Health inspection·January 10, 2025

F 689 CFR §483.25 (d)(2) Accidents. The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. §483.25(d) Accidents. The facility must ensure that – §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. § 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. § 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. An unannounced visit was conducted by California Department of Public Health on 12/16/2024 at 8:00 AM during an Annual Health Recertification survey and to investigate a facility reported incident regarding a fall. The facility failed to ensure Patient 1 who was assessed at risk for falls and with diagnoses of dementia (a progressive state of decline in mental abilities) was free from falls and injury in accordance with Patient 1’s care plan for “At risk for fall” and Occupational Therapist (OT; a healthcare provider who helps you improve your ability to perform daily tasks like getting dressed or using a computer) Evaluation & Plan of Treatment (OTEPT) to provide maximal assistance (helper does more than half the effort) to the Patient 1 when showering/bathing. On 12/3/2024, in the facility’s shower room, Certified Nurse Assistant (CNA) 3 turned away from Patient 1 to grab the chucks (under pad - a kind of ultra-absorbent incontinence [lack of voluntary control over urination or defecation] products that are designed to be placed on the top of a bed, wheelchair, or any surface you want to protect) and clean towel leaving the patient unattended while in the shower chair. This deficient practice resulted in Patient 1 leaning forward and falling in the shower room on 12/3/2024 around 10:40 AM. Patient 1 fell backwards in a supine (facing up) position where the patient struck her head during the fall. Patient 1 experienced pain to her head (specific location not specified). The paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) came to pick up the patient and identified a hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) on the back of Patient 1’s head. Patient 1 was sent to General Acute Care Hospital (GACH) by the paramedics on 12/3/2024 (time unknown) where the patient was found to have an acute (sudden) anterior (front) left second through sixth rib (slender curve bones protecting the lungs) fractures (a break in a bone) and was admitted to the GACH’s Intensive Care Unit (ICU; a specialized hospital ward that provides intensive medical care to critically ill or injured patients who require close monitoring and life-support measures). A review of Patient 1’s Admission Record indicated the patient is an 84- year- old female who was admitted to the facility on 11/26/2024 with diagnoses that included type 2 diabetes mellitus (DM; a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia, schizophrenia (a mental illness that is characterized by disturbances in thought) and history of falling. A review of Patient 1’s Admission Fall Risk Assessment (AFRA) dated 11/26/2024, indicated Patient 1 was a fall risk. A review of Patient 1’s Care Plan (CP) dated 11/26/2024, indicated Patient 1 was at risk for falls related to history of multiple falls prior to admission, seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), history of loss of consciousness and wheelchair bound with unsteady transfer. The CP indicated the CP goal was patient will have no injuries related to falls and interventions included: 1. Assess and anticipate patient’s needs: body positioning. 2. Keep environment free of clutter and safety hazards. 3. Refer to rehabilitation (health care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired) for evaluation and treatment as indicated. A review of Patient 1’s Psychologist Intake Note (PIN), dated 11/28/2024, indicated Patient 1 had poor insight, poor judgement/impulse control and functional status was severely impaired. A review of Patient 1’s History and Physical (H&P) dated 12/2/2024 indicated Patient 1 does not have the capacity to understand and make decisions. A review of Patient 1’s Minimum Data Set (MDS- a patient assessment tool) dated 12/3/2024, indicated the patient was assessed to have moderately impaired cognition (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) and required maximal assistance for showering/bathing. The MDS indicated Patient 1 was assessed to require moderate assistance (helper does less than half the effort) for toileting, upper/lower body dressing and taking on/off footwear. In addition, the MDS indicated Patient 1 had a fall in the last month prior to admission. A review of Patient 1’s Paramedic Report (PR) dated 12/3/2024indicated: 1. Patient 1 was found to have a hematoma to the posterior (back) left side of the patient’s head. 2. Staff (unspecified) reported Patient 1 fell backwards while taking a shower, hitting the back of the patient’s head on the floor. 3. Staff (unspecified) reported Patient 1 loss consciousness for about five (5) seconds. 4. Patient 1 was taken to GACH. A review of Patient 1’s GACH Trauma Surgery History and Physical (TSHP) dated 12/3/2024 entered at 12:33 PM, indicated Patient 1 sustained a ground level fall in the shower, complained of head pain and had a scalp (skin covering the head) hematoma. The GACH TSHP indicated a Computed Tomography (CT; a computerized x-ray [a quick, painless test that captures images of the structures inside the body] imaging procedure) of Patient 1’s chest, abdomen, and pelvis (the bones between the lower abdomen and upper thighs that connect the spine to the legs) were performed with findings of acute anterior left second through sixth rib fractures. The GACH TSHP indicated Patient 1 was admitted to the GACH’s ICU. A review of Patient 1’s Interdisciplinary Team Progress Note (IDT) dated 12/3/2024 entered at 4:55 PM, indicated Patient 1 had a witnessed fall on 12/3/2024 at around 10:40 AM in the facility’s shower room. The IDT indicated Patient 1 was seated in a shower chair while being assisted by CNA 3 and Certified Nursing Assistant Student 1 (Student 1). The IDT indicated CNA 3 turned to grab a clean towel, but Patient 1 leaned forward causing the shower chair to flip. The IDT indicated Patient 1 fell backwards in a supine position and struck the patient’s head (not specified where the patient hit her head) during the fall. The IDT indicated Patient 1 was assessed by staff but later in the patient’s room, the patient complained of pain to her head. The IDT indicated paramedics came to pick up the patient to transfer to GACH and the paramedics identified a hematoma on the back of Patient 1’s head. During an interview on 12/17/2024 at 1:06 PM, CNA 3 stated, on 12/3/2024, CNA 3 was with Patient 1 in the shower room. CNA 3 stated Patient 1 was sitting in the shower chair while Student 1 was at the right side of the patient buttoning Patient 1 ‘s gown. CNA 3 stated Student 1 was using both of her hands while buttoning Patient 1’s gown when Patient 1 fell. CNA 3 stated she was behind Patient 1 and turned around to put a chuck and clean towel on the patient’s wheelchair to prepare transferring Patient 1. CNA 3 stated while she was turned facing away from Patient 1, she suddenly heard a loud noise, a sound that something fell, she turned around and saw Patient 1 on the floor on her left side with the patient’s chest area and stomach on the floor. CNA 3 stated she did not actually see Patient 1 falling as she (CNA 3) was not facing the patient and was fixing the chuck and clean towel in the wheelchair. CNA 3 stated, to prevent Patient 1 from falling, Patient 1 should not be left unattended. CNA 3 stated, Patient 1 cannot sit on her own that was why CNA 3 always need someone to be with her when showering Patient 1. CNA 3 stated she did not try to find another CNA to assist her on 12/3/2024 to provide shower to Patient 1 since she had Student 1 with her but should have looked for another CNA to assist. During a concurrent interview and record review with Physical Therapist (PT; a healthcare provider who helps you improve how your body performs physical movements) 1 on 12/17/2024 at 2:12 PM, Patient 1’s PT Evaluation & Plan of Treatment (PTEPT) dated 11/27/2024 was reviewed. The PTEPT indicated: 1. Patient 1 had a history of fall. 2. Patient 1 required maximal assistance to stand from sitting. 3. Patient 1 required maximal assistance to transfer from chair to chair. 4. Patient 1 had impaired strength to both lower extremities (legs). PT 1 stated, "Patient 1 had a fall at home due to possible seizure. Patient 1 overestimated her abilities. PT 1 stated Patient 1 could not get on the wheelchair by herself. Her mind would stray to random incidents or topics. PT 1 stated it would not be safe to take your eyes off and hands off Patient 1 when taking a shower since the patient was assessed to need maximal assistance during shower. During a concurrent interview and record review with OT 1 on 12/17/2024 at 2:17 PM, Patient 1’s OTEPT dated 11/27/2024 was reviewed. The OTEPT indicated: 1. Patient 1 was a fall risk, had dementia and was hard of hearing. 2. Patient 1 required maximal assistance for showering/bathing. OT 1 stated, "She (Patient 1) was maximum assist for showers. That would require one helper. They would do the scrubbing, rinsing, drying.” OT 1 stated “She (Patient 1) required a shower chair. She required touching assistance for safety.” OT 1 stated “it would not be safe to leave Patient 1 unassisted.” OT 1 stated it would not be safe to “take your eyes off and hands off Patient 1 during a shower or after shower.” During an interview on 12/17/2024 at 3:20 PM with Student 1, Student 1 stated on 12/3/2024 between 10:30 AM to 11 AM, Student 1 was shadowing (observing) CNA 3 and have just completed assisting CNA 3 showering Patient 1. Student 1 stated she was at the right side of Patient 1, there was a low divider between her and the patient, while assisting CNA 3 to shower Patient 1. Student 1 stated Patient 1 was facing the wall where the shower head is, while the patient was sitting on the shower chair. Student 1 stated CNA 3 handed her Patient 1’s gown and Student 1 was buttoning Patient 1‘s gown using both of her hands when Patient 1 leaned forward and fell. Student 1 stated it happened so fast that she did not get a chance to go around the divider to catch Patient 1 from falling. Student 1 stated CNA 3 was behind Patient 1, and CNA 3 was not facing Patient 1 because CNA 3 was putting the chuck and clean towel on the wheelchair to prepare to transfer the patient. Student 1 stated Patient 1 landed on her back and/or on the left side. Student 1 stated she did not see Patient 1 hit Patient 1’s head, but Patient 1 was complaining of pain on the head after the fall. Student 1 stated CNA 3 did not tell her that Patient 1 was at risk for fall. During a concurrent interview and record review on 12/18/2024 at 11:58 AM with the Director of Nursing (DON), The Online Nurse Assistant Training Program Clinical Training Site Agreement (Training Agreement – contract between the Student 1’s school and the facility indicating the terms and limitations of CNA students with regards to patient’s care) dated 2/2022 was reviewed. The Training Agreement form indicated facility staff may not be used to proctor, shadow, or teach the training program students. The DON stated, the contract indicated, the nursing student including Student 1 should not be doing the CNA’s work, or doings hands on care to the patients without the presence of the school’s instructor. The DON stated CNA 3 should not have relied on the help of Student 1 when showering patients. During a concurrent interview and record review on 12/18/2024 at 12:05 PM with the DON, the facility’s policy, and procedure (P&P) titled, “Fall and Fall Risk Managing,” dated 3/2018 was reviewed. The P&P indicated: 1. Based on previous evaluations and current data, the staff will identify interventions related to the patient’s specific risks and causes to try to prevent the patient from falling and to try to minimize complications from falling. 2. Environmental factors that contribute to the risk of falls include wet floors. 3. Patient conditions that may contribute to the risk of falls include delirium and other cognitive impairment, lower extremity weakness, balance, and gait (a person’s manner of walking) disorders and incontinence. The DON stated, “the policy indicated, fall risk factors include wet floors, delirium and other cognitive impairment, lower extremity weakness, incontinence, and balance and gait disorders.” The DON stated, Patient 1 was in the shower room where the floor was wet, and the patient has dementia, incontinence, balance and gait problems and lower extremity weakness. The DON stated, all these factors increase the Patient 1 risk for falls and CNA 1 should not have turned away from the patient to get chucks and clean towel. The DON stated Patient 1’s fall could have been prevented if CNA 3 did not leave the patient unattended/turned away from the patient to get chucks and clean towel on 12/3/2024. The facility failed to ensure Patient 1 who was assessed at risk for falls and with diagnoses of dementia was free from falls and injury in accordance with the patient’s care plan for “At risk for fall” and OTEPT to provide maximal assistance to the patient when showering/bathing. On 12/3/2024, in the facility’s shower room, CNA 3 turned away from Patient 1 to grab the chucks and clean towel leaving the patient unattended while in the shower chair. This deficient practice resulted in Patient 1 leaning forward and falling in the shower room on 12/3/2024 around 10:40 AM. Patient 1 fell backwards in a supine position where the patient struck her head during the fall. Patient 1 experienced pain to her head. The paramedics came to pick up the patient and identified a hematoma on the back of Patient 1’s head. Patient 1 was sent to GACH by the paramedics on 12/3/2024 where the patient was found to have an acute anterior left second through sixth rib fractures and was admitted to the GACH’s ICU. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.