Health inspection·May 3, 2024

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 interviews and record reviews, the facility failed to follow their own policy when Resident 1 was transferred from bed to wheelchair without the use of a gait belt (assistance safety device). This failure resulted in Resident 1 ' s injury of chipped fracture to his right tibia (shin bone). Findings. A review of the Facility ' s undated admission Record indicated, Resident 1 was admitted on [DATE] with diagnoses that included Repeated Falls, Cognitive Communication Deficit and Retention of Urine Unspecified. An interview on 4/23/24 at 10:55 A.M., with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated she was supposed to be watching lights and provide assistance to residents when needed. CNA 1 stated if a resident wants to be left alone, CNA 1 will leave them alone but would be watching from a distance. A phone interview on 4/29/24 at 4:13 P.M., with CNA 2 was conducted. CNA 2 stated, she worked with Resident 1 that night of 3/15/24. CNA 2 stated at around 5:45 A.M., she asked Resident 1 if he wanted to go to the bathroom and Resident 1 agreed. CNA 2 transferred Resident 1 from the bed to his wheelchair with the use of a [NAME] steady (manual lift). After being transferred, Resident 1 slid from the wheelchair while being assisted by CNA 2 to the floor. CNA 2 stated she did not have a gait belt on him since he required minimal (the assisting person or device are required to perform 25 % of the work or a mobility task) assistance. CNA 2 acknowledged she should always have her gait belt with her to use with Resident 1 ' s transfers. An interview on 4/23/24 at 11:20 A.M., with the Assistant Director of Nursing (ADON) was conducted. The ADON stated Resident 1 required moderate (the assisting person or device are required to perform 50% of the work or mobility task) assistance with transfers as assessed by the Physical Therapist. The ADON stated the staff needs to always have the gait belt with them during transfers and ambulating residents in the facility. A phone interview on 4/29/2024 at 4:34 P.M., with the Director of Nursing (DON) was conducted. The DON stated the staff should always have their gait belts in their possession. The DON stated Resident 1 was a partial 1 per rehab assessment, and Resident 1 required moderate assistance with transfers and ambulation. Page 1 of 2 055632 055632 05/03/2024 Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942

F 0689 Level of Harm - Minimal harm or potential for actual harm A phone interview with family member (FM)1 on 4/24/24 at 9:04 A.M., was conducted. FM1 stated, the Administrator (ADM) told and confirmed that her husband did not have a gait belt on him when he fell and that he was assisted to the floor when he slid from his wheelchair. FM1 stated the facility stated it was a witnessed fall. FM1 stated her husband had a history of falls and had injured his right leg previously and then again at the facility as a result of the fall. Residents Affected - Few A record review of Resident 1 ' s MDS (minimum data set- tool assessment ) dated, 3/8/24 indicated, Resident 1 ' s cognition was severely impaired or a score of 5 (0-7 indicated severe cognitive impairment; 8-12 indicated moderate cognitive impairment; 13-15 indicated cognition is intact). A record review of the Physical Therapy Treatment Encounter notes dated, 3/13/2024 indicated, Resident 1 required moderate assistance of 1 person during sit to stand and transfers from chair/bed and to chair transfers and uses a front wheel walker as an assistive device. A record review of the Emergency Department visit at the Acute hospital on 3/15/24 indicated, final result impression of the x-rays of Resident 1 ' s tibia and fibula (calf bone) indicated Non-displaced acute medial tibial plateau fracture with associated A record review of the Facility ' s undated Gait Belt Policy indicated .#3 cnas/nas are required to have always assigned gait belt in their possession . #4 gait belts should be used when transferring and ambulating residents if and indicated . 055632 Page 2 of 2