Health inspection·July 5, 2024

42 CFR §483.25 (d)(2) Accidents. The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. 42 CFR §483.21(b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident. 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. (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 5/6/2024 at 9:54 a.m., the California Department of Public Health (CDPH) received a complaint indicating Resident 1 fell on 4/20/2024, 4/22/2024 and on 4/28/2024 sustaining a nasal (nose) fracture (broken bone) On 5/7/2024 at 9:35 a.m., the CDPH conducted an unannounced visit at the facility to investigate all allegations. The facility failed to: 1. Implement Resident 1’s physician’s order dated 4/23/2024, which indicated to apply a Soft Belt (a device that is placed on a person’s waist to prevent them from falling out of a bed or a chair) on Resident 1 when up in a wheelchair for safety. 2. Follow Resident 1’s care plan titled, “Restraint: Soft belt while up on wheelchair for safety,” dated 4/23/2024, which indicated to apply a soft belt on the resident while up in a wheelchair for safety, to prevent falls and injuries. 3. Follow the facility’s policy and procedure (P&P) titled, “Soft/ Self Release Belt,” which indicated a wheelchair soft self-release belt should be used on a resident for safety. As a result, Resident 1 fell on 4/28/2024 (the third fall in eight days), sustained a fracture on the nasal bridge, and required hospitalization at a general acute care hospital (GACH), for evaluation and treatment. Resident 1 was a 91-year-old male, originally admitted to the facility on 1/26/2018 and re-admitted on 8/22/2022 with diagnoses including muscle weakness, dementia (impaired ability to remember, think, or make decisions that interfere with everyday activities), cerebral infarction (stroke), and urinary tract infection (UTI, an infection in the kidneys, bladder, ureters). A review of Resident 1’s Minimum Data Set ([MDS] standardized assessment and care planning tool) dated 2/29/2024, indicated Resident 1 had a cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene, sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and chair/bed-to chair transfer (the ability to transfer to and from a bed to a chair or wheelchair). A review of Resident 1’s quarterly fall risk evaluation dated 2/26/2024, indicated Resident 1 had gait and balance problems and the use of antipsychotic medications (medicine suppressing symptoms of mental illness). A review of Resident 1’s care plan titled, “At risk for falls/injuries related to advanced age, dementia, and impaired mobility,” dated 3/25/2024, indicated staff’s interventions included to keep Resident 1 in frequent monitored areas when up in a wheelchair for closer staff monitoring, observe the resident’s location through periodic visual checks and provide safety reminders. A review of Resident 1’s care plan titled, “The resident uses bed/wheelchair alarm (device to notify staff when a resident attempts to get out of bed or wheelchair unassisted) related to poor safety awareness,” dated 3/26/2024, indicated staff’s interventions included, to anticipate and intervene for potential causes which have precipitated (caused) prior falls, discuss with the resident/ family members the risks and benefits of the restraint, and evaluate the need for ongoing use and the continuing need of the restraint. A review of Resident 1’s Change in Condition (COC) Evaluation form dated 4/22/2024, indicated on 4/22/2024 at 8:30 a.m., Resident 1 was found by the charge nurse (unidentified) sitting on the floor mat at the bedside. The COC indicated Resident 1 sustained a laceration (skin tear) on the forehead and abrasion (skin scrape) on the right knee. The COC indicated a neuro check (observing how a person speaks, thinks, walks, moves, or interacts with the examiner) was done and first aid treatment was provided. A review of Resident 1’s care plan titled, “Resident had an actual unwitnessed fall related to safety non-compliance,” dated 4/22/2024, indicated Resident 1 had an unwitnessed fall on 4/22/2024 with a lacerated forehead. The care plan indicated on 4/28/2024 Resident had another unwitnessed fall with bleeding and swelling on the nose. Resident 1’s care plan did not indicate changes were made to the interventions for safety after Resident 1 fell on 4/22/2024. A review of Resident 1’s Fall Risk Evaluation report dated 4/22/2024 indicated Resident 1 who had intermittent (on and off) confusion, had 1-2 falls in 3 months, and was chair bound. The report indicated Resident 1 required the use of assistive devices such as a wheelchair and a walker. The report indicated Resident 1 had a fall risk score of 15 (a score of 10 and above indicated high fall risk). A review of Resident 1’s Interdisciplinary Team ([IDT] group of healthcare professionals working together to provide residents with the care they need) Fall Review report dated 4/23/2024, indicated the IDT met and discussed Resident 1’s unwitnessed falls on 4/20/2024, and 4/22/2024, which resulted in injuries upon body checks (locations not indicated). The IDT report indicated on 4/20/2024, Resident 1 was found sitting on a floor mat by his bed. The IDT report indicated on 4/22/2024, Resident 1 was found on right side, lying on a floormat by his bed, awake but unable to follow simple instructions. The report indicated Resident 1 had impaired cognition, and impaired function for activities of daily living (ADLs) with history of falls. The IDT report indicated Resident 1 could not state what happened. The IDT report indicated the following recommendations: 1. Skilled rehabilitation services for safety with functional mobility and transfers. 2. Frequent visual checks. 3. Redirection and reorientation. 4. Monitor the resident in close one on one observations at all times. 5. Anticipate and provide the resident’s needs on time. 6. Use of bed/wheelchair alarm. 7. The resident will be in front of the nursing station when up in a wheelchair. A review of Resident 1’s physician order dated 4/23/2024, indicated to apply a Soft Belt restraint when up in wheelchair. A review of Resident 1’s Medication Administration Record (MAR) dated 4/23/2024 to 4/28/2024, did not indicate Resident 1 was monitored for the use of a Soft Belt. A review of Resident 1’s care plan titled, “Restraint: Soft belt while up in wheelchair for safety,” dated 4/23/2024, indicated staff interventions included to apply a Soft Belt when up in wheelchair for safety, to prevent falls/injuries for Resident 1 if the resident got up unassisted due to poor safety awareness and poor balance. A review of Resident 1’s COC Evaluation form dated 4/28/2024, indicated on 4/28/2024 at 12:31 p.m., Resident 1 was found by an unidentified licensed nurse, on a right-side lying position (the third fall in eight days), on the floor, by the nurses’ station. The COC indicated Resident 1 had nasal bleeding and swelling with no pain. The COC did not indicate Resident 1 had a Soft Belt restraint on, at the time of fall. A review of Resident 1’s nasal bones radiology (process of taking pictures to diagnose and treat diseases) result, dated 4/28/2024 at 4:37 p.m., indicated Resident 1 had a fracture on the bridge of the nose. A review of Resident 1’s GACH records, dated 4/29/2024, at 1:29 a.m., indicated Resident 1 was admitted to GACH with diagnoses of acute fall at a skilled nursing facility, acute contusion (bruise to the brain), acute fracture of the nasal bone, abrasions of the forehead and the face and periorbital (around the lining of eyes) ecchymosis (bleeding underneath the skin.). The GACH records indicated Resident 1 was referred to an ear, nose, throat specialist due to the nasal fracture and contusion. A review of Resident 1’s IDT Fall Review report dated 5/3/2024 indicated on 4/28/2024 (time not indicated), Resident 1 had an unwitnessed fall. The report indicated a Charge Nurse (unidentified) observed Resident 1 wheeling himself in the hallway, then, heard a thud (dull) sound by Room A. The report indicated Resident 1 was observed on a right-side lying position, on the hallway floor, near Room A. The report indicated Resident 1 was awake, unable to answer or follow simple instructions. The report indicated Resident 1 had nasal bleeding and swelling, without pain or discomfort. The report indicated preventive measures in place prior to Resident 1’s fall on 4/28/2024, included bed and wheelchair alarm, floor mats, siderails, bed in low position, visual checks, and call light placed within reach. The report did not indicate the use of a soft belt when in a wheelchair, per Resident 1’s physician’s order dated 4/23/2024. The IDT summary and new recommendations dated 5/3/2024 indicated the physician ordered a self-release belt (a seat belt on a resident's wheelchair that the resident can fasten and release without assistance), while in a wheelchair. During a concurrent interview and record review on 5/21/2024 at 2:38 p.m. with the Director of Nursing (DON), Resident 1’s care plan titled “Resident had an actual unwitnessed fall related to safety non-compliance,” dated 4/22/2024, was reviewed. The DON stated, “the care plan’s interventions did not make sense.” The DON stated Resident 1’s care plan was not updated after the resident fell on 4/22/2024, (2 days after the first fall dated 4/20/2024). The DON stated there were no additional interventions after the second fall on 4/22/2024, to prevent Resident 1 from falling the third time on 4/28/2024 (6 days after the second fall). During a concurrent interview and record review on 5/22/2024 at 2:05 p.m. with the DON, Resident 1’s MAR dated 4/23 to 4/30/2024 was reviewed. The DON stated the MAR did not indicate Resident 1 had a Soft Belt when sitting in a wheelchair. The DON stated the MAR did not indicate Resident 1 was monitored for the application or use of a Soft Belt. The DON stated staff failed to carry out Resident 1’s physician’s order for the use of a Soft Belt. The DON stated these failures might have contributed to Resident 1’s fall on 4/28/2024. During a telephone interview on 5/22/2024 at 5 p.m., Certified Nurse Assistant (CNA) 3 stated on 4/28/2024 at 12:30 p.m., Resident 1 was in a wheelchair by the nursing station. CNA 3 stated the wheelchair alarm was turned on for Resident 1. CNA 3 stated Resident 1 did not have a Soft Belt on him (Resident 1) while sitting in the wheelchair. CNA 3 stated Resident 1’s recent fall on 4/28/2024, could have been prevented had the soft belt been applied on the resident. CNA 3 stated she was not aware Resident 1 had an order for a Soft Belt. A review of the facility’s P&P titled, “Fall Reduction (General)”, dated 3/2024, indicated it was the policy of the facility to reassess all residents with falls every time a fall occurred. The P&P indicated residents will be assessed for a need of restraint/ safety device to minimize recurrence of falls such as alarms and self-releasing belts. A review of the facility’s P&P titled, “Soft/ Self Release Belt”, dated 3/2024, indicated a wheelchair soft/ self-release belt was allowed for a resident to use to promote resident safety. A review of the facility’s P&P titled, “Care Plans, Comprehensive Person-Centered”, dated 4/2013, indicated a comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and must be implemented for each resident. The facility failed to: 1. Implement Resident 1’s physician’s order dated 4/23/2024, which indicated to apply a Soft Belt on Resident 1 when up in a wheelchair for safety. 2. Follow Resident 1’s care plan titled, “Restraint: Soft belt while up on wheelchair for safety,” dated 4/23/2024, which indicated to apply a soft belt on the resident while up on a wheelchair for safety, to prevent falls and injuries. 3. Follow the facility’s P&P titled, “Soft/ Self Release Belt,” which indicated a wheelchair Soft Self-release belt was to be used on a resident for safety. As a result, Resident 1 fell on 4/28/2024 (the third fall in eight days), sustained a fracture on the nasal bridge, and required hospitalization at a GACH, for evaluation and treatment. 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 or serious physical harm would result.