Other·April 2, 2024

The following reflects the findings of the California Department of Public Health during investigation of an Entity Reported Incident CA00804752 and Complaint CA00806643. Representing the Department, 41119 RN, HFEN. 22 CCR  72521(a) Administrative Policies and Procedures. (a)Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. 22 CCR  72523 (a) Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 42 C.F.R.  483.25(d) Accidents The facility must ensure that - (d)(1) - The resident environment remains as free of accident hazards as is possible; and (d)(2) - Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR  72311(a)(1)(A), (a)(2) Nursing Services-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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 10/10/2022 at 10:00 a.m., an unannounced visit was conducted at the facility to investigate an entity reported incident and complaint regarding Resident 1's witnessed fall with injury that occurred on 9/23/2022. The facility failed to ensure residents' environment remained free of accident hazards when Certified Nursing Assistant (CNA) 1 and CNA 2 transferred Resident 1 using a sling (a hammock like cloth device used to hold the resident during transfer with a mechanical lift) that was larger than the manufacturer's size guide chart based on Resident 1's weight. Per Licensed Vocational Nurse (LVN) 1, on 9/23/22, during a transfer from the wheelchair to a bed, the sling clip that attached to the mechanical lift detached and caused Resident 1 to fall to the ground from a height of three to four feet. As a result of this failure, Resident 1 suffered pain in the lower back, neck, and head. Resident 1 was sent to the General Acute Care Hospital (GACH) where she was admitted, received pain medication, and was diagnosed with subdural hematoma (collection of blood outside the brain). A review of Resident 1's "Admission Record" (document containing resident demographic information and medical diagnosis) indicated Resident 1 was admitted to the facility on 12/6/2010. Resident 1' s diagnoses included left hemiparesis (inability to control muscles in the affected body part), tremor (involuntary shaking or movement), and a history of falling. During an observation on 10/10/22, at 2:04 p.m., in Resident 1's room, Resident 1 was observed lying in bed. Resident 1 was unable to answer questions when she was questioned regarding her fall. A review of Resident 1's "Minimum Data Set Assessment" (MDS - a resident assessment tool used to identify resident cognitive and physical function) dated 8/15/22, indicated Resident 1's "Brief Interview for Mental Status," (BIMS -assessment of cognitive status for memory and judgment) assessment score was 0 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was rarely/never understood. The MDS section "G" titled "functional status," indicated Resident 1 was totally dependent with a two-person physical assist required for transfers from bed, chair, and wheelchair. During an interview with CNA 1 on 10/10/22, at 2:10 p.m., CNA 1 stated on 9/23/22 she was assisting CNA 2 in transferring Resident 1 from her wheelchair to the bed utilizing the mechanical lift. CNA 1 stated, she attached the sling to the mechanical lift on the leg section of the sling. CNA 1 stated during the transfer she heard a "pop", and the right side of the sling's clip that attaches to the mechanical lift detached. CNA 1 stated the sling was undamaged and was unsure how the sling came apart resulting in Resident 1 falling to the ground. During an interview on 10/10/22, at 2:21 p.m., with CNA 2, CNA 2 stated CNA 1 was assisting in transferring Resident 1 from her wheelchair to the bed utilizing the mechanical lift. CNA 2 stated, she attached the sling to the mechanical lift towards the head section of the sling. CNA 2 stated, during the transfer she heard a "pop", and the right side of the sling clip that attach to the mechanical lift detached resulting in Resident 1's fall. CNA 2 stated, there were different slings that the facility used with colors on the edges of the sling such as yellow, green, and blue. CNA 2 stated the sling used on 9/23/22 had green edges. CNA 2 stated she used the sling assigned to the resident, and if one was not assigned, she would use a sling based on what was previously used by other CNA. CNA 2 stated, she did not know how the sling detached because the sling and the mechanical lift had no damages. A review of Resident 1's "Progress Note" (PN), dated 9/23/22, indicated, " ...This writer was summoned to residents [Resident 1's] room by CNA at approximately 1200, resident was on floor. Two CNAs were transferring resident to bed via [mechanical lift] when resident fell out of sling, approximately 3-4 feet to the ground ...RN [registered nurse] assessed resident, pain to back of neck & head, lower back pain. MD [Medical Doctor] notified and gave order to send resident out to ER [emergency room] for further evaluation. This writer administered pain medication to resident before leaving to ER..." During a concurrent interview and record review on 10/10/22, at 2:50 p.m., with LVN 1, Resident 1's "weights", dated 9/6/22 and 9/24/22 was reviewed. The "weights" indicated, Resident 1 weighed 133 pounds on 9/6/22 and 130.4 pounds on 9/24/22. LVN 1 stated the sling had colored edges and the color was based on the resident's weight. LVN 1 stated CNA 2 informed her that Resident 1 had fallen from the mechanical lift. LVN 1 stated she observed the right upper sling detached and Resident 1 on the ground. LVN 1 stated the sling used on 9/23/22 had green color edges. LVN 1 stated she was unsure how CNA's knew which color sling to use during mechanical lift transfers. LVN 1 stated Resident 1 was in pain and was sent out to the hospital for further evaluation. During an interview on 10/10/22, at 3:34 p.m., with Assistant Director of Facility Management (ADFM), ADFM stated, he inspected the sling and the mechanical lift and did not find anything wrong with the devices. During a review of the facility "Investigation Information," dated 9/29/22, the "Investigation Information" indicated, "...During our investigation the lift used during the transfer was inspected by maintenance and was noted to be in good working condition and did not show any signs of malfunctioning. The sling that was used during the transfer was also inspected and was noted to be in good condition without and holes, fraying [define] and the attachment clip was undamaged ..." During a review of Resident 1's General Acute Care Hospital (GACH) notes titled, "Medications Administered" dated 9/23/22, the "Medications Administered" indicated, Resident received tramadol (pain medication used to treat moderate to severe pain) for pain. During a review of Resident 1's GACH notes titled, "History and Physical" (H&P), dated 9/23/22, the H&P indicated, " ...Chief Complaint: Patient presents as a victim of falling from height ...patient admitted on 9/23/22 ...has history of ...left sided deficits ...BIBA [brought in by ambulance] for fall off her [mechanical lift] at 3-4 feet ...Head strik [strike] ...She complains of HA [headache], L [left] shoulder/back/ ...pain ...Plan and Recommendations: Admit to ICU [intensive care unit] ..." During a review of Resident 1's "Computed Tomography (CT-medical imaging technique used to obtain detailed internal images of the head)" dated 9/23/22, the "CT" indicated, Resident 1 sustained a subdural hematoma 4 mm (millimeters-unit of measure) thick and about 3 cm (centimeters-unit of measure) length. During a concurrent interview and record review on 10/10/22, at 4:48 p.m., with the Director of Nursing (DON), the mechanical lifts manufacturer guideline for "Sling Color/Size Guide" undated was reviewed. The "Sling Color/Size Guide" indicated, " ...Adults ...M [medium] Yellow 121-165 lbs [pounds] ...L [large] Green 154-264 lbs ...[brand name] makes sizing and sling selection easy with a color-coded sling system. The sling sizes covering ...adult ...have a distinctive color code that can be clearly seen on the edge of [brand name] slings ..." The DON reviewed the manufacturers sling size guide and validated based on Resident 1's weight of 133 the yellow-colored sling should have been used during the mechanical lift transfer. The DON stated the green colored sling was size large and should be used for residents with a weight of 154-264 lbs. During a review of the manufacturer's guidelines titled, "Instructions for Use" dated 12/2021, the "Instructions For Use" indicated, " ...To avoid injury, always read this Instructions for Use and accompanied documents before using the product. Mandatory to read the Instructions for Use ...Before Approaching the Patient ...The attendants should always tell the patient what they are going to do, and have the correct size sling ready ... To Lift from a Chair ...Ensure that the [brand name-mechanical lift] is close enough to be able to attach the sling ' s shoulder clips to the spreader bar [bar used for lifting resident] ...Once the [brand name-mechanical lift] is in position, attach the shoulder strap attachment clips to the sling ...Caution: Always check that all the sling attachment clips are fully in position before and during the lifting cycle, and in tension as the patient ' s weight is gradually taken up ..." During a review of the facility's policy and procedure (P&P) titled, "Safe Lifting and Movement of Residents" dated 7/2017, the P&P indicated, " ...In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents ...Enough slings, in the sizes required by residents in need, will be available at all times ...All equipment design and use will meet or exceed guidelines and regulations concerning resident safety and the use of restraints ..." During a review of professional reference of the FDA- The Food and Drug Administration titled "Patient Lifts", retrieved from https://www.fda.gov/files/medical%20devices/published/Patient-Lifts-Safety-Guide.pdf undated, indicated, the "Patient Lifts" indicated, " ...Choose size of sling based on manufacturer recommendation for patient ' s measurements. Choosing correct sling size is critical for safe patient transfer ...Sling too large: patient may slip out ...Using the wrong sling or attaching the sling incorrectly may cause an accident that can result in serious injury or death ..." In violation of the above cited standards, the facility failed to ensure Resident 1's environment remained free of accident hazards when CNA 1 and CNA 2 transferred Resident 1 using a sling that was larger than the manufacture's size guide chart based on Resident 1's weight. This failure resulted in Resident 1 falling out of the sling, to the ground from a height of three to four feet per LVN 1. Resident 1 suffered pain in the lower back, neck, and head. Resident 1 was sent to the GACH where she was admitted, received pain medication, and was diagnosed with subdural hematoma. This violation presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result and caused Resident 1's injury and constitutes an A Citation.