Health inspection·July 29, 2022

Health and Safety Code Section 1424 (d) Class "A" violations are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. Title 42 of the Federal Code of Regulations 483.25 (d) (2) Accidents and Supervision The facility must ensure that - (2) Each resident receives adequate supervision and assistance devices to prevent accidents. Title 22, California Code of Regulations, Division 5, Chapter 3, Article 3, Required Services, Section 72311, Nursing Services- General, Subdivisions (a)(1)(A), (B) and (C), and (a)(2). (a) Nursing Service-General: 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 plans 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. (b) Licensed nursing personnel shall ensure that patients are served the diets as ordered by the attending licensed healthcare practitioner acting within the scope of his or her professional licensure. Title 22, California Code of Regulations, Division 5, Chapter 3, Article 5, Required Services, Section 72523, Subdivision (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. The Department determined during the investigation of a facility reported incident, the facility failed to: a) provide the required supervision and assistance for Resident 1 during a mechanical lift transfer with one-person assistance instead of two-person or more assistance from bed to a wheelchair by the Certified Nursing Assistant (CNA); b) implement Resident's 1's plan of care to provide two-person assistance during transfer from bed to wheelchair when using a mechanical lift; and, c) follow its policy and procedure on Transferring and Lifting Using Hoyer Lift (mechanical device used to lift residents safely), using a Portable Lifting Machine and Fall Prevention Policy. As a result of these failures, on 11/17/19 at 10:10 am, Resident 1 fell to the floor on her right side, landed on top of metal base of the mechanical lift requiring immediate hospital transfer. Resident 1 was admitted at the hospital emergency room with severe hypoxia (deficiency in the amount of oxygen reaching the tissues). Resident 1 sustained right scapular fracture (a break/crack on the right shoulder blade), multiple right rib fractures (an injury that occurs when one of the bones in the rib cage cracks) with a subpleural hematoma (collection of blood in the lungs) and a right posterior parietal scalp hematoma (an injury involving the outside part of the skull, often felt as a bump on the head). Resident was placed in intensive care unit and died the same day at 9:21 pm. Resident 1 was an 87-year old female, initially admitted to the facility on 1/5/16, re-admitted on 1/6/18, with diagnoses including but not limited to history of a non-traumatic intracranial hemorrhage (brain bleed/stroke), hemiplegia affecting the left nondominant side (paralysis of the left half of the body, pulmonary embolism (blood clot in the lungs), acute respiratory failure (inadequate gas exchange), dysphagia (difficulty in swallowing), anemia (lack of healthy red blood cells causing weakness) and major depressive disorder (persistent feeling of sadness). Review of Resident 1's minimum data set (MDS- comprehensive assessment of resident's healthcare, functional needs, and abilities) with assessment reference date of 9/15/19, indicated ability to hear, does not speak, unable to express ideas and wants, and sometimes understands others. Resident 1's Brief Interview for Mental Status (BIMS) indicated a total score of zero (0). BIMS is a test for cognitive (mental awareness) function, scores 13 to 15 means intact cognition, 8 to 12 means moderately impaired cognition, and 0-7 means severely impaired cognition. Resident 1's functional status included total dependence requiring two or more persons' assistance for bed mobility and transfer. Resident 1 was not steady and only able to stabilize with staff assistance during surface-to-surface transfer (between bed and wheelchair). Resident 1's upper and lower extremities were both impaired, limiting range of motion. Review of Resident 1's "Fall Risk" assessment dated 9/12/19 indicated high risk for falls due to the following clinical conditions: a) disoriented at all times, b) chair bound requiring assist with elimination, c) poor vision status, d) not able to perform gait balance, e) on 3-4 medications affecting balance and alertness, and f) 1-2 present predisposing conditions including stroke, and fractures. Review of Resident 1's care plan titled, "Resident Care Plan" for Falls, initiated on 4/5/18, and re-evaluated on 9/19, indicated Resident 1 was at risk for falls due to factors including respiratory failure with tracheostomy (a hole in front of the neck and into the windpipe and a tube is place to keep the hole open for breathing), non-ambulatory (unable to walk without physical assistance), total assist with activities of daily living, Parkinson's disease (a disease affecting movement, often including tremors), and seizure (nerve cell activity in the brain is disturbed from previous brain injury such as trauma or stroke). The care plan interventions for fall prevention included use of mechanical lift for transfer. Review of Resident 1's "Resident Care Plan" for ADL (activities of daily living) Functioning," initiated on 4/5/18, and re-evaluated on 9/19, indicated Resident 1 required assistance, "total x 2" (required two or more persons) with transfers using a mechanical lift. Review of the facility's "SBAR 4.0 (Situation, Background, Appearance/Evaluation, Review/Notify) Communication Form," dated 11/17/2019, authored by licensed nurse (RN 1) set forth the following: "At 1010 a.m., CNA called charge nurse due to patient's (Resident 1) fall while being transferred to the wheelchair from her bed using Hoyer Lift, patient was hooked to the sling in order for transfer and during the process, she slid from the sling. When charge nurse entered the room, patient was found on the floor on her right side with her head on the metal rod (base) of the Hoyer Lift. Patient (Resident 1) was awake and making hand gestures. Patient was also found to have desaturating (decreased amount of oxygen in the blood) with O2 (oxygen) level in low 80s ..." Further review of the SBAR Form indicated, "a bump on the right side of head, no open wound and bleeding noted. At 10:14, attending physician was called and received an order to transfer to [name of the hospital] ER(emergency room) via 911 ..." Review of Resident 1's hospital emergency room report (History and Physicals - H&P), dated 11/17/2019, at 1:53 pm, indicated Resident 1 was admitted at 10:48 a.m., and workup in the emergency department showed severe hypoxia (lack of oxygen in the blood), the resident was placed on a ventilator (a machine that helps a person breath) and sent to intensive care unit for further work up at 4 p.m. on 11/17/19. Review of Resident 1's computerized tomography angiogram of the chest (CT scan - a test that uses a scanner to produce detailed images of blood vessels and tissues around the chest area) report at the hospital, dated 11/17/2019, 3:43 p.m., included multiple right rib fractures (an injury that occurs when one of the bones in the rib cage cracks) with a subpleural hematoma (collection of blood in the lungs), , and right scapular fracture (a break/crack on the right shoulder blade)." The CT Scan of the head report dated 11/17/19 at 1:26 p.m., included a right posterior parietal scalp hematoma (an injury involving the outside part of the skull, often felt as a bump on the head). Review of Resident 1's "Discharge Summary" dated 11/26/2019, set forth the following, 'Patient (Resident 1), was admitted and was placed in ICU. However, patient expired on 11/17/2019 2121 (9:21 pm). During an interview on 1/8/20, at 1:30 pm regarding the fall of Resident 1 on 11/17/19, Licensed Nurse (LN 1) confirmed, she responded to a call for help and saw Resident 1 in her room laying on the floor, partially on top of the lift's legs. During an interview on 1/8/20, at 4 p.m. regarding the fall of Resident 1 on 11/17/19, facility Administrator (ADM), confirmed, there was only 1 person assistance provided during the transfer. The ADM stated, "My best guess is that the hook from the sling that was supposed to latch on, did not go in all the way. So when the body moved to one side, it detached and the Resident fell." During an interview on 1/8/20, at 4:30 p.m., the Director of Nursing (DON) regarding the one staff assisting Resident 1 instead of two staff as required during the fall on 11/17/19, stated, "I really don't know why she (CNA 1) didn't ask for help ...she was supposed to, but did not ...". During an observation and concurrent interview on 1/8/20, at 4:55 p.m., CNA 1 demonstrated how Resident 1 fell on 11/17/19. CNA 1 stated as she was turning the lift toward the right side, she felt and saw the left base of the lift tilt above the floor, thus causing the sling's hook to detach, causing the Resident to fall down on the floor, on top of the lift's leg base. CNA 1 also confirmed that she was the only one that attempted to transfer Resident. Review of the facility's undated document titled, "Transferring & Lifting Using Hoyer Lift," the document indicated in part, "..Check ADL Profile: If marked mechanical lift, use lift. Always 2 person when using mechanical lift; Hoyer or sit to stand ...Moving Resident: Always 2 CNAs when using lift, watch head, feet, legs of the resident.." Review of the facility's undated policy and procedure (P&P) titled, "Using a Portable Lifting Machine," the P&P indicated in part, "..The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, two (2) nursing assistants will be required to perform the procedure.." Review of the facility's undated P&P titled, "Fall Prevention Policy", the P&P indicated in part, "The care plan will state the goals, interventions and approaches for every resident who is identified as being at risk for falls ...3. Direct care providers will be instructed regarding approaches and goals for the management of the resident falls risk.." Review of Resident 1's "Autopsy Report" dated 11/19/19, sets forth the following, "CAUSE OF DEATH: MULTIPLE BLUNT FORCE INJURIES"; Autopsy Summary included, I. Multiple blunt force injuries A. Status post fall from transfer lift B. Multiple right rib fractures C. Right acromioclavicular fracture D. Right tibial fracture E. Scalp hematoma Review of Resident 1's "Certificate of Death", issue date 04/08/2020, sets forth the following, "Immediate Cause of Death: Multiple Blunt Force Injuries". The facility failed to provide adequate supervision and assistance for Resident 1, when a CNA attempted a mechanical lift transfer with one-person assistance instead of two-person assistance. As a result, Resident 1 fell to the floor and sustained multiple injuries requiring immediate hospital transfer and admission to intensive care unit, where Resident 1 ultimately died. The failure presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.