Health inspection·February 29, 2024

The following reflects the findings of the California Department of Public Health during the investigation of two complaint numbers CA00879228 and CA00879116. Representing the Department, Health Facility Evaluator Nurse # 36395 A Class A State citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations: F689 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. Title 22 California Code of Regulations: § 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 01/12/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding a resident's (Resident 1) neglect after Resident 1 sustained an unwitnessed fall and injury. The facility failed to implement measures to prevent recurrent falls and injury for Resident 1, who was confused, was assessed as high fall risk, had unsteady gait, and had history of four unwitnessed falls. The facility failed to: 1. Supervise and monitor Resident 1's who used the wheelchair for mobility around the facility unattended. 2. Identify interventions related to the resident's specific risks and causes to prevent the resident from falling and minimize complications from falling. As a result, on 11/23/23 at 2 p.m., Resident 1 suffered a fifth (5th) unwitnessed fall, was found in his room with his face down and was bleeding from the right side of the head. Resident 1 required transfer to General Acute Care Hospital 1 (GACH 1) by paramedics where he was diagnosed with traumatic brain injury (TBI, caused by a forceful bump, blow or jolt to the head), subarachnoid (the middle of three membranes that cover the brain) and subdural (area between the brain and the skull) hemorrhage (bleeding in the space surrounding the brain that is life threatening and can cause brain damage). Resident 1 had a three-centimeter (cm, unit of measurement) laceration (cut) on the right forehead. Resident 1 was admitted in the trauma intensive care unit (ICU) for further treatment. A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 6/30/22 with diagnoses including Parkinson's disease (disorder of the nervous system [controls internal functions of the body that receives, interprets and responds to stimuli] that affects movement), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) with right side hemiplegia (weakness or paralysis [inability to move] on one side of the body) and hemiparesis (one sided muscle weakness). A review of Resident 1's Fall Risk Evaluation dated 3/15/23 at 3:07 p.m., indicated Resident 1 was at risk for falls. The Evaluation indicated Resident 1 had fallen one to two times within the last six months, had impaired vision, totally incontinent, confined to a chair and disoriented. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 6/13/23, indicated Resident 1 had severely impaired cognitive skills (mental process that take place in the brain including thinking, attention, language, learning, memory, and perception). Resident 1 needed one-person physical assistance with bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing. Resident 1 was unsteady and was only able to stabilize with assistance when moving from seated to standing position and transfer between bed and chair or wheelchair. Resident 1 had impaired range of motion (ROM, measurement of movement around the joint or body part) in the lower extremities (hip, knee, ankle, and foot). The same MDS indicated Resident 1 used the wheelchair as mobility device. A review of Resident 1's Care Plan revised on 6/20/23, indicated Resident 1 was at risk for falls and injury due to unsteady gait and attempting to get out of his wheelchair and bed unassisted. The care plan goal was for to minimize fall and injury through the next review date. The interventions included observing Resident 1 for unsafe behavior such as attempting to get out of bed or wheelchair unassisted. The interventions included verbally remind resident not to attempt to raise out of bed or wheelchair unassisted and visual monitoring at regular intervals. A review of Resident 1's Post Fall Review dated 8/20/23 at 3:27 p.m., indicated Resident 1 had an unwitnessed fall on 8/20/23 at 2:55 p.m. (first fall). Resident 1 was found lying on the floor in the hallway. Resident 1 was observed "wandering per self on wheelchair" prior to the fall. The IDT (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the residents) recommendation indicated will "...escalate the plan of care for when he (Resident 1) is up in the chair to facilitate increased safety for the resident." A review of Resident 1's Care Plan initiated on 8/20/23 and revised on 9/5/23 indicated Resident 1 was found on the floor on 8/20/23 and 9/5/23. The care plan goal was for Resident 1 not to have further injury related to the falls through the next review date. The interventions included frequent visual checks and referring to the IDT for further review of the plan of care. A review of Resident 1's Post Fall Review dated 9/5/23 at 4:36 p.m. indicated Resident 1 had an unwitnessed fall on 9/5/23 at 3:10 p.m. (second fall). Resident 1 was found sitting upright on the floor next to the sofa in the front lobby. The section on IDT review and summary of the root cause [fall] was left blank. A review of Resident 1's MDS dated 9/13/23, indicated Resident 1 had severely impaired cognitive skills (mental process that take place in the brain including thinking, attention, language, learning, memory, and perception). Resident 1 needed one-person physical assistance with bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing. Resident 1 was unsteady and was only able to stabilize with assistance when moving from seated to standing position and transfer between bed and chair or wheelchair. The same MDS did not indicate if Resident 1 used the wheelchair as mobility device and no other devices were marked in that section. Resident 1 had limited range of motion (ROM, measurement of movement around the joint or body part) in the lower extremity (hip, knee, ankle, and foot). A review of the Post Fall Review dated 9/27/23 at 3:15 p.m. indicated Resident 1 was found on the floor on 9/27/23 at 3:15 p.m. (third Fall) lying on his left side in the lobby area. Resident 1 was attempting to self-transfer to the wheelchair. Resident 1 was able to move all upper and lower extremities and denied pain. The Post Fall IDT indicated Resident 1 had "bare feet" and the IDT Review, summary of root cause of the fall and recommendations were blank. The Care Plan for fall was not updated. A review of the Post Fall Review dated 11/19/23 at 3:00 p.m. (Fourth Fall) indicated Resident 1 had a fall on 11/19/23 at 3 p.m. Resident 1 was seen getting out of bed from a sitting position, stood up and lost his balance and landed on the floor. Resident 1 had "no apparent signs of injury, however pain was noted after the fall." Resident 1 had x-ray of the lumbar spine (lower back) and had no fracture. A review of Resident 1's Care Plan initiated on 11/19/23 indicated Resident 1 had an actual fall with no injury. The care plan goal indicated Resident 1 will resume usual activities without further incident through the next review date. The care plan interventions included determine, address causative factors of the fall and to "continue interventions on the at-risk plan." A review of Resident 1's Situation, Background, Appearance, Review and Notify (SBAR, communication tool that share information among healthcare team about resident condition) and Progress Notes, dated 11/23/23 at 2 p.m., indicated Resident 1 was found on the floor in his room face down beside his bed (Fifth fall). The SBAR indicated Resident 1 was "bleeding a lot" from the right side of his head. The paramedics were called and transported Resident 1 to the GACH 1. A review of Resident 1's Paramedic Patient Care Report dated 11/23/23 at 2:17 p.m., indicated the facility informed paramedics Resident 1 fell out of bed and the fall was unwitnessed. Resident 1 had laceration in the eyebrow area and bleeding was controlled. Resident 1 was transported to the GACH 1. A review of Resident 1's GACH 1 Emergency Documentation dated 11/23/23 and timed at 2:56 p.m., indicated Resident 1 was found with blunt head trauma and had changes in mentation (mental activity). Resident 1 was admitted to trauma ICU. A review of Resident 1's GACH 1 computerized tomography scan (CT, procedure that use combination of x-rays and computer to produce images) of the head dated 11/23/23 and timed at 3:23 p.m. indicated Resident 1 had acute subarachnoid and subdural hemorrhage within the left parietal region (near the back of the head). The CT scan also indicated there is right scalp subcutaneous (beneath the skin) hematoma (a pool of clotted blood that forms in an organ, tissue of body space caused by an injury) and right frontal scalp/lateral orbital (bony cavity that contains the eyeball) subcutaneous hematoma. A review of Resident 1's GACH 1 Physician Notes dated 11/24/23, indicated Resident 1 had a three-cm laceration on the right forehead. A review of Resident 1's Physician Note, dated 11/24/23, indicated Resident 1 had a subdural hematoma (serious condition where blood collects between the skull and the surface of the brain) that was non operable (cannot be treated with surgery). A review of Resident 1's Physician Note, dated 11/27/23, indicated Resident 1, "Keeps his eyes closed and had no movement to stimuli, was not improving and appears will be his current mental status in the future". Resident 1 needed nasogastric tube (NGT, a thin, soft tube that goes through the nose, down the throat and into the stomach) for feeding, hydration, or medication. A review of the Physician Note dated 11/28/23 at 5:52 a.m., indicated Resident 1 did not open his eyes or react to voice/light/name during the physician evaluation. A review of the Physician Note dated 11/30/23 at 6:42 p.m., indicated Resident 1 was "unarousable to verbal or noxious stimuli" (no response when stimulus such as pain was applied). A review of Resident 1's GACH 1 Discharge Summary dated 12/2/23 indicated Resident 1 was discharged to GACH 2 for traumatic brain injury with subarachnoid and subdural hemorrhage. During an interview on 1/12/24 at 7:46 a.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was confused, restless, tries to get out of bed and wheelchair unassisted. LVN 1 stated Resident 1 had history of falls and Resident 1 needed a one to one (1:1, continuous observation/monitoring) sitter (staff that are immediately at hand to prevent fall or redirect unsafe behavior) to make sure Resident 1 did not fall. The LVN and the DON stated that resident needed a sitter, but there was no documentation or MD order. During an interview on 1/12/24 at 10:52 a.m., the Director of Rehabilitation (DOR) stated Resident 1 was confused, impulsive, had poor safety awareness and a fall risk. DOR stated Resident 1 was able to stand but balance is poor. Resident 1 needed constant supervision and to have someone keep an eye on him to prevent Resident 1 from falling. During an interview on 1/12/24 at 11:53 a.m., the Director of Nursing (DON) stated she was not employed at the facility when Resident 1 had the five fall incidents. The DON stated Resident 1 should not have fallen five times. The DON stated she would have asked the family if they were willing to provide 1:1 sitter for Resident 1. DON further stated Certified Nursing Assistants (CNAs) could alternate as 30-minute room sitters to monitor Resident 1 and prevent the resident from falling. On 1/24/24 at 1:38 p.m., during an interview with LVN 2 and concurrent review of Resident 1's care plan, LVN 2 stated she was unable to find floor mat and that the bed was not always in the lowest position as part of the fall intervention for Resident 1. LVN 2 stated the floor mat and bed placed in the lowest position will prevent injury in case Resident 1 falls. A review of the facility's policy and procedures (P&P) titled Falls and Fall Risk, Managing, reviewed on 8/30/23, indicated, "based on previous evaluations and current data, the facility will identify interventions related to the resident's specific risks and causes to try to prevent resident from falling and try to minimize complications from falling. Environmental factors that contribute to the risk of falls include incorrect bed height. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling". A review of the facility's P&P titled Safety and Supervision of Residents reviewed on 8/30/23, indicated, "the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices". The facility failed to implement measures to prevent recurrent falls and injury for Resident 1, who was confused, was assessed as high fall risk, had unsteady gait, and had history of four unwitnessed falls. The facility failed to: 1. Supervise and monitor Resident 1's who used the wheelchair for mobility around the facility unattended. 2. Identify interventions related to the resident's specific risks and causes to prevent the resident from falling and minimize complications from falling. As a result, on 11/23/23 at 2 p.m., Resident 1 suffered a fifth (5th) unwitnessed fall, was found in his room with his face down and was bleeding from the right side of the head. Resident 1 required transfer to GACH 1 by paramedics where he was diagnosed with TBI, subarachnoid, and subdural hemorrhage. Resident 1 had a three-cm laceration on the right forehead. Resident 1 was admitted in the trauma ICU for further treatment. The above 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 to Resident 1.