Other·October 16, 2023

The following reflects the findings of the California Department of Public Health during the investigation of facility-reported incident # CA00763500. Survey Event ID: N0DR11. Representing the Department, HFEN # 27406. State Citation B was written. F 689 CFR §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident [Patient, the terms 'patient' and 'resident' can be used interchangeably] 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. On 5/22/23 at 2:00 pm, an unannounced visit was conducted at the facility to investigate a facility-reported incident regarding an accident involving a patient. The facility failed to ensure nursing staff followed policy and procedure for use of a mechanical lift (an assistive device for lifting and transferring people from one surface to another) for one of two patients (Patient 1) when two staff members attempted transfer of Patient 1 instead of the four staff members as per Patient 1's care plan. This failure resulted in the mechanical lift tipping over, causing Patient 1 to fall and break her femur (the thigh bone) during a transfer from her bed to her wheelchair. Patient 1's broken femur resulted in a five-day hospitalization, pain, and emotional distress. During a review of Patient 1's Admission Record (AR), undated, the AR indicated Patient 1 was a woman in her 80s admitted to the facility in 2015 with diagnoses that included obesity, difficulty walking, and general weakness. The AR indicated Patient 1 had a conservator (a person appointed through legal proceedings to make healthcare and/or financial decisions for a person adjudged to be without mental capacity to make such decisions). During a review of the Minimum Data Set (MDS, a patient assessment instrument used to identify patient care problems to be addressed in an individualized care plan), dated 10/18/21, the MDS indicated Patient 1 had impaired vision which required use of corrective lenses, was totally dependent upon two or more staff for transfer between surfaces, and required extensive assistance from one person for dressing, toilet use, personal hygiene, and bathing. The MDS indicated Patient 1 had a score of 12 on the Brief Interview for Mental Status exam (BIMS, a scoring system used to determine the patient's cognitive status with regard to attention, orientation, and ability to register and recall information. A BIMS score of 8-12 is an indication of moderate cognitive impairment.) During a review of Patient 1's "Fall Risk Assessment" (FRA), dated 9/8/21, the FRA indicated Patient 1 had a score of 16. The FRA indicated a score of 10 or more represents high risk. During a review of Patient 1's care plan titled, "Safety," initiated 2/23/17, the care plan indicated Patient 1 was a high risk for falls due to impaired mobility, lacked awareness of safety needs, disorientation, mood-altering medications, and shortness of breath (SOB). The care plan indicated Patient 1 was provided a wheelchair for mobility and safety. The care plan indicated an intervention, dated 2/22/19, cancelled on 12/22/21, for transfers between surfaces to be completed through use of a mechanical lift with the assistance of three certified nursing assistants and one licensed nurse. During a review of Patient 1's progress notes dated 11/30/21, by Licensed Nurse 1 (LN 1), the progress notes indicated on 11/30/21 at 5:00 a.m., while Certified Nursing Assistant 1 (CNA 1) and Certified Nursing Assistant 2 (CNA 2) transferred Patient 1 with the mechanical lift, the mechanical lift tilted sideways, and Patient 1 fell on the floor. The progress notes indicated six staff physically assisted Patient 1 from the floor to the wheelchair. The progress notes indicated Patient 1 was given acetaminophen at 5:45 p.m. for right knee pain. During an interview on 5/22/23, at 11:30 a.m., with CNA 1, CNA 1 stated she and CNA 2 were transferring Patient 1 from the bed to a wheelchair using a mechanical lift. CNA 1 stated the legs of the lift hit the bed frame when turning toward the wheelchair which caused the lift to tilt to one side and required the certified nursing assistants to lower Patient 1 to the floor. During an interview on 5/22/23, 12:50 a.m., with CNA 2, CNA 2 stated she and CNA 1 had been using a mechanical lift to transfer Patient 1 out of bed, while Licensed Vocational Nurse 1 (LVN 1) and Registered Nurse 1 (RN 1) observed the process. CNA 2 stated the lift wheels had hit the bed frame during the transfer causing the lift to tilt and drop Patient 1 to the floor in a seated position. During an interview on 8/31/23, at 2:40 p.m., with LVN 1, LVN 1 stated on the morning of 11/30/21, he and RN 1 had been supervising while CNA 1 and CNA 2 had transferred Patient 1 from the bed to a wheelchair. LVN 1 stated CNA 1 and CNA 2 were turning and backing up when the mechanical lift hit the bedframe, tilted, and Patient 1 fell to the floor. During an interview on 8/31/23, at 2:52 p.m., with RN 1, RN 1 stated she and LVN 1 were in Patient 1's room supervising Patient 1's transfer with the mechanical lift while CNA 1 and CNA 2 placed Patient 1 in the mechanical lift to transfer her from the bed to a wheelchair. RN 1 stated she had not known how to use the manual mechanical lift which the certified nursing assistants were using. RN 1 stated when Patient 1 was lifted off the bed, the mechanical lift tilted and dropped Patient 1 on the floor. During a concurrent observation and interview on 5/22/23, at 1:30 p.m., with Patient 1 in her room, Patient 1 sat on the side of her bed with her feet dangling off the side of the bed. Patient 1 stated she had been "clobbered" and asked why she had received a bill after being injured. During an interview on 8/31/23, at 3:30 p.m., with the Director of Nursing (DON), the DON stated Patient 1's fall was caused by lack of sufficient staff as Patient 1's care plan required the use of four staff members during transfer with the mechanical lift. The DON stated only the two certified nursing assistants had used the lift while licensed staff had observed and had not provided necessary hands-on assistance. During a review of Patient 1's Radiology Report, dated 11/30/21, the Radiology Report indicated another X-ray would need to be completed as the 11/30/21 exam was not adequate to "definitely" conclude whether Patient 1 had sustained a supracondylar fracture of the right femur (the thigh bone is broken at the knee joint). During a review of Patient 1's Radiology Report, dated 12/1/21, the Radiology Report indicated the repeat X-ray was not able to determine if Patient 1 had a supracondylar fracture of the right femur. During a review of Patient 1's progress notes dated 12/1/21, at 5:05 a.m., the progress notes indicated Patient 1 had received acetaminophen for a complaint of pain at the right knee at a level of three (on a scale of zero to ten with zero equal to no pain and ten the worst pain). During a review of Patient 1's progress notes dated 12/2/21, at 1:30 p.m., the progress notes indicated Patient 1 was sent to acute care hospital for a 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 right knee to rule out a fracture. During a review of Patient 1's CT report of Lower Extremity without Contrast-Knee from the acute care hospital, dated 12/2/21, the CT report confirmed there was a comminuted (broken in at least two places) fracture of the right femur at the knee joint. During a review of Patient 1's discharge notes from the acute care hospital dated 12/7/2023, the progress notes indicated Patient 1 was hospitalized from 12/2/21 to 12/7/21. During a review of the facility's "Lifting Machine" policy and procedure (P&P) dated 9/1/13, the Lifting Machine P&P indicated the policy of the facility was to utilize portable lifting equipment in a safe and comfortable manner, based on individual resident's needs and/or plan of care. In violation of the above cited standards, the facility failed to ensure Patient 1's environment remained as free of accident hazards as is possible; and that Patient 1 received adequate supervision and assistance devices to prevent accidents, including but not limited to: the facility failed to ensure nursing staff followed policy and procedure for use of a mechanical lift (an assistive device for lifting and transferring people from one surface to another) for one of two patients (Patient 1) when two staff members attempted transfer of Patient 1 instead of the four staff members as per Patient 1's care plan. This violation had a direct or immediate relationship to the health, safety, or security of Patient 1.