Health inspection·June 24, 2021

F 689 Free of Accident Hazards/Supervision/Devices §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. § 72637 General Maintenance (a) The facility, including the grounds, shall be maintained in a clean and sanitary condition and in good repair at all times to ensure safety and well-being of patients, staff and visitors. The facility failed to follow the aforementioned regulation by failing to ensure Resident 1 was securely fastened in the wheelchair during transportation in a facility van which resulted in dislodgement from the wheelchair during transportation, causing a fracture (broken bone) of the left leg. During a review of Resident 1's Face sheet, the Face sheet indicated Resident 1 was admitted to the facility in 2019 with a diagnosis of cerebral vascular accident (CVA, loss of blood supply to the brain, commonly known as stroke), which caused a left sided hemiplegia (paralysis of one side of the body) and hemiparesis (loss of strength). Resident 1 also had a diagnosis of chronic kidney disease (CKD), and required dialysis (dialysis is the process of removing excess water and toxins from the blood in people whose kidneys can no longer perform these functions). During a review of Resident 1's Minimum Data Sheet (MDS, a resident assessment tool use to guide care) dated 2/15/21, the MDS indicated Resident 1 had a score of 14 on the Brief Interview for Mental Status test. (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) The MDS also indicated Resident 1 required total assistance from one or two staff for transfer between surfaces, had limited mobility of one side of her body, and was wheelchair bound (required use of a wheelchair for all locomotion.) During a review of Resident 1's nursing progress notes dated 2/5/21, the notes indicated Resident 1 had eye surgery on 2/5/21, for a retinal tear (a tear in the tissue that lines the inner surface of the eyeball and is responsible for providing sight), and would require a follow-up visit on Saturday 2/6/21. During an interview on 2/22/21 at 15:20 p.m., with Resident 1, Resident 1 stated she had an appointment on a Saturday morning to follow-up after her eye surgery. Resident 1 stated she was transported to her appointment in the facility van driven by Licensed Vocational Nurse 1 (LVN 1). Resident 1 stated while in the van she was seated in her wheelchair, facing forward, in the passenger section of the van. Resident 1 stated LVN 1 had attempted three times to use the built-in seat belt attached to the left wall of the facility van but LVN 1 was unable to fasten the seat belt around the wheelchair. After LVN 1 was unable to secure the vehicle seat belt, LVN 1 used a cloth belt, placed around Resident 1's chest, under her armpits, and tied in a knot behind the backrest of the wheelchair. During the transport, Resident 1 stated the driver had to stop quickly because of traffic, which caused her to fall, not slide, out of the wheelchair toward the front of the vehicle. Resident 1 stated immediately after falling, her foot began to hurt. Resident 1 stated she had to wait on the floor of the vehicle until LVN 1 could find a place to stop and pull the van over. After the van stopped, LVN 1 lifted Resident 1 back into her wheelchair, and they drove back to the facility. Resident 1 stated the pain got worse during the drive back to the facility. When she arrived at the facility, she received pain medication, and the pain improved. Resident 1 stated she was sent to the emergency room the next day and was treated for a broken left leg. Resident 1 stated since the accident, she was unable to move her left foot and toes and has occasional pain of the left leg. During an observation with LVN 1 on 2/22/21 at 12:55 p.m., the facility transport van had four metal hooks on the floor of the van, behind the driver seat. LVN 1 used an empty wheelchair to demonstrate how the wheelchair legs locked into the metal hooks on the floor to prevent the wheelchair from moving. On a shelf in the back-passenger area of the facility van was a cloth strap, and a shoulder harness (a set of straps worn around the torso and shoulders). A seat belt was attached to the van wall behind the driver's seat. During an interview with LVN 1 on 2/22/21 at 12:55 p.m., LVN 1 stated that the four hooks on the floor were where he had locked Resident 1's wheelchair to the facility van floor, and he had used the cloth strap to secure Resident 1 to the wheelchair during transport. LVN 1 stated on Saturday morning 2/6/21, Resident 1 needed transportation to the eye doctor for an eye appointment. LVN 1 stated he had placed Resident 1 in her wheelchair behind the driver's seat, with her wheelchair secured in the metal hooks. LVN 1 stated he had used the cloth strap as a lap belt to secure Resident 1 in the wheelchair. LVN 1 had tied the cloth strap around Resident 1's chest, under her arms, and tied the belt in a knot behind the wheelchair backrest. LVN 1 stated the shoulder harness was an alternate system for securing the resident to a wheelchair during transport in the van, but he thought the harness was inappropriate for Resident 1's size, so he had not used it. LVN 1 stated during Resident 1's transport, he had to make a sudden stop due to traffic, which caused Resident 1 to slide out of the lap belt, off the wheelchair, and down to the floor toward the front of the vehicle. LVN 1 stated it took him a couple of minutes to pull the vehicle to the side of the road so he could park and help Resident 1 back into the wheelchair. LVN 1 stated he noticed Resident 1 had a "small" skin tear on her left forearm, which was bleeding, and she complained of leg pain at a level of four on a pain scale of zero to ten (zero means no pain, ten means the highest pain). After the incident, LVN 1 decided to drive Resident 1 back to the facility, as they were too late for the eye appointment and Resident 1 was complaining of pain. LVN 1 stated Resident 1 continued to complain of increasing pain during the drive back to the facility. LVN 1 stated when they arrived back at the facility, Resident 1 said her leg pain level was at a score of nine. During a review of Resident 1's nursing progress notes dated 2/6/21, at 4:14 p.m., by Licensed Vocational Nurse 3 (LVN 3), the notes indicated Resident 1 had returned to the facility at 1 p.m. and received pain medication for a complaint of left leg pain. The notes indicated Resident 1 left the facility at 1:15 p.m. for her routine dialysis treatment. A review of Resident 1's progress note by LVN 3 dated 2/6/21 at 4:34 p.m. indicated, "LN [licensed nurse] contacted RP [responsible party], aware eye appointment not done...also aware patient had a skin tear 1 X 1 on right forearm, no active bleeding, cleansed with normal saline and dry dressing applied." During an interview on 4/21/21 at 3:25 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated on 2/6/21 between 4:00 p.m. and 4:30 p.m., he notified Resident 1's physician about her fall in the vehicle, and that she had received pain medication for a complaint of leg pain. LVN 2 further stated the physician ordered neuro checks every 4 hours and to monitor the skin tear. LVN 2 stated he informed the physician Resident 1 was currently at dialysis. During an interview on 4/23/21 at 7:51 a.m. with Registered Nurse 1 (RN 1), RN 1 stated on 2/7/21 at around 3:00 a.m., a certified nursing assistant informed her Resident 1 was complaining of left leg pain and had swelling in her left leg. RN 1 stated she went into Resident 1's room and examined Resident 1's left leg. Resident 1 told RN 1 she was in pain and rated her pain as a three to four on the zero to ten pain scale. RN 1 offered pain medication to Resident 1, but Resident 1 refused and told her she had been given pain medication the day before [2/6/21]. RN 1 further stated Resident 1 appeared stable and went back to sleep. RN 1 stated she notified Resident 1's physician of the left leg swelling on 2/7/21 around 7:00 a.m., and the physician ordered an Xray. During a review of Resident 1 Radiology Report, date of service 2/7/21 at 11:42 a.m., the report indicated Resident 1 had a recent fracture (broken bone) of the left leg; the Report indicated the results were sent to the facility at 2:50 p.m. the same day. During a review of nursing progress notes dated on 2/7/21, at 4:30 p.m., the notes indicated the physician ordered Resident 1 be sent to the acute care hospital. During a review of Resident 1's acute care hospital after visit summary dated 2/9/21, the notes indicated Resident 1 was admitted to the hospital from the emergency room on 2/7/21 at 6:21 p.m., for a broken left leg. Resident 1 was discharged back to the facility on 2/9/21 at 4:30 p.m. The after-visit summary indicated Resident 1 should have no weight bearing on the left leg for 6 to 12 weeks and should use a continuous left immobilizer (a fabric full leg brace and support) for 6 to 12 weeks. During an interview on 2/22/21, at 3:30 p.m., with Resident 1, Resident 1 stated since the accident she was not able to move her left leg or feel her toes, and the left leg was painful "most" of the time. Resident 1 stated she wished she had not lost function and abilities in her left leg. During a review of the facility document, "Van Owner's Manual [brand name]," the Manual indicated, "to use a tie down retractor or manual belts, occupant lap belt, occupant shoulder belt and hardware when transporting wheelchair occupants." The Manual also indicated, "Warning, that wheelchair occupants (person or passenger in the wheelchair) should be properly restraint (tie down in place) during transport. And in the case of a collision a restraint wheelchair and its occupant could become a projectile (ejected or pulled out) in the vehicle and be seriously injured or killed if the passenger was not restrained securely following recommendations of the manual." During a review of Facility Van Safety Policy and Procedure (P & P) dated 8/15/2001, the P & P indicated the van be maintained in good condition, equipped with safety devices, and drivers be trained in the use of such devices. The P & P indicated the designated driver must ensure securing station are properly equipped with straps, lap, and shoulder belts and should check belt buckles and hardware functions properly before and during transportation with wheelchair occupants. Therefore, the facility failed to provide securely fasten Resident 1 in a wheelchair during transportation in a facility van which resulted in dislodgement from the wheelchair during transportation, causing a fracture (broken bone) of the left leg.