Health inspection·February 4, 2025

The following reflects the findings of the California Department of Public Health during the investigation of: Facility-Reported Incident (FRI) # CA00932802. Survey Event ID: LXDR11 State Citation B was written. §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. On 12/11/24 at 10:30 a.m., an unannounced visit was conducted at the facility to investigate a Facility-Reported Incident regarding an accident allegation. Patient 2 was an elderly female who was admitted to the facility in February 2023 with diagnoses that included chronic pain syndrome (persistent pain that lasts for more than three months and does not respond to conventional treatments), abnormalities of gait and mobility, polyneuropathy (disease that damages the peripheral nerves, causing weakness, numbness, and burning pain), and osteoarthritis (a joint disease that occurs when the cartilage and bone in a joint break down over time). Patient 2 was totally dependent (helper does all the effort, or the assistance of two or more helpers is required for the patient to complete the activity) on staff for care and mobility, and did not have the ability to come to standing position from sitting in a wheelchair even with help from staff. On 11/19/24, Certified Nursing Assistant (CNA) 1 transferred Patient 2 from the wheelchair to the bed, by herself, without using a Hoyer lift (also known as a mechanical lift, uniquely designed, electronically operated patient lift to transfer patients from their bed to another surface such as a wheelchair or couch). Patient 2 fell during the transfer and sustained right femur (thigh bone) fracture. Patient 2 was taken to the hospital and underwent surgery. The facility failed to ensure Patient 2's individualized care plan was implemented when CNA 1 transferred Patient 2 from the wheelchair to the bed without another staff present and without using a Hoyer lift. This failure resulted in Patient 2's fall that led to right femur fracture. During a review of Patient 2's Minimum Data Set (MDS, an assessment tool used to direct patient care) dated 11/10/24, the MDS indicated Patient 2 had intact cognitive status (a person's ability to process and understand information), but functional ability with everyday activities (ADL) was impaired on both sides of the upper and lower extremities. The MDS indicated Patient 2 was dependent on staff with everyday activities that included rolling from left and right side while in bed, sitting on the side of the bed to lying flat, lying on the back to sitting on the side of the bed, transferring to and from a bed to a chair or wheelchair. The MDS also indicated, Patient 2's ability to come to a standing position from being seated in a wheelchair was not performed due to safety concern. During an interview and concurrent review on 12/11/24 at 1:02 p.m. with Director of Nursing (DON), Patient 2's ADL care plan dated 2/22/23 was reviewed. The ADL care plan indicated a target goal date of 12/31/24, with no indication that it was revised after 2/22/23. The interventions listed were all dated 2/22/23 with no new interventions added to indicate the specific care to be given during transfers. DON stated a Hoyer lift was required to transfer Patient 2 from the wheelchair to and from the bed which should have been indicated in the care plan. During a review of the facility's undated policy and procedure (P&P) titled "Resident Transfers", the P&P indicated for staff to assess resident's functional ability and type of assist needed, and to document the type of transfer and assistance device needed on the resident's comprehensive care plan, in the electronic health record system and progress notes. During a follow-up interview and concurrent record review on 12/11/24 at 1:28 p.m. with DON, Patient 2's "Care Plan Essentials" (a communication tool with specific details about the resident's care needs) initiated 3/4/24 was reviewed. The "Care Plan Essentials" indicated Patient 2 needed Hoyer lift with assistance of two staff for transfers to and from the wheelchair to a bed. DON stated, after Resident 1's fall on 11/19/24, an in-service education was done to teach CNAs to always use Hoyer lift to transfer dependent residents like Patient 2. During an interview on 12/11/24 at 1:08 p.m., Patient 2 stated while she was up in a wheelchair, CNA 1 picked her up and "dropped" her. During an interview on 12/11/24 at 1:12 p.m. CNA 2, Patient 2's regular CNA for almost six months, stated, Patient 2 needed a Hoyer lift and help of another CNA to transfer to and from the wheelchair to a bed. During an interview on 12/11/24 at 1:16 p.m., with Nurse Supervisor (NS), NS stated Patient 2 was not able to move both legs to stand up even with help from staff. NS stated Patient 2 required Hoyer lift, with two staff assisting, for transfers. During a telephone interview on 12/11/24 at 1:59 p.m. with CNA 1, CNA 1 stated working her first shift at the facility on 11/19/24. CNA 1 stated she received report from a regular staff that Patient 2, who was in a wheelchair at the start of the shift, would go back to bed around 8:00 p.m. to 9:00 p.m. CNA 1 stated, around 9:00 p.m. CNA 1 went to the room to get Patient 2 back to bed. CNA 1 stated she took both of Patient 2's arms and wrapped them around her while she grabbed Patient 2's waistband on the back, in a hugging position. CNA 1 stated Patient 2 told her "Don't drop me". CNA 1 stated reassuring Patient 2, everything was going to be okay as the bed and the wheelchair had already been locked. CNA 1 stated she lifted Patient 2 to a standing position towards the bed but noticed Patient 2 was "dead weight", did not have good function on both legs, and started to slide down. CNA 1 stated she asked Patient 3 (Patient 2's roommate) to lower the bed so CNA 1 could have Patient 2 sit on the side of the bed. CNA 1 stated she thought, Patient 3 was "demented" (one who has impaired memory and decision-making) and could not understand CNA 1's instruction, so CNA 1 eased Patient 2 down to the floor. CNA 1 stated she needed to be told at the start of the shift that a Hoyer lift and another CNA were needed to transfer Patient 2. CNA 1 also stated she thought Patient 2 could stand up from the wheelchair with little help from one staff. During a review of Patient 3's MDS dated 11/3/24, the MDS indicated a BIMS score of 14 (A score of 13-15 indicates intact cognitive status). During an interview on 12/11/24 at 1:42 p.m. with Patient 3, Patient 3 stated CNA 1 came to the room to get Patient 2 back to bed. Patient 3 stated she offered help to CNA 1 to transfer Patient 2 as she thought to herself "How did she think she could pick [Patient 2] up by herself?." Patient 3 stated CNA 1 just picked up Patient 2 then "dropped" her. During a telephone interview on 12/11/24 at 1:55 p.m. with Registered Nurse Supervisor (RNS), RNS stated CNA 1 came out of the room and said she needed help with Patient 2. RNS stated, upon entering the room, Patient 2 was already sitting on the floor with her back against the bed. During a follow-up telephone interview on 12/13/24 at 9:47 a.m. with RNS, RNS stated Patient 2 could not bear weight at all and had always used a Hoyer lift for transfers. During an interview on 12/11/24 at 3:05 p.m. with DON, DON stated, for residents who are dependent on staff with transfers, a Hoyer lift should be used. During a review of Patient 2's SBAR (Situation, Background, Assessment, Recommendation, written communication tool that helps provide essential, concise information, usually during crucial situations) dated 11/19/24, the SBAR indicated, Patient 2 had an assisted fall. The SBAR indicated, when Patient 2 slid off the bed, CNA 1 eased Patient 2 down to the floor. During a review of Patient 2's "Risk Meeting Notes Initial Week One" dated 11/25/24 created by DON, the "Risk Meeting Notes Initial Week One" indicated the following: - On 11/19/24, Patient 2 had a "Guided (assisted) fall while transferring from wheelchair to bed". - On 11/22/24, Patient 2 complained of pain on the right thigh and right knee, a STAT (suggests a possible emergency condition, one where treatment must immediately be undertaken) x-ray was ordered by the Nurse Practitioner (NP). - On 11/23/24, STAT x-ray result came back. Patient 2 had a right proximal femur (thigh bone) fracture ...Patient 2 was transferred to the hospital for further evaluation and management per Nurse Practitioner's order. During a review of Patient 2's "Radiology (imaging) Report " dated 11/23/24, the "Radiology Report" indicated, Patient 2 had a "Proximal right femur fracture [generally referred to as hip fracture] as described. The findings are new compared to 23JUN2023." During a review of Patient 2's Physician's Order dated 11/23/24, the Physician's Order indicated an order to transfer Patient 2 to the hospital for management of fractured femur. During a review of Patient 2's hospital "Internal Medicine Discharge Summary" dated 11/27/24, the "Internal Medicine Discharge Summary" indicated Patient 2 was admitted to the hospital after a fall that resulted in right femur fracture. Patient 2 was sent back to the facility after IMN (Intermedullary Nailing, a surgical procedure used to treat bone fractures by inserting a metal rod [nail] into the hollow center [medullary canal] of the bone) and an order to receive Lovenox (an injectable blood thinner that helps prevent the formation of blood clots) for 30 days. During a review of Patient 2's Progress Notes dated 11/27/24, the Progress Notes indicated Patient 2 returned to the facility from the hospital, on 11/27/24, with a 4 centimeter (cm) right upper hip incision with six staples, 5 cm right hip incision with seven staples, and a 2 x 5 cm incision behind the right knee with six staples. In violation of the above cited standards, the facility failed to ensure Patient 2's individualized care plan was implemented when CNA 1 transferred Patient 2 from wheelchair to bed without another staff present and without using a Hoyer lift. This failure resulted in Patient 2's fall that led to right femur fracture requiring surgery. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.