Health inspection·August 26, 2024

The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident (ERI) #: CA00866508 Abbreviated-Survey Event ID: 05L511 Representing the Department, HFEN #48616 State Citation B was written. §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. Title 22, §72315(e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her professional licensure. On 7/3/24 at 8:50 AM, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding an assisted fall with fracture. The facility failed to safely transfer Resident 1 with two persons assist using a Hoyer lift. This resulted in a fall and multiple injuries: Multiple broken ribs, Right-Sided Pneumothorax (presence of air in the space between the lung and chest wall leading to breathing difficulty and chest pain), and broken bone around the artificial joint of the left thigh; and caused Resident 1's pain, emotional trauma, and an increased fear in Hoyer lift transfers. Resident 1 was a 76-year-old female, a long-term resident since September 2014 and was readmitted to the facility in October 2023 with diagnoses that included contact with lifting devices, generalized muscle weakness, bed confinement status, obesity, and anxiety (mental disorder characterized by excessive worry or fear). Resident 1 had a cognitively intact mental status and was dependent on transfer to and from a bed to a chair. During a concurrent observation and interview on 7/3/24, at 12:00 p.m. with Resident 1, she was in a mid-fowlers (Head of bed elevated at 45 degrees) position in bed, fully awake and able to carry out a meaningful conversation. Resident 1 stated she had a fall and went to the hospital because of fractures on her ribs and hip. Resident 1 stated a CNA came alone to transfer her from bed to the shower chair using the lift and sling. Resident 1 also stated she knew there were supposed to be two staff to use the lift. During a follow-up interview with Resident 1, on 7/3/24 at 12:15 p.m., Resident 1 stated she told CNA she did not want to be transferred because she was scared. She stated CNA did not listen, placed her on the sling, and lifted her. Resident 1 stated she felt the sling was too small for her size and caused her to move due to hip discomfort and fear. Resident 1 further stated her fear of transfer using the sling and lift had increased. During a telephone interview with Registered Nurse (RN), on 7/3/24 at 12:25 p.m., RN stated he found Resident 1 on the floor inside her room and assessed her. RN stated he called 911 because Resident 1 had difficulty speaking upon assessment. Resident 1 also complained of pain on the right side of her chest. RN stated he did not recall CNA asking for help that day. RN stated it had been emphasized to nursing staff they should always use a two person assist with the Hoyer lift to ensure residents safety during transfer. During an interview with Director of Nursing (DON), on 7/3/24 at 2:50 p.m., DON stated she and Director of staff Development (DSD) spoke to CNA and asked about Resident 1's fall. DON also stated that CNA confirmed transferring Resident 1 by herself using the Hoyer lift. DON stated that Hoyer lift transfers always require a two person assist and expected nursing staffs to follow per the facility's policy and Hoyer lift training instructions. During a review of Resident 1's "Minimum Data Set" (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated October 2023 indicated Resident 1's "Brief Interview for Mental Status" (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) was 14 out of 15, indicating cognitively intact mental status. The "MDS" also indicated resident was dependent on transfer to and from a bed to a chair. During a review of Resident 1's "Fall Care Plan," problem start dated 4/16/16, indicated "Resident 1 was at risk for fall and injury due to history of falls and balance problem...Resident's risk of fall and injury will be minimized...Keep environment free of hazards...identify type of assistance resident needs...provide assistance as identified in transfer." During a review of Resident 1's "Care Plan Essentials" (pertinent information on resident's care used by nursing staffs), dated May 2023, indicated Resident 1 was a high risk for falls, required a Hoyer lift for transfers, and an assist of two people required. During a review of Resident 1's "Observation Detail List Report," dated 10/14/23 and completed by RN, the report indicated at 8:15 a.m., Resident 1 fell from a Hoyer lift during a transfer from the bed to a bath chair. The fall was witnessed by Certified Nursing Assistant (CNA). Resident 1 hit her head and had a lump on her head. Resident 1 complained of pain under her right armpit and ribs and had difficulty talking. RN called 911 and Resident 1 left the facility at 8:45 a.m. via ambulance. A facility document titled "Nurse Staffing Assignment and Sign-in Sheet," dated 10/14/23, indicated CNA worked that morning from 6:24 a.m. until 3:02 p.m. and she was the assigned CNA for Resident 1. During a review of Resident 1's "History and Physical (H&P)," from the medical-surgical department, dated 10/14/23, indicated Resident 1 was admitted due to fall from a Hoyer lift. Resident 1 had multiple right-sided broken ribs that includes the third, fourth, fifth, sixth ribs and trace right-sided pneumothorax from the Computerized Tomography (CT, an imaging method that uses x-rays and a computer to create pictures of cross-sections of the body) scan of the chest. The H&P also indicated Resident 1 had a Periprosthetic fracture of the left femur from the hip Xray. Resident 1's "Trauma and Critical Care Surgery Consult Notes," dated 10/14/23, indicated Trauma Surgeon (medical doctor who specializes in treating patients with traumatic injuries) assessed Resident 1 in the emergency room. The consult notes further indicated that Resident 1 had met the Alameda County criteria for trauma activation (immediate attention) due to her injuries. Resident 1's "Discharge Summary" from the acute hospital, dated 10/20/23, indicated Resident 1's right-sided pneumothorax got worse, and required an Interventional Radiology pigtail (IR pigtail- image-guided procedure of a catheter insertion) into the right chest cavity to treat the Pneumothorax from 10/16/23 until 10/19/23. During a review of the facility training instruction document titled, "Use of Hoyer Lift Training," indicated "knowing the lift and how to use it correctly can prevent patient falls from lifts-which may cause injuries, including head trauma, fractures, and death...choosing correct sling size is critical for safe patient transfer...sling too small: patient may fall out. Sling may worsen patient's condition...lifts require two or more caregivers to safely operate lift and handle patient." The facility's policy and procedure (P&P) titled, "Resident Transfer: Mechanical Lift," undated, indicated "A mechanical lift is used to safely facilitate transfer of residents whose functional ability or preference requires use of a lift...Manufacturer's instructions and recommendations should always be followed, including the number of staff needed for a safe transfer. Mechanical lifts require at least a 2-person assist or as per manufacturer's instructions." The facility failed to safely transfer Resident 1 with two persons assist using a Hoyer lift. This resulted in a fall and multiple injuries: Multiple broken ribs, Right-Sided Pneumothorax (presence of air in the space between the lung and chest wall leading to breathing difficulty and chest pain), and broken bone around the artificial joint of the left thigh; and caused Resident 1's pain, emotional trauma, and an increased fear in Hoyer lift transfers. The above violation had a direct relationship to the health, safety, or security of patients.