Health inspection·May 2, 2023

42 CFR § 483.25 (d) Accidents. The facility must ensure that- (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR §72637 - General Maintenance (a) The facility, including the grounds, shall be maintained in a clean and sanitary condition and in good repair at all times to ensure safety and well-being of patients, staff and visitors.(b) Buildings and grounds shall be free of environmental pollutants and such nuisances as may adversely affect the health or welfare of patients to the extent that such conditions are within the reasonable control of the facility.(c) All buildings, fixtures, equipment and spaces shall be maintained in operable condition. 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. (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. 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 3/10/2023, the California Department of Public Health (CDPH) received a complaint indicating Resident 1 fell and sustained a head laceration during care. On 3/13/2023, the CDPH conducted an unannounced visit at the facility. The facility failed to: 1. Follow Resident 1’s care plan titled “At risk for falling from Low Air Loss Mattress ([LAL], a mattress designed to prevent and treat pressure wounds) which indicated Resident 1 required a two-person assist with transfers, repositioning, and daily care. 2. Follow its policy and procedures (P&P) titled “Positioning/Repositioning Residents,” which indicated staff will “turn the resident onto the side and place the side rail up on one side as needed.” As a result, Resident 1, who was at risk for falls and had a history of involuntary movements, fell, and sustained a bump and laceration to the back of the head, which required two staples closure to the laceration, at a General Acute Care Hospital (GACH). Resident 1 was an 80 year-old-female admitted to the facility on 1/19/2022 with diagnoses including contractures (A permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of the right and left knees, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), seizures (a burst of uncontrolled electrical activity in the brain that causes temporary abnormalities such as stiffness, confusion and involuntary movements), tracheostomy (a small surgical opening that is made through the front of the neck into the windpipe to allow air to flow in and out of the windpipe), and dependence on respiratory ventilator (machine used to provide breathing assistance to patients who have lost the ability to breathe on their own). During a review of Resident 1's History and Physical (H&P), dated 1/20/2022, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Physician Order Summary dated 1/19/2022, the Physician Order Summary indicated bilateral upper half side rails up when in bed for safety and protection secondary to involuntary movement. During a review of Resident 1's care plan titled, “Side rail use as non-restraint, resident is at risk for movement from bed to floor due to head of bed elevated and gravity-related to involuntary movements and unresponsiveness,” initiated on 4/20/2022, the care plan intervention indicated staff will reposition Resident 1 as indicated and use side rails. During a review of Resident 1's care plan, dated 5/4/2022, titled, “Resident has self-care deficits: in bed mobility, transfer, total assist,” the care plan intervention indicated staff may provide 1-2 staff assistance when performing turning, repositioning, and activities of daily living ([ADL] activities related to personal care such as dressing, and toilet use) care. During a review of Resident 1's care plan initiated on 5/4/2022 titled, “At risk for falling from low air loss mattress due to involuntary movements, spontaneous movements, large heavy resident requiring total care, turning and repositioning,” the care plan intervention indicated Resident 1 required a two-person assist with transfers, repositioning and daily care, and the use of side rails. During a review of Resident 1's Fall Risk Assessment dated 1/15/2023, the fall risk assessment indicated Resident 1 had a high risk for falls. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 1/17/2023, the MDS indicated Resident 1 was rarely/never able to understand or be understood by others. The MDS indicated Resident 1 required a one person assist for bed mobility, dressing, eating, toilet use, and personal hygiene. During a review of Resident 1's Change of Condition (COC)/Interact Assessment Form, dated 3/5/2023 at 10:07a.m., the form indicated Resident 1 fell on 3/5/2023 at 9 a.m., and sustained a head bump, skin abrasion and minimal bleeding. The COC indicated the back of Resident 1’s head was cleaned with normal saline (a type of water used to clean wounds) and a pressure dressing applied. The COC indicated Resident 1 was transferred to a GACH. During a review of Resident 1's Physician Order Summary dated 3/6/2023, the Physician Order Summary indicated Resident 1 returned to the facility after a fall with staples on the head. The order summary indicated to remove staples at the back of Resident 1’s head in 7-10 days. During a review of a letter dated 3/13/2023, provided by the facility, the letter indicated on 3/5/2023 at 9:43 a.m., during supervised care with CNA 1, Resident 1 had a witnessed fall when CNA 1 turned Resident 1 to her right side to finish cleaning Resident 1 while in bed. The report indicated Resident 1 was shaking and jerking, causing her to slide off the bed to the floor. The report indicated Resident 1 sustained a cut to the back of the head with minimal bleeding. The letter indicated Resident 1’s fall was due to the resident’s spontaneous movements evidenced by the shaking and jerky movement. During a review of Resident 1’s GACH admission record, the admission record indicated Resident 1 was admitted to the GACH on 3/5/2023 and discharged on 3/6/2023. The record indicated Resident 1 was admitted for a closed head injury, scalp laceration (deep cut) and abrasion, after a fall. The report indicated Resident 1 had bilateral upper and lower extremities contractures. The record indicated staff was rolling Resident 1 over without the side rails up and Resident 1 rolled out of the bed and hit her head. The report indicated Resident 1 had a hematoma (a pool of clotted blood) to the occipital region (back of the head) of the scalp with 1.5-centimeter ([cm] unit of measurement) in length and 3 millimeters ([mm] unit of measurement) deep, and laceration that was bleeding in the center of the hematoma. The report also indicated Resident 1 had abrasions to the left hip and lower back. The report indicated two (2) staples were used to close the laceration. During a review of Resident 1's Admission Assessment dated 3/6/2023 at 1:33 a.m., the Admission Assessment indicated Resident 1 was readmitted to the facility from the GACH on 3/6/2023. The admission assessment indicated Resident 1 had a laceration with two (2) staples at the back of the head from a fall. During an interview with Resident 1’s Family (FM) 1, FM 1 stated on 3/5/2023, during morning care, Resident 1 slid off the bed to the floor. FM 1 stated there were supposed to be two staff assisting Resident 1 during care and not just one staff to prevent Resident 1 from falling and getting injured. FM 1 stated she had always seen two staff changing Resident 1 and did not understand why CNA 1 had to change Resident 1 alone. FM 1 stated, she was informed by the GACH that Resident 1 had two staples on the head to control the bleeding from the back of her head. FM 1 also stated Resident 1 sustained a fracture after the fall. During an interview with CNA 3, on 3/14/2023, at 3 p.m., CNA 3 stated Resident had spasms and jerky movements when repositioned. CNA 3 stated he always asked for help from other staff to reposition or bathe Resident 1. CNA 3 stated it usually required 3 staff members including a Restorative Nursing Assistant (RNA), and a Respiratory Therapist ([RT] certified medical professionals who treat problems with your lungs or breathing), because Resident 1 had a tracheostomy. During an interview with CNA 1, on 3/16/2023, at 11:30 a.m., CNA 1 stated on 3/5/2023 around 9 a.m., during morning care, Resident 1 who was laying on a low air loss mattress, suddenly started to jerk forcefully about two or three times but she (CNA 1) did not hold Resident 1 while the resident was jerking because she was on the opposite side of Resident 1’s bed. CNA 1 stated she noticed Resident 1 was sliding off the bed to the floor. CNA 1 stated the side rails at the head of Resident 1’s bed was up but there were no side rails at the foot of the bed to prevent Resident 1 from falling and getting injured. CNA 1 stated if she knew Resident 1 had sudden jerky movements, she would have asked for help from another CNA. During an interview with RN 1 on 3/16/2023, at 12:05 p.m., RN 1 stated LVNs and RNs were supposed to endorse, update, and report any changes in residents’ conditions to CNAs for care continuity. During a review of the facility’s undated “Initial Fall Risk Assessment,” the assessment indicated each resident will be assessed for falls, a plan of care developed, and its interventions implemented to prevent falls. The P&P indicated recommended interventions including the use of side rails, lower bed, and floor mats. During a review of the facility’s undated P&P titled, “Fall Policy and Procedures,” the P&P indicated the facility will identify high risk residents for falls and minimize falls through appropriate interventions, to meet residents’ specific needs. During a review of the facility’s undated P&P titled “Positioning/Repositioning Residents,” the P&P indicated staff will provide repositioning as indicated. The P&P indicated staff will “turn the resident onto the side, place the side rail up on one side as needed.” The facility failed to: 1. Follow Resident 1’s care plan titled “At risk for falling from a LAL mattress which indicated Resident 1 required a two-person assist with transfers, repositioning, and daily care. 2. Follow its P&P titled “Positioning/Repositioning Residents,” which indicated staff will “turn the resident onto the side and place the side rail up on one side as needed.” As a result, Resident 1, who was at risk for falls and had a history of involuntary movements, fell, and sustained a bump and laceration to the back of the head, which required two staples closure to the laceration, at a GACH. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.