Health inspection·May 23, 2024

F689 42 CFR § 483.25 Free of Accidents / Supervision The facility must ensure that – (d)(1) The resident environment remains as free of accident hazards as is possible; and (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 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 4/22/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident (FRI) regarding resident safety. The facility failed to ensure Resident 1, who had dementia (impaired ability to remember, think, or make decisions), a history of multiple falls, and was a high risk for falls, received the care and services necessary to prevent accidents and falls by failing to: 1. Implement facility's policy and procedure (P&P) titled "Fall Prevention Program," to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling. 2. Evaluate interventions for effectiveness and implement new interventions to prevent repeated fall incidents after Resident 1 fell on 12/7/2023, 3/20/2024, and 4/17/2024. 3. Monitor the resident for the behavior of trying to get out of bed without assistance as per physician's order dated 11/10/2023. As a result, Resident 1 had repeated fall incidents and on 4/17/2024 was found on the floor with a laceration (a deep cut or tear in the skin) to the right eyebrow requiring transfer to the General Acute Care Hospital 1 (GACH 1). A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 9/11/2023, with diagnoses including history of falling, dementia, lack of coordination and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of Resident 1's admission Fall Risk Assessment dated 9/11/2023, indicated the resident had a very high risk for potential for falls. The assessment indicated the resident had not had any falls 90 days prior to the assessment date. The assessment indicated Resident 1 had adequate vision, was confined to bed (unable to get up from bed without assistance), did not use the call light or the bathroom call cord reliably. A review of Resident 1's admission Risk for Falls Care Plan initiated on 9/11/2023, indicated Resident 1 had a history of falls prior to admission to the facility and the resident had dementia and Alzheimer's disease. The care plan goal for the resident was to have reduced occurrence of injury from falls for three months. The care plan interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) to prevent falls were to monitor the resident`s whereabouts daily, help with transfers and ambulation, provide proper fitting shoes, provide safe and clutter free environment, and to keep the call light and personal items within the resident's reach. According to a review of Resident 1's History and Physical dated 9/14/2023, the resident did not have the capacity to understand and make decisions due to dementia. A review of the Physician’s Orders dated 11/10/2023, indicated facility staff was to monitor Resident 1 for the behavior of trying to get out of bed without assistance every shift. A review of Resident 1's Situation, background, assessment, and recommendation (SBAR: a form that is a documentation of a complete assessment in response to a change in condition) Communication Form dated 12/7/2023, indicated the charge nurse found Resident 1 on the floor next to the bathroom door. The SBAR form indicated Resident 1 stated she went to the bathroom (on 12/7/2023) to void (urinate) and when she was returning to the bed, lost her balance and fell on the floor. A review of Resident 1's Post Fall Assessment dated 12/7/2023, indicated Resident 1 was forgetful and confused, had impaired hearing, impaired judgment skills (the ability to make effective decisions), and impaired safety awareness. The post fall assessment indicated Resident 1 exhibited declined (lessening) cognitive skills, and loss of coordination due to Alzheimer's disease and dementia and was not using ambulation aid (walker, wheelchair) or appropriate footwear. A review of Resident 1's Fall Scene Investigation Report dated 12/7/2023, indicated Resident 1 lost her balance and was found on the floor in her room. The investigation report indicated Resident 1 refused help and tried to go to the bed from the bathroom after voiding. According to a review of Resident 1's Interdisciplinary Team Summary and Recommendation (IDT, a team of health care professions, which include the facility's medical director, Director of Nursing [DON], social worker, registered nurse, and other staff as needed who work together to establish plans of care for residents) dated 12/7/2023, the IDT team recommended the following: to instruct the resident not to get out of bed without assistance, monitor the residents behavior of trying to get out of bed without assistance every shift, apply floor mats (a small piece of strong material that covers and protects part of a floor and is designed to absorb impact and reduce the risk of injury) at bedside, place the resident on Falling Star Program (a fall prevention program, that focuses on promoting a safe environment and anticipating the patient's needs to prevent a fall) for three months, and offer toileting program (helping a resident ambulate to the toilet, scheduling regular bathroom trips to avoid accidents, or changing adult diapers). A review of Resident 1's Risk for Falls Care Plan revised on 12/11/2023, indicated Resident 1 was found on the floor in front of the bathroom on 12/7/2023. The care plan indicated Resident 1 complained of pain to the left hip area. The care plan indicated the X-Ray (digital image of part of the body) results indicated no fracture. The care plan interventions indicated the resident was to be placed on the Falling Star program for three months, staff was to perform visual checks every hour for four (4) weeks, apply floor mats to the bedside, monitor for the behavior of trying to get out of bed, instruct the resident not to try to get out of bed without assistance, use the call light, keep the bed in the lowest position, and to start the resident on toileting program. The care plan intervention indicated Resident 1 refused toileting program on 12/13/2023. A review of Resident 1's Physical Therapy (PT- certain exercises, massages, and treatments that relieve pain and help you move better) Evaluation and Plan of Treatment dated 12/12/2023, indicated the resident was referred to PT due to falling. The evaluation form indicated Resident 1 presented with generalized weakness, incoordination (lack of coordination), and impaired balance resulting in overall decline with functional mobility skills. The evaluation form indicated Resident 1 required extensive assistance with task performance and was at risk for falls and immobility (unable to move). A review of Resident 1's Medication Administration Record (MAR) for the month of January 2024, indicated the resident did not demonstrate the behavior of trying to get out of bed during any shift in January 2024. A review of Resident 1's Occupational Therapy (OT-therapy that focuses on helping people do all the things that they want and need to do in their daily lives) Evaluation and Plan of Treatment dated 2/22/2024, indicated the resident demonstrated decreased safety and dynamic sitting/standing balance which placed the resident at risk for falling. According to a review of Resident 1's MAR for the month of February 2024, the resident did not demonstrate behavior of trying to get out of bed during any shift in February 2024. A review of Resident 1's Minimum Data Set (MDS- standardized assessment and care planning tool) dated 3/7/2024, indicated the resident had severely impaired cognition and was dependent on facility staff for showering. The MDS indicated Resident 1 required maximum facility staff assistance with toileting hygiene, personal hygiene, lower body dressing, sit to stand (the ability to come to standing position from sitting in a chair, wheelchair and or on the side of the bed), and chair/bed to chair transfer (the ability to transfer to and from a bed to chair or wheelchair). The MDS indicated Resident 1 required partial/moderate assistance from facility staff with oral hygiene, upper body dressing, toilet transfer (the ability to get on and off a toilet or commode) and sit to lying (the ability to move from sitting on side of the bed to lying flat on the bed). A review of Resident 1's Quarterly Fall Risk Assessment dated 3/7/2024, indicated the resident was at a very high risk for potential falls. The fall risk assessment form indicated Resident 1 had 1-2 falls within the last 90 days prior to the assessment date (3/7/2024), displayed behaviors which placed the resident at risk for falls, had impaired safety awareness. The Fall Risk Assessment indicated Resident 1 had adequate vision, was incontinent (not able to control the flow of urine from the bladder or the escape of stool from the rectum), did not use call light or bathroom call cord reliably, and did not have adequate safety awareness to wait for help. A review of Resident 1's Incident Report dated 3/20/2024, indicated Certified Nursing Assistant (CNA- unnamed) reported she heard sounds (on 3/20/2024) coming from Resident 1's room. Upon entering, CNA (unnamed) found Resident 1 on the floor next to her bed. A review of Resident 1's SBAR Communication Forms for 3/20/2024, indicated no SBAR communication form was documented by the licensed staff after Resident 1 fell on 3/20/2024. A review of Resident 1's Fall Morse Assessment dated 3/20/2024, indicated the resident had fallen previously, had impaired gait, and overestimated (think they are stronger than they really are) or forgot her limits. The fall assessment did not indicate whether Resident 1 was considered a high risk for fall or not. According to a review of Resident 1's Post Fall Assessment dated 3/20/2024, the resident was forgetful and confused, exhibited loss of coordination due to Alzheimer's disease and dementia, had impaired safety awareness and hearing, and was not using ambulation aid (walker, wheelchair) and appropriate footwear. A review of Resident 1's Fall Scene Investigation Report dated 3/20/2024, indicated Resident 1 lost her balance and strength and was found on the floor in her room. The investigation report further indicated Resident 1 stated she was trying to go to bathroom. A review of Resident 1's IDT Summary and Recommendation form dated 3/20/2024, indicated the following recommendations: remind resident to use the call light when assistance needed, instruct the resident not to get out of bed without assistance, monitor behavior of trying to get out of bed without assistance every shift, apply floor mats at bedside, keep the resident`s bed in the lowest position, answer the call light in timely manner, provide frequent visual checks, and to offer toileting program. A review of Resident 1's Actual Fall Care Plan initiated on 3/25/2024, indicated on 3/20/2024 at 7:35 PM, Resident 1 was observed on the floor at the bedside. The care plan indicated the resident stated she lost her balance and fell on the floor while trying to go to the restroom by herself. The care plan indicated a goal for the resident was to minimize episodes of falls or injury within the next 30 days. The care plan interventions were to anticipate and meet the resident`s needs, place the call light within his reach, encourage the resident to use the call light for assistance as needed, educate and remind the resident to request assistance prior to transfer/ambulation, conduct frequent visual checks, keep her bed in a low position, monitor her behavior of trying to get out bed without assistance, and to provide non-skid (designed to prevent sliding), proper fitting socks/shoes as indicated. A review of Resident 1's SBAR Form dated 4/17/2024, indicated the resident had a fall on 4/17/2024 with a laceration to the right eyebrow with moderate bleeding and pain. The SBAR communication form indicated Resident 1’s physician ordered to transfer the resident to GACH 1. According to a review of Resident 1's Fall Morse Assessment dated 4/17/2024, the resident had fallen previously, had weak gait, and overestimated or forgot her limits. The fall assessment did not indicate whether Resident 1 was considered a high risk for fall or not. A review of Resident 1's Post Fall Assessment dated 4/17/2024, indicated Resident 1 had diagnoses of dementia and Alzheimer's, and incontinence, was forgetful and confused, exhibited declined cognitive skills and a loss of coordination due to Alzheimer's disease and dementia, had impaired safety awareness, judgment skills and hearing. A review of Resident 1's IDT Summary and Recommendation dated 4/17/2024, indicated the following recommendation: Rehabilitation services as needed, continue to monitor behavior of trying to get out of bed without assistance, remind the resident to use the call light when assistance needed, visual checks every hour for three months, and to instruct the resident not to get out of bed without assistance. A review of Resident 1's GACH 1 Emergency Department (ED) Summary of Care dated 4/18/2024 at 4:23 AM, indicated the resident was sent to ED for head injury and laceration to right eyebrow which was treated in the ED. A review of Resident 1' MAR for the month of April 2024, indicated the resident did not display the behavior of trying to get out of bed during any shift in April 2024. During a concurrent observation and interview on 4/22/2024 at 9:10AM, inside Resident 1's room, Resident 1 was observed laying in her bed. Resident 1 had a dressing over her right eyebrow. The Certified Nursing Assistant 1 (CNA1) present at Resident 1's bedside stated Resident 1 was confused and was trying to get out of bed. During an interview on 4/22/2024 at 9:30AM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was forgetful and confused. LVN 1 stated Resident 1 was not able to walk independently and required assistance with walking. LVN 1 stated "She [Resident 1] tried to get up on her own. Today [4/22/2024] she did not get up without assistance and she was calm. She [Resident 1] said, 'I want to go outside, or I want to go see my son