Health inspection·April 3, 2025

F689 The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00944714 A Class A Citation was written. 42 CFR §483.25(d) Free of Accident Hazards/Supervision/Devices 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. 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 CR §72523: §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. 22 CCR § 72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. On 2/18/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident about a fall and conduct an annual recertification survey. The facility failed to revise or update fall care plan for Resident 165, who was a high fall risk, to include updated interventions after the resident fell on 12/28/2024. As a result, on 2/3/2025, Resident 165 fell causing the resident to suffer severe pain and a left hip fracture (broken bone) requiring an open reduction and internal fixation (ORIF - a type of surgery used to stabilize and repair broken bones, using screws, plates, sutures, or rods to hold the bone together and for healing). During a record review, Resident 165's Admission Record indicated the facility admitted the resident, a 92-year-old male, on 10/2/2019 with diagnoses including dementia (a progressive state of decline in mental abilities), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and a history of falling. During a record review, of Resident 165's "at risk for falls" care plan, the care plan was initiated on 10/17/2019 and reviewed on 1/7/2025, indicated the resident was at risk for falls due to the resident's dementia, lack of safety awareness, and poor judgment. The care plan indicated the goal included to reduce the resident's risk of falls and injury. The care plan interventions directed staff to: - Visibly observe resident frequently. - Encourage the resident to attend and participate in activity programs; and - Provide safety instruction to resident regarding ambulation, transfers, and ADLs when appropriate. Bilateral 1/3 side rails (a barrier on the side of the bed that prevents one from falling out of bed) up and grab bars (bars are safety devices designed to enable a person to maintain balance, lessen fatigue while standing), walker. The care plan indicated all interventions were initiated on 10/18/2019. During a record review, Resident 165's care plan titled, "Resident is at risk for spontaneous/ pathological (a break in the bone caused by a disease and not an injury)/ stress fracture (a small crack in the bone caused by placing too much stress on the bone)," initiated on 2/22/2022 and reviewed on 1/7/2025, indicated the resident was at risk for fracture related to osteoarthritis. The care plan goal included to reduce the risk of fracture and injury to Resident 1. The care plan interventions indicated to: - Perform x-ray as indicated - Provide a safe and hazard free environment - Assist with all transfers and ambulation as needed - Facility POP (Protect Our Patients from Pathological Fracture) program -Fall risk interdisciplinary team (IDT - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) conference. The care plan indicates interventions have not been updated since the plan was first initiated on 02/22/2022. During a record review, Resident 165's History and Physical (H&P), dated 11/13/2024, indicated Resident 165 did not have the capacity to understand and make decisions. During a record review, Resident 165's Change of Condition (COC- clinically important deviation from a patient's baseline) form, dated 12/28/2024, indicated Resident 165 was observed sitting on the floor on the left side by the housekeeping staff and the charge nurse in the smoking patio. The COC indicated the resident reported to Registered Nurse (RN) 1 that he was walking towards the resident's chair to sit down when he [Resident 165] fell. The COC indicated that per Resident 165, the resident landed on the butt and back and did not have pain or discomfort. The COC further indicated Resident 165 was noted with same shuffling gate pattern. During a record review, Resident 165's Quarterly Minimum Data Set (MDS- a resident assessment tool) dated 1/2/2025, indicated the resident's cognition (ability to think, understand, and reason) was moderately impaired. The MDS indicated Resident 165 required supervision or touch assistance (helper provides verbal cues and /or touching/steadying as the resident completes the activity) with oral hygiene, upper body dressing and toileting hygiene. The MDS also indicated Resident 165 uses a walker for mobility and required supervision or touching with walking 10 feet, 50 feet and 150 feet. The MDS further indicated Resident 165 had one prior fall since the last MDS assessment (assessments are completed every 3 months. [Date not indicated.]) During a record review, Resident 165's Fall Risk Assessment dated 1/2/2025 (one month prior to the 2/3/2025 fall), indicated Resident 165 scored 22 (high risk for falls). During a record review, Resident 165's COC form, dated 2/3/2025 (37 days after the 12/28/24 fall), indicated Resident 165 was observed sitting on the smoking patio floor. Resident 165 complained of pain to the buttocks and both thighs. The COC also indicated the resident reported a 7/10 pain level with movement and the physician ordered a stat (immediate) x-ray of both hips. During a record review, Resident 165's Radiology Results Report (from the facility), dated 2/4/2025, indicated Resident 165 had x-ray of both hips. The x-ray report indicated Resident 165 had an intertrochanteric left femoral fracture (left thigh bone break). During a record review, Resident 165's COC form, dated 2/4/2025, indicated the x-ray results indicated Resident 165 had left thigh fracture. The COC further indicated a physician ordered to transfer the resident to GACH. During record review, Resident 165's Physician Order, dated 2/4/2025, indicated the facility to transfer Resident 165 to GACH 1 for evaluation of acute intertrochanteric left femoral fracture sustained after a fall. During a record review Resident 165's Progress Note, dated 2/5/2025, indicated the resident was transferred to GACH 1 via non-emergency medical transportation. During a record review, Resident 1's GACH 1's Emergency Department (ED) Medical Doctor (MD) Note, dated 2/5/2025, indicated Resident 165 presented to the ED after falling while trying to go smoke. The ED MD note also indicated Resident 165 complained of left arm and hip pain and received Morphine (an opioid pain medication) 2 milligrams (mg - unit of measurement) intravenously (IV -inside a vein) for pain control (pain level not indicated). The ED MD note further indicated Resident 165's x-ray showed a comminuted (where the bone breaks in two or three places) left hip fracture. During a record review, Resident 165's Orthopedic (branch of medicine that focuses on the diagnosis and treatment of bones, muscles, and ligaments) Surgical Consultation Report, dated 2/5/2025, indicated the resident came to the GACH complaining of pain involving the left hip, which developed following a ground level fall landing on the left hip. The Orthopedic Surgical Consultation Report also indicated there was tenderness and swelling around the left hip and that Resident 165 experienced pain when attempting range of motion (ROM - the extent to which a joint in the body can move) to the left hip. The Orthopedic Surgical Consultation Report further indicated the x-ray of the left hip revealed a comminuted unstable left hip fracture. During a record review, Resident 165's GACH 1 Operative Report, dated 2/16/2025, indicated Resident 165 had an ORIF surgery on 2/16/2025 to treat the resident's left femoral fracture. During a record review, Resident 165's GACH Discharge Orders dated 02/20/2025 at 5:47 PM, indicated to discharge the resident back to the facility. During a record review, Resident 165's Discharge Planning dated 02/20/2025 at 5:51 PM, indicated the resident to take Hydrocodone (Norco - strong controlled pain medication) 5 mg (milligrams-unit of measurement) + (plus) Acetaminophen oral (mouth) - 325 mg, take 1 tablet every 4 hours PRN (as necessary) ... Do not exceed 3 grams (gms - unit of measurement) per day of Acetaminophen. During a concurrent interview and record review 2/20/2025 at 10:18 AM with Registered Nurse Supervisor (RN) 1, Resident 165's electronic health records were reviewed. While reviewing Resident 165's COC form dated 2/3/2025, RN 1 stated that Resident 165 was found sitting on the ground on the smoking patio. RN 1 stated whenever a resident is found on the floor, the resident is considered to have fallen. RN 1 stated Resident 165 complained of pain when found on the patio floor and was administered Tylenol (pain medication). RN 1 stated Resident 165 had slight pain relief. RN 1 further stated that on 12/28/2024, Resident 165 fell while RN 1 was on duty but was not injured from that fall. During a concurrent review of Resident 1's care plans, RN 1 stated RN 1 did not update Resident 165's fall care plan after the fall on 12/28/2024 or did not create a new care plan that addressed the resident falling. RN 1 stated the fall care plan should have been updated to prevent the resident from falling again. RN 1 further stated an updated care plan should address the resident's needs and may have prevented the resident from falling and breaking his bone. During a concurrent interview and record review with the Director of Nursing (DON) on 2/21/2025 at 10:40 AM, Resident 165's care plans and COCs were reviewed. The DON stated Resident 165 had two recent falls. The DON stated after Resident 165 fell on 2/3/2025, the resident was transferred to a GACH and was diagnosed with a left hip fracture. Upon reviewing Resident 165's care plans, the DON stated Resident 165's care plan interventions to prevent falling were not updated after the resident fell on 12/28/2024. The DON stated Resident 165's risk for fall care plan interventions were not updated after 10/18/2019. The DON further stated the care plan addresses the resident's identified problems and contains interventions to prevent or minimize the risk to residents. The DON further indicated staff update the care plan when new issues arise, and the care plan should have been updated after the 12/28/24 fall to prevent or minimize the risk of Resident 165 falling again. During a record review, the facility's policy, and procedures (P&P) titled, "Safety and Supervision of Residents," revised 7/2017, indicated, "resident safety and supervision and assistance to prevent accidents are facility-wide priorities." The P&P also indicated, "monitoring the effectiveness of interventions shall include evaluating the effectiveness of interventions, modifying or replacing interventions as needed and evaluating the effectiveness of new or revised interventions." During a record review, the facility's P&P titled, "Falls - Clinical Protocol," revised 3/2018, indicated, "while many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. For an individual who has fallen, the staff will begin to try to identify possible causes within 24 hours of the fall. Often, multiple factors contribute to a falling problem." The P&P also indicated, "The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable." The P&P further indicated, "based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling." During a record review, the facility's P&P titled, "Care Plans, Comprehensive Person-Centered," reviewed 3/2023, indicated, "a comprehensive care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was to be developed and implemented for each resident. The care planning process will include an assessment of the resident's strengths and needs, incorporate the resident's personal and cultural preferences in developing the goals of care." The P&P further indicated, "assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change." The facility failed to revise or update fall care plan for Resident 165, who was a high fall risk, to include updated interventions after the resident fell on 12/28/2024. As a result, on 2/3/2025, Resident 165 fell causing the resident to suffer severe pain and a left hip fracture requiring an ORIF. 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 for Resident 165.