Other·March 21, 2024

Golden Sonora The following reflects the findings of the California Department of Public Health during the investigation of: Complaint #: CA00885082 Survey Event ID: 0MXH11 Representing the Department, HFEN #43496 State Citation B was written. §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 On 2/26/24 at 8:20 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding an injury to a resident. The facility failed to provide an environment free of hazards to prevent an accident from occurring to Resident 1 when the facility did not remove the brackets that held the footboard in place when the footboard had been removed from Resident 1's bed which resulted in a laceration (a cut) to Resident 1's right lower leg on 2/13/24 and an infection to the laceration on 2/22/24. This failure resulted in an extensive injury to Resident 1's leg which required an emergency room intervention of ten staples (metal material used to close a wound to help it heal). Subsequently Resident 1's injury became infected which had the potential for further bodily harm. Review of Resident 1's "ADMISSION RECORD" indicated Resident 1 was admitted with diagnosis which included but not limited to difficulty in walking. Review of Resident 1's "Nursing Note," dated 2/13/24, indicated, "...At approximately [2 p.m.] [Resident 1] yelled out while CNA [Certified Nursing Assistant] was passing his room, per [Resident 1] "I was trying to get around my bed when my leg got caught on the metal piece under the bedframe." CNA reported skin tear to nurse, this writer completed a further assessment. Site was cleansed with Normal saline to see depth of wound, upon assessment this LN [Licensed Nurse] noted tissue was visible and wound was producing large amounts of blood, closure of wound not possible with steri-strips [thin adhesive bandages] ..." During a review of Residents 1's Emergency Department (ED) Physician Notes, dated 2/13/24, the note indicated "...Patient reports laceration occurred on his bed...diagnosis of skin laceration, muscle injury, boney injury, tendon [connects muscles to your bone] laceration, vascular [blood vessels] injury...with a 6 cm [centimeters, unit of measurement] gaping laceration right...lower extremity...10 staples..." During an interview on 2/26/24, at 1:30 p.m., Resident 1 explained that he had got out of bed on his own, had got too close to the end of the bed, and sliced his leg on the bedframe. Resident 1 stated the footboard was never on his bed that he recalled. When asked if he requested the footboard to be removed, Resident 1 stated he did not request for the footboard to be taken off his bed. During an interview on 2/26/24, at 1:58 p.m., CNA 3 stated she was assigned to care for Resident 1 on the day the injury occurred. CNA 3 stated Resident 1 was trying to get up out of bed and hit his leg on a metal piece that was sticking out at the end of his bed. CNA 3 stated the bracket at the end of the bed that Resident 1 injured himself on was there to hold the footboard in place and the footboard had been removed at a time that she was unaware of. During an interview, on 2/26/24, at 2:05 p.m., the Director of Maintenance (DOM) stated for the removal of resident footboards, staff should call the maintenance department to let them know that there was a need to remove the foot board. The DOM stated that he would then remove the footboard and the accompanying brackets because the brackets stick out from the bed and were a hazard. The DOM reported that he was not aware of the removal of Resident 1's footboard prior to the accident. During an interview on 2/26/24, at 2:57 p.m., the Administrator (ADM) stated the risk of not having a footboard in place could result in an injury to the resident if the footboard was removed. The ADM stated that if a resident did not want the foot board on their bed, maintenance should be notified by staff, and the maintenance department would remove the footboard and brackets. During a review of Resident 1's "Nursing Note," dated 2/22/24, indicated, "...During wound care today resident's lacerations to his R [right] shin was noted to be inflamed and warm to touch. MD [medical doctor] notified and ordered [name of antibiotic] ... for 10 days..." During an interview on 3/11/24, at 12:35 p.m., the Assistant Director of Nursing (ADON) stated an injury to a resident could lead to skin impairment which could result in a wound infection. The ADON explained, a wound infection could potentially result in complications such as sepsis (a serious life-threatening medical emergency in which the body responds improperly to an infection) and loss of limb. During a review of a facility P&P titled "Bed Safety" dated 12/2007, the P&P indicated, "...The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions...To try to prevent death/injuries from the beds and related equipment(including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote...inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks." In violation of the above cited standard, the facility failed to provide an environment free of hazards to prevent an accident from occurring to Resident 1 when the facility did not remove the brackets that held the footboard in place when the footboard had been removed from Resident 1's bed which resulted in a laceration to Resident 1's right lower leg on 2/13/24 and an infection to the laceration on 2/22/24. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.