Health inspection·September 13, 2024

F689 42 CFR §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. 42 CFR §483.40 Behavioral Health Services Each resident must receive and the facility must provide the necessary behavior health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. (b) Based on the comprehensive assessment of a resident, the facility must ensure that - (3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. 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. (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 7/31/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility during the investigation of a facility reported incident. As a result of the investigation, CDPH determined the facility failed to: 1. Ensure that Resident 1, whose fall risks included sensory deficits, abnormal gait self-injurious behaviors, and dementia with poor insight, received treatment and care in accordance with professional standards of practice for patients at high risk of injury and a comprehensive person-centered care plan to avoid falls. 2. Provide Resident 1, who had a diagnosis of dementia and behavioral issues, with the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 3. Ensure that Resident 1's environment remained as free of accident hazards as possible, causing Resident 1 to sustain a fall. 4. Ensure that Resident 1 received adequate supervision and assistance devices to prevent accidents, including failing to monitor Resident 1 after an initial fall on 7/22/2024 at 8:49 PM, resulting in a subsequent fall. 5. Identify Resident 1's care needs based upon an initial written assessment and continuing assessment of Resident 1's needs due to their fall risk. 6. Develop an individualized, written patient care plan including supervision for Resident 1 given their high fall risk in the absence of supervision due to their abnormal gait, visual and auditory deficiencies, dementia with poor insight, and self - injurious behaviors. 7. Review, evaluate, and update Resident 1's care plan as necessary, at least quarterly, and following any changes to Resident 1's condition. 8. Implement the facility's policy and procedure (P&P) titled, "Fall Risk Assessment," under Monitoring Subsequent Falls and Fall Risk, under Monitoring Subsequent Falls and Fall Risk, requiring the facility to monitor and document each resident's response to interventions intended to reduce falling and to evaluate the resident's response. As a result, on 7/22/2024, Resident 1 had two consecutive falls within one hour and complained of pain to the right thigh. Resident 1 was transferred to a General Acute Care Hospital (GACH) 1 where Resident 1 was diagnosed with a fracture (crack or break) of the right hip and surgery was recommended. A review of Resident 1's GACH 1 History and Physical (H&P) dated 4/17/2021 at 9 AM, it indicated the resident was brought in for evaluation of a mechanical fall and pelvic pain. The H&P indicated "the resident had a history of unsteady gait and generalized weakness that could have contributed to the fall." A review of Resident 1's Admission Record indicated the 91-year-old female resident was admitted the facility on 4/19/2021 from GACH 1 with diagnoses including pelvic fracture, Alzheimer's disease (brain disorder that affects memory and thinking skills), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), right ear hearing loss, and history of falling. A review of Resident 1's care plans indicated the resident had an actual unwitnessed fall on 4/18/2023, related to poor judgment and insight into her support needs. Resident 1 perceived herself as independent. The care plan intervention indicated Resident 1 required a psychological evaluation due to throwing herself off the bed. There was no intervention to include supervising the resident. A review of Resident 1's annual Fall Risk Assessment titled dated 6/21/2024 at 10:51 AM, indicated the resident was a high risk for falls with a score of 65 (a score of 45 or more indicated a resident was a high risk for falling). The Fall Risk Assessment indicated Resident 1 had a history of falling, had more than one diagnosis, had a weak gait (stooped posture [having the head and shoulders bent forward] but able to lift head without losing balance, steps were short, resident may shuffle [to walk pulling your feet slowly along the ground rather than lifting them], and overestimates or forgets limits. According to a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 6/21/2024 the resident had severely impaired cognition (reduced ability to think, understand, and reason) and required substantial / maximum assistance (helper does more than half the effort) with walking 50 feet with two turns. The MDS indicated Resident 1 was continent of urine and bowel and the resident had fallen at least one time since admission on 4/18/2023. A review of Resident 1's High Risk for Recurrent Falls and Injury Care Plan related to dementia, hearing loss, impaired vision secondary to glaucoma (eye condition that can cause blindness), history of falls, impaired physical mobility, and impaired hearing was initiated on 1/16/2023, revised 6/29/2024. The care plan indicated a goal was to have no injuries related to falls for Resident 1. The care plan interventions included assisting Resident 1 with their activities of daily living (ADL's) and use of a sensor pad alarm when Resident 1 was in bed, to alert the staff when the resident was attempting to get out of bed unattended. The care plan did not include any supervision of Resident 1. A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, a technique that provides a framework for communication between members of the health care team about a patient's condition) Form and Progress Note dated 7/23/2024 at 10:19 AM, indicated the resident sustained two witnessed falls. The note indicated that on 7/22/2024 at 8:49 PM, "Resident 1 got up from the chair, lost balance and fell to the floor landing on her right thigh. Resident 1 complained of pain on their right thigh and two tablets of Tylenol (pain medication) 325 milligrams (mg- unit of measurement) was administered by mouth. Shortly after Resident 1's first fall, the resident threw herself on the floor and hit the back of her head on a treatment cart." The note further indicated Resident 1's physician was notified and gave orders to transfer the resident to GACH 1 for further evaluation for pain in right hip and right leg. The note indicated the resident would be picked up via ambulance at 2 AM on 7/23/2024. A review of Resident 1's Physician's Order dated 7/22/2024, indicated to transfer the resident to GACH 1 for further evaluation related to status post fall and pain on right hip and right leg. According to a review of Resident 1's GACH Emergency Department (ED) general visit note dated 7/23/2024, the resident fell twice earlier, had right hip pain and was confused. The ED Note indicated Resident 1 had dementia and the right leg was shortened and externally rotated. The ED Note indicated Resident 1's X-ray of the right hip showed a fracture with fragments and was admitted the GACH's medical / surgical unit for an Open Reduction Internal Fixation (ORIF, type of surgical procedure to treat broken bones, reposition broken bones, some form of hardware is used to hold the bone together so it can heal). A review of Resident 1's Post Fall Interdisciplinary Team (IDT) note dated 7/23/2024, indicated on 7/22/2024 the resident had a witnessed fall in the hallway during the 3-11 PM shift. Three to five minutes after the fall, the resident threw herself on the floor. The Post Fall IDT noted indicated Resident 1 was receiving hourly monitoring and using a front wheel walker when ambulating. During an interview on 7/31/2024 at 10:15 AM with Registered Nurse (RN 1), she stated Resident 1 could easily get upset and agitated because of the dementia. RN 1 stated residents with dementia need constant supervision as they were more at risk for falls and could act out irrationally. RN 1 stated she believed Resident 1 was receiving one-to-one supervision which means that someone was constantly watching Resident 1 and that it should be in the resident's orders and care plan. RN 1 was unable to provide documented evidence that Resident 1 was receiving one-to-one supervision prior to Resident 1's fall on 7/22/2024. During a telephone interview on 7/31/2024 at 11:48 AM, Certified Nursing Assistant (CNA 2) stated she was assigned to Resident 1 on the 3-11 PM shift on 7/22/2024. CNA 2 stated she was not present when the resident fell the first time, but it was witnessed by Licensed Vocational Nurse (LVN) 2. CNA 2 stated the resident was talking to herself and more agitated than usual. After Resident 1 had the first fall, LVN 2 assessed Resident 1 for injuries and sat the resident in a chair in the hallway. LVN 2 asked CNA 2 to watch Resident 1 while she called the resident's physician. CNA 2 stated she left Resident 1's side to get the resident juice to calm her down because she was agitated (severe restlessness). While CNA 2 was getting Resident 1's juice, CNA 2's back was turned, and Resident 1 threw herself to the floor. CNA 2 stated it happened so quick that there was no way to get to the resident in time to prevent her from falling. During an interview on 7/31/2024 at 12:46 PM, the Director of Nursing (DON) stated Resident 1 had a history of "impulsive" (doing things suddenly without thought) behaviors. If the resident did not get what they want right away, such as a juice or snack, the resident would become agitated. The DON stated that according to the report from LVN 2, LVN 2 stated that Resident 1 was sitting in a chair in the hallway and LVN 2 witnessed resident get up and fall to the floor on 7/22/2024. LVN 2 instructed CNA 2 to supervise Resident 1 while LVN 2 notified the resident's physician of the fall. CNA 2 left Resident 1 sitting in a chair in the hallway to get the resident a drink. While CNA 2 was away from Resident 1, the resident then threw herself to the floor. The DON stated that according to the Fall Risk Assessment dated on 6/21/2024, Resident 1 was a high risk for falls, had a history of falls and was identified as a high fall risk were placed on hourly visual checks. On 7/31/2024 at 2:23 PM, during an interview, the Administrator (ADM) stated close supervision was based on the needs of the resident. If a resident had a history of falls, was identified as a high fall risk, or posed a risk of harm to themselves one-to-one supervision would be recommended. The ADM stated Resident 1 should have probably been closely monitored and no one should have left the resident's side. The ADM stated Resident 1's care plan could have been adjusted to personalize her needs and potentially prevent the resident from falling. During a telephone interview on 8/5/2024 at 3:56 PM, LVN 2 stated she was the charge nurse during the 3-11 PM shift. LVN 2 stated that around 9 PM on 7/22/2024 she was at the medication cart and noticed Resident 1 standing in the hallway and making incoherent noises. LVN 2 stated she asked Resident 1 what she needed when Resident 1 continued walking and tripped and fell on her right side. LVN 2 assessed resident and assisted the resident with two other CNA's. LVN 2 then asked CNA 2 to take Resident 1's vital signs. CNA 2 then informed LVN 2 that Resident 1 was refusing to have her vitals taken and LVN 2 suggested for CNA 2 to get her juice to calm Resident 1 down. LVN 2 then stated CNA 2 yelled for LVN 2 because the resident threw herself on the ground. LVN 2 stated that if she did not ask CNA 2 to get the resident juice, she probably would not have fallen a second time because someone would have been watching the resident. A review of the facility's P&P revised November 2023 and titled, "Falls and Fall Risk Managing," indicated staff will monitor resident with dementia for any changes in condition and decline in function and report findings to the physician. The policy indicated the IDT would adjust interventions and overall plan depending on the progression of the dementia and other relevant factors. A review of the facility's P&P revised November 2023 and titled, "Fall Risk Assessment," indicated under Monitoring Subsequent Falls and Fall Risk, that staff would monitor and document each resident's response to interventions intended to reducing falling. If the resident continued to fall, the policy indicated the staff would re-evaluate the situation to continue or change current interventions. The facility failed to: 1. Ensure that Resident 1, whose fall risks included sensory deficits, abnormal gait self-injurious behaviors, and dementia with poor insight, received treatment and care in accordance with professional standards of practice for patients at high risk of injury and a comprehensive person-centered care plan to avoid falls. 2. Provide Resident 1, who had a diagnosis of dementia and behavioral issues, with the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 3. Ensure that Resident 1's environment remained as free of accident hazards as possible, causing Resident 1 to sustain a fall. 4. Ensure that Resident 1 received adequate supervision and assistance devices to prevent accidents, including failing to monitor Resident 1 after an initial fall on 7/22/2024 at 8:49 PM, resulting in a subsequent fall. 5. Identify Resident 1's care needs based upon an in