Health inspection·February 2, 2022

F689 Free of Accident Hazards/Supervision/Devices Section 483.25(d) Accidents. The facility must ensure that - Section 483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and Section 483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents The following reflects the findings of the California Department of Public Health during an unannounced visit to the facility to investigate Entity Reported Incident #:CA00755194. Representing the Department, HFEN #32096. State Citation B was written. As a result of the investigation, the Department determined the facility failed to ensure the safety of one of three sampled residents (Resident 1) during a Hoyer lift (an electrical assistive equipment device used for transfers) transfer from the bed to a wheelchair when Resident 1's leg thumped against the wall. This failure resulted in Resident 1's leg fracture, excruciating pain, an unintended Emergency Room visit, subsequent hospital stay, and compromised the resident's ability to enjoy normal life activities due to the injury. According to Resident 1's face sheet, she was a long-term resident and recently readmitted to the facility on 9/27/21, after a hospitalization due to a left leg fracture. The resident's diagnoses included diabetes and above the right knee amputation. Review of the MDS (Minimum Data Set, an assessment tool), dated 8/2/21, indicated Resident 1 was cognitively intact with a score of 14/15 in the Brief Interview for Mental Status (BIMS) assessment. In a concurrent observation and interview on 10/12/21 at 11:30 a.m., Resident 1 was lying on her bed in her room. Resident 1 stated she fractured her leg one morning, a few weeks ago, when a Certified Nurse Assistant (CNA) transferred her from her bed to her wheelchair using the Hoyer lift. The resident recounted that the CNA first transferred her from the bed onto the wheelchair using the lift and then she "suddenly put the back down" of the wheelchair behind the resident which made her recline backward abruptly. The resident stated she shrieked for fear of falling backward and on her shrieking, the CNA quickly lifted the back of the wheelchair straight up and "at that time" the resident hit her left leg hard against the wall. The resident voiced it hurt so much she screamed. Resident 1 stated only one CNA operated the lift during the transfer and no other staff was in the room. Resident 1 grimaced in pain and the interview was discontinued. Review of Resident 1's clinical record, "Change of Condition, LTC" (Long Term Care), dated 9/24/21, Licensed Nurse (LN) 1 documented, "Resident c/o [complained of] severe pain on her left upper leg...noted upper leg with tenderness to touch, pt [resident] been jumpy when slightly touch the area. Even when touch the foot pt stated its (sic, it's) radiating the pain to her upper leg. Also stated even little shaking on he (sic, the) bed causes pain to her upper leg. Per pt the [pain] gradually started from morning when she was sitting down from the w/c [wheelchair]...ordered to transfer pt to ED for further evaluation." Review of the hospital "Emergency Department (ED) Physician Notes", dated 9/24/21, indicated, "The resident [Resident 1] presents with Left-sided lower extremity pain...presenting with a chief complaint of left hip, leg, and foot pain since this morning. Resident states that she has been in pain since she was transferred earlier today in her room." The ED physician documented, "Resident has a markedly angulated [the ends of the broken bone have shifted out of alignment] left proximal shaft femur fracture [where the upper bone of the left leg head joins to the hip bone] ...She is bedbound and paralyzed. She is however in marked pain." The resident was admitted to the hospital on the same day. Review of Resident 1's clinical record, 9/28/21 "History and Physical" (H&P), indicated the resident was readmitted to the facility after the hospitalization for the leg fracture on 9/24/21. The H&P indicated Resident 1's fracture was to be treated with anticoagulant (blood thinner) therapy, rehabilitation, and pain management as documented, "Start on heparin [to decrease blood clot] drip transition to Lovenox [to prevent deep veins and arteries blood clot blockage] recommended to rehab [rehabilitation] and skilled care continue pain control." In an interview on 10/12/21 at 11:45 a.m., CNA 2 indicated Resident 1 used to get up and out of bed every day for either attending activities at 10 a.m. or for lunch at the dining hall at 11:40 a.m. daily. CNA 2 stated, "She loves to get up...able to self-wheel herself and look outside near the nursing station." CNA 2 indicated the resident no longer got out of bed since her return from the hospital because she had "so much pain...for now...has been in bed." CNA 2 stated Hoyer lift transfers were a two-person assist that always required two staff to conduct the lift. In an interview on 10/12/21 at 12:26 p.m., the Clinical Manager (CM) verified Resident 1 did not have diagnoses or underlying diseases that included osteoporosis (less bone mass or strength) or osteopenia (a condition that begins to lose bone mass therefore bones get weaker). The CM confirmed the ED physician notes on 9/24/21 did not indicate the resident 's fracture was related to a pathologic disease (i.e., a pathologic fracture: a break in a bone that is caused by an underlying disease). The CM verified it was CNA 1 who transferred the resident in the morning on 9/24/21 and stated CNA 1 no longer worked for the facility. The CM stated Resident 1 had no history of false accusations. In an interview on 10/12/21 at 12:55 p.m., the Director of Nursing (DON) stated the facility's care goals for all residents were to be active and indicated Resident 1 used to be active getting up daily, participating in activities and having meals in the dining hall. The DON stated it was the facility's policy for 2 persons to assist in the transfer of residents using a Hoyer lift. In an interview on 10/12/21 at 1:15 p.m., the Activity Director (AD) stated Resident 1 used to be very active, sociable and participate in group activities like Bingo, word games, cookie carnival, Catholic mass, and parties. The AD stated she had not seen Resident 1 in group activities since her readmission from the hospital. The AD recounted that Resident 1 recently told her that she was, "Looking forward to going back to group activities." In a concurrent interview and review of Resident 1's Medication Administration Record (MAR) on 10/12/21 at 2:15 p.m., LN 2 verified the resident took narcotics which were a combination of two pain medications, hydrocodone/acetaminophen (a strong prescription pain reliever 5/325 milligram, a unit of measurement) from one to four tablets daily since her readmission. The MAR from 9/28/21 through 10/12/21 indicated Resident 1 took the narcotics to control the fractured leg pain as follows: >1 tablet: 9/28/21, 9/29/21, 10/4/21, 10/6/21, 10/9/21, 10/10/21, and 10/12/21 >2 tablets: 9/30/21, 10/1/21, 10/3/21, 10/5/21 and 10/7/21 >4 tablets: 10/2/21, 10/8/21 In an interview on 10/12/21 at 2:35 p.m., LN 2, in the presence of the CM, acknowledged Resident 1 was in pain due to the fracture and stated the resident did not take pain medications prior to the leg injury. LN 2 and the CM acknowledged the fracture injury negatively affected the resident 's daily routine and resulted in the resident's inability to participate in activities that she used to enjoy. LN 2 stated the facility's policy and procedure, safe handling, required two staff, "always a pair" when using the Hoyer lift to transfer residents. LN 2 stated, "The CNA should have gotten another CNA's assistance...to ensure safety of the resident." In a telephone interview on 10/14/21 at 10:32 a.m., LN 1 stated on 9/24/21 she worked double shifts both AM and PM on the day of Resident 1's emergency room transfer. LN 1 stated she had taken care of the resident for more than a year, therefore, she was familiar with the resident 's care and her health status. LN 1 stated she thought it was unusual when Resident 1 asked for pain medication on 9/24/21 at about 8 p.m. stating, "[Resident 1] never asked for pain meds[medications]...maybe 1 or 2 times during the year." LN 1 assessed the resident and recited what she documented on Change of Condition notes on 9/24/21. LN 1 stated Resident 1 used to get up in her wheelchair every day, attend activities, have meals in the dining hall, sit in her wheelchair in the room and enjoyed getting out of bed. LN 1 stated Resident 1 had changed since she returned from the hospital and refused to get up. LN 1 stated Resident 1 had been taking hydrocodone/acetaminophen two tablets as needed. CNA 1 did not return the two calls requesting interviews when voice messages were left on the facility provided phone number for CNA 1 on 10/14/21 at 10:07 a.m. and on 10/21/21 at 4:08 p.m. On 10/19/21, the CM confirmed via email that CNA 1 transferred Resident 1 by herself in the morning of 9/24/21. The CM's email wrote, "I called the CNA [CNA 1's Name] who confirmed she was by herself the morning she assisted [Resident's Name] into the wheelchair with a Hoyer lift." Therefore, the Department determined the facility failed to ensure one of three sampled resident's (Resident 1) safety during a Hoyer lift transfer from bed to a wheelchair when Resident 1's leg thumped against the wall. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility residents.