Health inspection·April 25, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and procedure on Resident lifting/Assisting Transfer Policy, regarding resident lifting for dependent residents (Resident 1). Residents Affected - Few Certified Nurse Assistant (CNA) 1 and CNA 2 did not use the mechanical lift transfer to Resident 1, who was totally dependent with transfers, held Resident 1 ' s arm pits to stand up from the wheelchair. This deficient practice had result in Resident 1 ' s left shoulder fracture and hospitalization. Findings: A review of the admission Record indicated Resident 1 was originally admitted on [DATE], with diagnoses that included but not limited to sclerosis (an abnormal hardening of a tissue or body part (as arteries or muscles) that occurred in several serious diseases), hemiplegia (paralysis that affected only one side of body) on left and right side, osteoporosis, left hand contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that caused the joints to shorten and become very stiff). A review of the Resident 1 ' s History and Physical (H&P), dated 3/24/24, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 3/21/24, indicated the resident had impairment on both sides of upper and lower extremities. The MDS indicated Resident 1 was dependent (helper did all of the effort. Resident did none of the effort to complete the activity) on staff with transfers, sit to stand, dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 1 ' s care plan, revised on 4/2/24, indicated the resident was at risk for spontaneous/pathological/stress fracture related to: osteoporosis, with intervention to handle gently and carefully during care. A review of Resident 1 ' s Radiology Results Report, dated 4/10/24, indicated probable acute left humeral (upper arm bone) neck fracture (a break or a crack in a bone). A review of the Resident 1 ' s Physician orders dated 4/10/24, indicated Transfer pt [patient] to [acute hospital] for further eval [evaluation] of left shoulder, discomfort pain and swelling. Page 1 of 2 055181 055181 04/25/2024 San Gabriel Conv Center 8035 E Hill Drive Rosemead, CA 91770

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 4/25/24 at 10:23 am, CNA 1 stated she was working morning shift on 4/10/24. when Resident 1 needed to be changed. CNA 1 stated Resident 1 required two CNAs ' assistance for transfers. CNA 1 stated Resident 1 was sitting on the wheelchair in her room on 4/10/24 around 2pm, and privacy was provided by closing door. CNA 1 stated, that both she and CNA 2 grabbed Resident 1 ' s arms and assisted Resident 1 to stand up on her feet. CNA 1 stated she was grabbing Resident 1 ' s left armpit and left arm while she cleaned Resident 1 ' s buttocks with her (CNA 1) right hand. CNA 1 stated that CNA 2 was on Resident 1 ' s right side and holding Resident 1 ' s right armpit. According to CNA 1, the whole cleaning and changing process was less than one minute, and Resident 1 was held up standing less than one minute. Per CNA 1, Resident 1 did not complain of pain during that time. CNA 1 stated CNA 1 and 2 returned Resident 1 back on the wheelchair after a new diaper was changed. Per CNA 1, Resident 1 complained of pain on the left shoulder as soon as Resident 1 sat back down on the wheelchair. CNA 1 stated that CNA 1 and 2 did not use the mechanical lift or gait belt was when Resident 1 was assisted with standing up during cleaning and changing. During an interview with the Occupational Therapist (OT 1) on 4/25/24 at 1:54pm, OT 1 stated the facility staff should use a mechanical lift to transfer to dependent residents. OT 1 stated that the appropriate way to assist dependent residents was to use the mechanical lift. OT 1 stated it was not appropriate to hold or grab Resident 1 ' s arm pits to stand up from the wheelchair. OT 1 stated that another appropriate way was to use the gait belt. OT 1 stated, residents with diagnosis of lateral sclerosis, osteoporosis, and cancer, their bone were more fragile and need to be handled more carefully. OT 1 stated the risk of holding on to the arm pits to stand up a resident from wheelchair can cause fracture. During an interview with the Director of Staff Development (DSD) on 4/25/24 at 3:17 pm, the DSD stated that dependent residents needed to be assisted using two people with a mechanical lift, and/or a use a gait belt to transfer. The DSD stated that the facility staff need to change Resident 1 in bed, and they will need to transfer Resident 1 from wheelchair to bed. During a telephone interview with Resident 1 ' s family (Family 1) on 4/25/24 at 3:31 pm, Family 1 indicated that Resident 1 was still hospitalized and complaint about the same level of pain on her left shoulder fracture. A review of the facility ' s policy and procedure titled Use of Transfer Belts Policy, (undated), indicated in the interest of safety and welfare to residents and staff, it is our policy that all facility employees use transfer belts when transferring residents or use the appropriate lifting device. A review of the facility ' s policy and procedure titled Resident lifting/ Assisting Transfer Policy, updated 2/26/14, indicated that No resident lift or assisted transfers will be attempted without using either a Vander-Lift, an Invacare lift, or a Hoyer lift except as detailed below: Note: use of mechanical lift requires at least two persons. 055181 Page 2 of 2