Health inspection·December 7, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from injury when the Certified Nurse Assistant 1 (CNA 1) was assisting Resident 1 from a standing position and held Resident 1 with one hand, while reaching for the wheelchair with the other hand during transfer from bed to wheelchair. Resident 1's knees lost postural stability while standing. This failure resulted in Resident 1 falling and sustaining a fractured pelvis (hip bone). Findings: During an interview of on December 7, 2023, at 1:35 PM with Resident 1, Resident 1 stated she had a fall incident, but was unable to give details about it. During a review of Resident 1's admission Record (AR) , dated December 7, 2023, the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included senile (poor mental ability because of old age) degeneration of brain and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (disrupted blood flow to the brain) affecting left non-dominant side. During a review of Resident 1's History and Physical (H&P-a brief documentation of a resident's medical condition), dated November 27, 2023, the H&P indicated, Resident 1 has fluctuating capacity to understand and make decisions. During a review of Resident 1's Section GG- Functional Abilities and Goals, dated November 9, 2023, the Section GG indicated Resident 1 uses wheelchair for mobility and requires partial/moderate assistance during transfers from bed to wheelchair. During a concurrent interview and record review on December 7, 2023, at 4:06 PM with the Director of Nursing (DON), Resident 1's Progress Notes (PN), dated November 17, 2023, was reviewed. The PN indicated, Patient (Resident 1) fell on floor on left side of body during a transfer from bed to wheelchair. CNA turned around to reach for the wheelchair when patient fell . The DON stated the CNA referred on the PN is CNA 1. The DON stated CNA 1 was assisting Resident 1 with both hands while standing up from bed when CNA 1 turned and grabbed the wheelchair with her right hand. Resident 1's legs lost stability while standing and fell to the floor while being held by CNA 1. The DON further stated Resident 1 was eventually sent to the hospital on the same day. During a record review on December 7, 2023, at 4:25 PM with the Director of Nursing (DON), Resident 1's Adult Trauma H&P/Consult from (Name of Hospital), dated November 18, 2023, was reviewed. The Page 1 of 2 055299 055299 12/07/2023 Loma Linda Post Acute 25383 Cole Street Loma Linda, CA 92354

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few H&P indicated Resident 1 had a fall incident and underwent a CT (Computerized Tomography- a diagnostic imaging used to assess a medical condition) of the Abdomen and Pelvis on November 17, 2023. The CT result indicated, .Impression: Minimally displaced oblique (slanting direction) fracture (a break or crack) of the left inferior (lower position) pubic ramus (bones that make up part of the pelvis) and left superior (higher position) pubic ramus adjacent (next or near) to the symphysis (a place where two bones are closely joined) . During an interview on December 7, 2023, at 5:20 PM with Physical Therapist 1 (PT 1), PT 1 stated residents should be held with both hands during transfer from bed to wheelchair using standing pivot (a technique used to transfer a person). PT 1 further stated letting go of one hand would not provide support and stability should the resident fall. During an interview on December 11, 2023, at 10:21 AM with CNA 1, CNA 1 stated she was transferring Resident 1 from bed to wheelchair. CNA 1 stated she assisted Resident 1 to stand up from bed to transfer to the wheelchair. CNA 1 stated she noticed that the wheelchair was not as close to them as it should be. CNA 1 stated reached for the wheelchair with her right hand to bring it closer for the transfer but Resident 1's knees lost stability. CNA 1 stated Resident 1 fell on the floor while she was attempting to reach the wheelchair. During a concurrent interview and record review on December 12, 2023, at 1:00 PM, with the Director of Staff Development (DSD), the facility's policy and procedure (P&P) titled Resident Safety and Transfer Technique, revised July 2017 was reviewed. The P&P indicated, Policy Statement. Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and transfer assistance to prevent accidents are facility-wide priorities .Helping patient to stand. When helping a patient to stand up from a chair or bed, it is important to guard the patient from falling .2. Put on a transfer belt around the patient 's waist if you have one. 3. Lock your hands behind the patient 's waist or grip the transfer belt .7. Stand and lift the patient, while pivoting towards the chair .From bed to wheelchair .5. Help the patient to standing position. 6. Support the patient with your arms and knee as needed . DSD stated CNA should have held Resident 1 with both hands at all times during the transfer to guard against fall. 055299 Page 2 of 2