Review Form dated 10/23/2023, indicated Resident 1 was able to walk independently with the FWW ad lib. The Plan of Care Review Form indicated Resident 1 did not have a fall incident for three months and had no behavioral issues. The Plan of Care Review Form indicated Resident 1 had a FWW available at bedside, was stable to ambulate in and out of bed and the rest room, had socks and a FWW within reach, and the assistive device was working properly without issues in maintenance. A review of the Fall Risk Assessment dated 10/27/ (no documentation of year), indicated Resident 1 had a fall risk score of 6 (a total score above 10 represents high risk for fall). The Fall Risk Assessment indicated Resident 1 had intermittent confusion or poor safety awareness, no falls in the past three months, was ambulatory, had normal gait and balance, no noted drop of systolic blood pressure between lying and standing, takes 1-2 medications (from list of anti-histamines, anti-hypertensive, anti-seizure, benzodiazepines, cathartics, hypoglycemics, narcotics, psychotropics, or sedatives/hypnotics) currently and/or within the last seven days, and had no predisposing disease present (from the list of hypotension, vertigo, CVA, Parkinson’s disease, loss of limb, seizure, arthritis, osteoporosis, or fractures). The Fall Risk Assessment indicated the vision status portion of the assessment was not completed. The Fall Risk Assessment did not indicate whether Resident 1 was low or moderate risk for falls. According to a review of the Joint Mobility Assessment dated 10/27/2023, there were no problems noted in the summary for Resident 1 and Resident 1 was to continue ad lib ambulation. A review of the Physician’s Order dated 11/7/2023, indicated to send Resident 1 to the General Acute Care Hospital (GACH)’s Emergency Room (ER) for evaluation of hematoma (an abnormal collection of blood outside of a blood vessel) on the right forehead. A review of the Progress Note dated 11/7/2023 at 1:31 PM, indicated at 1:20 PM the Certified Nursing Assistant (CNA) was passing by and noted that Resident 1 was sitting on the floor leaning towards the door with blood on the face and some drops on the floor. The Progress Note indicated the CNA alerted the Licensed Nurse (LN) immediately, an assessment was completed, and Resident 1 was able to verbalize what happened stating attempted to pick up something on the floor. The Progress Note indicated the floor was free from scattered belongings and was dry. Resident 1’s bilateral lower extremity and upper extremity range of motion was conducted and indicated there was no limitation, no pain, and no facial grimacing. The Progress Note indicated Resident 1 was assisted back to bed with a two-person assist, had no complaints of pain or discomfort during the transfer. A body re-assessment was done, and indicated Resident 1 had no pain and no swelling on both hips, knees, or part of the body. The Progress Note indicated Resident 1 was noted with a hematoma on the right side of the forehead, first aid was rendered, and an ice pack was applied. Resident 1 was noted with a five-centimeter skin tear which was cleansed with steri-strips applied and covered with a dry dressing. The Progress Note indicated Resident 1 had an elevated blood pressure of 195/110 (normal blood pressure between 90/60 millimeters of mercury (mmHg) and 120/80mmHg), the paramedics and Resident 1’s physician were notified. The Progress Note further indicated the paramedics arrived at 1:45 PM and transferred Resident 1 to the GACH. A review of the Situation Background Assessment and Recommendation (SBAR) Communication Form and Progress Note dated 11/7/2023 at 1:51 PM, indicated Resident 1 had an unwitnessed fall in the room and sustained a large hematoma to the right side of the forehead with bleeding. The SBAR note indicated Resident 1 remained awake and responsive during the transfer to the Emergency Department. The SBAR note indicated Resident 1’s blood pressure was 195/110, pulse 88, respirations 22, temperature 97.2, and oxygen saturation 97%. A review of the Computed Tomography (CT, an imaging exam that takes pictures of the inside of the body) of the brain without contrast (refers to a substance taken by mouth or injected into a vein that causes the particular organ under study to be seen more clearly) result dated 11/7/2023 at 3:24 PM, indicated Resident 1 had a right frontal soft tissue hematoma. According to a review of the right hip x-ray (an imaging procedure that takes pictures of the inside of the body using radiation) results dated 11/7/2023 at 3:57 PM, Resident 1 had a concern for a fracture of the femoral neck/head junction on the right side (break in the upper thigh bone). A review of the GACH History and Physical (H&P) dated 11/8/2023 at 10:42 AM, indicated Resident 1 was admitted to the GACH on 11/7/2023. The H&P indicated Resident 1 was brought to the GACH after having had a fall and per nursing home documentation Resident 1 missed the rail and fell with hematoma to the right upper forehead. The H&P indicated Resident 1 was seen and evaluated in the ER by the ER physician and neurosurgery (specializes in the diagnosis and surgical treatment of disorders of the central and peripheral nervous system). The H&P indicated a subsequent brain imaging was done which showed a small contusion (type of hematoma). The H&P indicated Resident 1 had a laceration (deep cute or tear in the skin) on the right upper forehead that was repaired using prolene sutures (sterile sutures). The H&P indicated a CT of the brain was obtained which showed Resident 1 had a 6 millimeter (mm, a measure of length) right temporal hemorrhage/cortical contusion (brain bruise). The H&P indicated a CT of the hip was also done which showed Resident 1 had an impacted subcapital right femoral neck fracture (break in the upper thigh bone). A review of the CT of the brain without contrast imaging result dated 11/8/2023 at 2:04 AM, indicated Resident 1 had the second CT due to head trauma with worsening mental status and concern for delayed hemorrhage. The CT indicated Resident 1 had interval development of 6 mm right temporal hemorrhagic cortical contusion. A review of the GACH Orthopedic Surgery (physicians who specialize in surgery of bones and joints) Note dated 11/14/2023 at 2:04 PM, indicated Resident 1 was to be on strict non-weight bearing to the right lower extremity. The note further indicated Resident 1 had non-operative fractures and was to receive Eliquis 2.5 mg by mouth twice daily due to the resident’s high risk for deep vein thrombosis (DVT, blood clot formation in a deep vein). During an observation on 11/20/2023 at 10 AM, Resident 1 was observed with a bump to the right upper side of the forehead and a small laceration above their right eye. Resident 1 was observed with the bed in low position with floor mats to the left and right side of the bed. Resident 1’s FWW was observed at bedside. During a concurrent interview, Resident 1 stated he got the bump on the forehead when he “Turned the corner a little too fast,” and hit his head on the corner. Resident 1 stated he did not remember the date or the time the fall happened. Resident 1 stated he did not call the nurses for help because he did not need help. Resident 1 stated, “I don’t need to call for help to the bathroom, if I need to go, I will go by myself.” On 11/20/2023 at 10:29 AM, during an interview, CNA 1 stated she was walking past Resident 1’s room when she saw the resident sitting on the floor by the door with blood. CNA 1 stated there was blood on the floor and on Resident 1’s head. CNA 1 stated Resident 1 was confused and was not able to say what happened. CNA 1 stated there was a lot of blood on the floor. CNA 1 stated she called the charge nurse to report what she saw. During an interview on 11/20/2023 at 10:37 AM, CNA 2 stated she was assigned to take care of Resident 1 the day the resident had the fall. CNA 2 stated she was with another resident when Resident 1 was found and indicated staff had called for her. CNA 2 stated when she went to Resident 1’s room, the resident was already on the floor and the charge nurse was there. CNA 2 stated prior to Resident 1 having the fall, the resident would get up and go to the bathroom by themselves. CNA 2 stated Resident 1 had moments of confusion. CNA 2 stated Resident 1 had a FWW next to him but never used it. CNA 2 stated sometimes Resident 1 would call out for help if he saw someone walking by, but stated the resident was reluctant to have assistance, stating that when staff would offer help the resident would refuse. CNA 2 stated prior to Resident 1 having the fall, the resident did not have a bed alarm or floor mats. During an interview on 11/20/2023 at 11:40 AM, Resident 2 stated Resi