Incident investigation·December 15, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Program Director Karen Pultorak. LPA also met with Executive Director Bonghabih “BeeBee” Shey, who arrived later during the visit. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/06/2023), involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a facility tour and welfare check on R1 and other residents in care. LPA reviewed and collected copies of pertinent care, hospital, and personnel records. LPA also interviewed relevant staff and outside sources and observed the facility’s mechanical lift machines. According to R1’s latest LIC602 Physician’s Report (dated 08/04/2023): R1 was diagnosed with “Advanced Dementia” and “Gait Disorder,” was wheelchair-bound, and required use of a “Hoyer Lift” machine to transfer from bed to wheelchair, and vice versa. The Needs and Services Plan which licensee authored on R1 reiterated that R1 was “non-weight-bearing” and “wheelchair bound.” Due to their baseline memory loss, R1 could not recall the above incident. However, records and staff interviews showed: On the morning of 11/29/2023, Staff #1 (S1), without the assistance of a teammate, used a Hoyer Lift machine to try to transfer R1 from bed to wheelchair. The two legs of the Hoyer Lift machine were not spread and locked in the wide-open position (to maximize stability) while R1 was suspended in the air (via the associated sling). During a subsequent pivot maneuver, the machine tipped over and R1 landed on the floor of their bedroom. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] During the landing, R1’s right arm / shoulder was pinned between a chair and a small dresser, which were nearby. A facility nurse quickly determined R1’s had pain and limited range of motion and phoned 911. R1 was sent to a hospital emergency room where they were diagnosed with a fracture of their right humerus (a bone in the upper arm). R1 was discharged back to the facility later the same day, with a sling for their arm and as-needed pain medication. Staff interviews unanimously showed: Even prior to this incident, licensee’s training expectations for its direct care staff included: a) use of the Hoyer Lift machine must be accompanied by assistance of at least two staff persons to ensure safety; and, b) the legs of the Hoyer Lift machine must be locked in the open-wide position prior to lifting a resident. Personnel and training records showed: Following the incident, Licensee performed written corrective action and coaching with S1 on 11/29/2023 and 12/06/2023. On 12/11/2023 and 12/13/2023, Licensee also retrained its larger direct care staff team on correct use of Mechanical Lifts; the training included a skills validation component. Manager and staff interviews, corroborated by the facility’s work schedule, showed: The AM shift on 11/29/2023 (when the incident occurred) was fully staffed at the caregiver, med tech, and nurse positions (i.e., there was no shortage of teammates available to S1 to ask for help with the Hoyer Lift machine). Following the incident, licensee inspected the specific Hoyer Lift machine and sling used during the incident and found them free of defects – LPA observation of said machine and sling, during today’s visit, confirmed this. S1 admitted to CCLD that their performance with the Hoyer Lift machine on 11/29/2023 did not display the level of competence necessary to ensure R1’s safety. Interviews of staff and outside sources showed: As R1 was being sent to the hospital on 11/29/2023, facility staff timely notified R1’s physician and responsible person (RP) of the incident via phone call, then sent a written LIC624 Incident Report to CCLD on 12/06/2023. However, the licensee did not send a copy of the LIC624 to R1’s responsible person, which was required to be done within seven days of incident occurrence. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] A preponderance of evidence exists to show that during the incident in question, licensee’s staff (S1) did not display competence necessary to meet a resident’s needs, which was material to R1 sustaining serious bodily injury. A preponderance of evidence exists to show that licensee did not fully meet reporting requirements. Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). An immediate civil penalty of $500 was also assessed (refer to the LIC421-IM). Plans of Correction was jointly developed with the licensee. LPA also provided Technical Assistance (TA) regarding another Hoyer Lift machine present at the facility, different than the one used by S1 during the above incident (refer to the LIC9102-TA). An exit interview was conducted with Shey, to whom a copy of this report, the LIC 809-D, the LIC421-IM, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.