Health inspection·August 2, 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.

F744 42 CFR §483.40(b)(3) Treatment / Service for Dementia 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 6/24/2024, 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. Develop a comprehensive Fall Prevention Care Plan for Resident 1, who had diagnosis of Dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that the loss interferes with a person's daily life and activities), per the facility's policy and procedure (P&P) titled, "Person Centered Plan of Care." 2. Frequently monitor / supervise Resident 1 and anticipate Resident 1's needs to ensure the resident's safety to prevent falls. As a result, on 6/8/2024 (two days after admission), Resident 1, a 94 year old female, was found on the floor, complaining of pain, and was transferred to the General Acute Care Hospital (GACH) where Resident 1 was diagnosed with a left subcapital impaction fracture (type of intracapsular fracture in the proximal femur, where the fracture line runs through the junction of the head and neck of the femur) of the left femur (broken thigh bone) with minimal callus (thickening of or a hard thickened area on skin or bark), and mild displacement (change in position). The GACH recommended surgery. A review of Resident 1's Admission Record indicated the facility admitted the resident on 6/6/2024, with diagnoses including a history of falling, dementia, and osteoporosis (bone disease that develops when the structure and strength of the bone weakens). A review of Resident 1's Admission Assessment dated 6/6/24, indicated the resident's Morse Fall Score (method of assessing a patient's likelihood of falling) was 75. A score of 45 or higher indicated Resident 1 was a high risk for falls. A review of the Activities of Daily Living Self Care Performance Deficit Care Plan dated 6/6/2024 indicated the resident had activity intolerance due to disease process of dementia. The care plan goal indicated Resident 1 would improve current level of function and the care plan interventions included the following: -Provide the resident with 1-2 staff for repositioning and turning in bed every two hours and as necessary. -Provide the resident with total assistance with eating. -To have a side rails 1/5 up per physician's order for safety during care provision, to assist with bed mobility, reposition every two hours and as necessary to avoid injury. -Provide the resident with two staff for transferring. The care plan interventions did not include monitoring or supervision. A review of Resident 1's Nursing Progress Note dated 6/7/2024, indicated the resident was alert and oriented with periods of confusion and forgetfulness. The Nursing Progress Note indicated Resident 1 did not have any complaints of pain or discomfort. According to a review of the medical record, Resident 1 did not have a care plan for falls developed and there was no documentation regarding monitoring Resident 1 on 6/7/2024. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated 6/8/2024 at 7:21 AM, indicated Resident 1 was observed sitting on the floor. The SBAR indicated Resident 1 complained of pain but refused pain medicine. The SBAR indicated Resident 1's bed was in the lowest position and a floor mat was placed at bedside. The SBAR indicated the family and physician were notified of the incident. A review of Resident 1's Pain Assessment dated 6/8/2024 at 7:30 AM, indicated Resident 1's pain level was assessed as a three out of 10 for left knee pain, using the zero to 10 pain rating scale (zero equals no pain, and 10 equals the worst possible pain). The Pain Assessment indicated Resident 1's acceptable level of pain was a one. According to a review of the Nursing Progress Note dated 6/8/2024 at 12:53 PM, Resident 1 had mild left knee pain with facial grimacing but refused pain medication. The Nursing Progress Note indicated Resident 1 was alert with confusion and a floor mat was ordered for safety. A review of Resident 1's Nursing Progress Note dated 6/8/2024 at 10:33 PM, indicated Resident 1 continued to complain of pain on the left hip but stated the pain was tolerable and she refused pain medication. A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 6/9/2024, indicated Resident 1 had severe cognitive impairment (problems with a person's ability to think, remember, and make decisions). The MDS indicated Resident 1 required substantial to maximal assistance of facility staff with toileting hygiene, rolling to the left and right side and sit to lying and lying to sitting on the side of the bed. The MDS indicated Resident 1 was dependent on facility staff for transfers and the fall history on admission was unable to be determined. A review of Resident 1's Laboratory and Radiology Patient Report dated 6/9/2024 at 1:49 AM, indicated Resident 1 had a left subcapital impaction fracture (type of intracapsular fracture in the proximal femur, where the fracture line runs through the junction of the head and neck of the femur) with minimal callus (thickening of or a hard thickened area on skin or bark, and mild displacement (change in position). The report indicated the joint (part of the body where two or more bones meet to allow movement) showed no dislocation (separation of two bones where they meet at a joint). A review of Resident 1's SBAR dated 6/9/2024 at 6:55 AM, indicated Resident 1 had a left hip fracture and orders to transfer the resident to the GACH for further diagnosis and treatment were implemented. According to a review of the GACH History & Physical (H&P) dated 6/9/2024, Resident 1 was admitted for left hip pain and was noted to have a left hip fracture. The GACH H&P indicated Resident 1 was confused, disoriented, and complained of left hip pain. A review of Resident 1's GACH Computed Tomography (CT - diagnostic imaging procedure that uses a computer linked x-ray machine to create detailed images of the inside of the body) of the left hip, dated 6/10/2024, indicated Resident 1 had a subcapital fracture of the left femur (thigh bone) without significant displacement. A review of the GACH General Notes dated 6/10/2024, indicated Resident 1's legal guardian did not want the resident to have the recommended surgery. As a result, the surgery was cancelled. A review of Resident 1's H&P dated 6/12/2024, indicated Resident 1 was unable to provide accurate history of medical issues and did not have medical decision-making capacity. During an observation on 6/24/2024 at 10:45 AM in Resident 1's room at the facility, Resident 1 was observed lying in bed, call light within reach, a mat to the right and left side of the bed, and the bed was in the lowest position. Resident 1 stated there was pain in the left hip but refused pain medication. During an interview on 6/24/2024 at 11:15 AM, Licensed Vocational Nurse (LVN) 1 stated Resident 1 was a high risk for falls and the facility should have been monitoring Resident 1 for the risk for falls more frequently, because the resident was confused. On 6/24/2024 at 2:19 PM, during a concurrent interview and record review with LVN 1, Resident 1's care plans were reviewed. LVN 1 stated Resident 1 did not have a care plan for a history of falls developed or implemented since admission on 6/6/2024 (over two weeks). LVN 1 stated there should have been a care plan developed and implemented so the facility could anticipate and plan accordingly to accommodate the resident's needs to prevent falls. LVN 1 stated because there was a history of falls, Resident 1 was a known fall risk and should have been assessed further to prevent harm to Resident 1. LVN 1 stated this incident could have been prevented. During a concurrent interview and record review on 6/24/2024 at 2:44 PM with the Director of Nursing (DON), Resident 1's care plans were reviewed. The DON stated because the resident had a history of falls, a care plan should have been developed and implemented upon admission to the facility, to prevent Resident 1 from another fall or injury. The DON stated the fall could have been prevented if a Fall care plan was developed with interventions such as frequent monitoring to prevent injury. A review of the facility's policy and procedure (P&P) titled, "Person Centered Plan of Care," dated June 2023, indicated the person-centered care plan must describe services that were provided to the resident to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being that would accommodate resident needs, requests, and refusal to treatment. The P&P indicated the person-centered care plan would include interventions to attempt to manage risk factors and be periodically reviewed and revised by the Interdisciplinary Team as changes in the resident's care and treatment occur. The P&P indicated to re-evaluate and modify care plans as necessary to reflect changes in care, service, and treatment, quarterly, and with significant change in status assessment. Care plan evaluation must occur in response to changes in the resident's physical, emotional, functional, psychosocial, or communicative status as they occur. The facility failed to: 1. Develop a comprehensive Fall Prevention Care Plan for Resident 1, who had diagnosis of Dementia, per the facility's P&P titled, "Person Centered Plan of Care." 2. Frequently monitor / supervise Resident 1 and anticipate Resident 1's needs to ensure the resident's safety to prevent falls. As a result, on 6/8/2024 (two days after admission), Resident 1 was found on the floor, complaining of pain, and was transferred to the GACH where Resident 1 was diagnosed with a left femur fracture (broken thigh bone). The GACH recommended surgery. The above violations presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.