Health inspection·November 9, 2023

The following reflects the findings of the California Department of Public Health during the investigation of: Complaints #CA00847307, CA00847682 and Entity Reported Incident (ERI) #CA00847392. Event ID: 4J1M11 Representing the Department, HFEN #27007 A Class "A" Citation was written for the following violation: F689 Free of Accident Hazards/Supervision/Devices §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 §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Based on interview and record review, the facility failed to follow their policy and procedure (P&P) to ensure two staff members were involved when transferring a resident in a mechanical lift. Resident 1 was being transferred with a mechanical lift from her bed to a shower chair by one staff member, Certified Nursing Assistant (CNA) A. During the transfer, one of the straps from the sling became disconnected, which resulted in Resident 1 falling out of the sling onto the floor. Resident 1 sustained head injuries and lacerations to the left arm, requiring a transfer to the emergency department and admission to the hospital. Findings: On 6/28/2023, at 9:30 a.m., an unannounced visit was conducted at the facility to investigate both complaints and an entity reported incident regarding quality of care/resident safety. Clinical record review for Resident 1 was conducted on 6/28/2023. Review of Resident 1's Emergency Department Provider Report, dated 6/23/2023, indicated Resident 1 was brought to the emergency department after falling from a mechanical lift at the skilled nursing facility. The resident groaned in discomfort. Examination of her head indicated a laceration to her right forehead region requiring suture repairs, a right eye hematoma (bleeding around the eye), abrasion to the lips and dried blood in her mouth. Her left lower leg had a small hematoma on the front of her shin. A computerized tomography (CT scan - combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside the body. CT scan images provide more-detailed information than plain X-rays do.) indicated Resident 1 also sustained a right-sided subdural hemorrhage (bleeding in the brain). Review of Resident 1's hospital Neurosurgery (medical discipline that specializes in surgery performed on the nervous system, especially the brain and spinal cord) Consultation Note, dated 6/23/2023, indicated no surgery would be performed and that the subdural hematoma was potentially life-threatening. The family requested comfort care only (symptom control, pain relief, and quality of life). Review of the facility's P&P, "Lifting machine, using a mechanical" (revised 7/2017) indicated, "... at least two nursing assistants are needed to safely move a resident with a mechanical lift." Steps in the procedure (using the lift) included, "... to make sure the straps to the sling bar are securely attached to the clips and that it is properly balanced, before the resident is lifted, double check the security of the sling attachment and lift the resident two inches from the surface (bed) to check the stability of the attachments, the fit of the sling, and the weight distribution." Review of the manufacturer's manual titled "Manual/electric Portable Patient Lift Owner's Installation and Operating Instructions," dated 2001, showed "warning: when elevated a few inches off the surface of the bed and before moving the resident, check again to make sure that the sling is properly connected to the hooks of the swivel bar." Review of the facility's Unusual Occurrence Initial Report, dated 6/24/2023, indicated, on 6/23/2023 at approximately 3:35 p.m., Licensed Vocational Nurse (LVN) C was called to Resident 1's room after it was reported Resident 1 had fallen. The nurse found Resident 1 on the floor laying on her right side on top of one of the Hoyer legs with CNA A by her side. Resident 1 sustained lacerations to her left forearm, laceration to her bottom lip, bruising to her right arm/elbow and crepitus (grating sound) was noted to her forehead above her eyebrow. The maintenance staff checked the mechanical lift and sling and noted both were functioning properly. Review of Resident 1's Unusual Occurrence Final Report indicated that, on 6/23/2023 at approximately 3:35 p.m., LVN C was called into Resident 1's room by a CNA. LVN C stated she saw Resident 1 lying on the ground and there was blood on the floor. LVN C yelled for additional staff to help with Resident 1. CNA A stated she went to transfer Resident 1 with the mechanical lift and a sling. She placed the sling under the resident and hooked the straps to the machine. CNA A stated she lifted Resident 1 off the bed (with the lift) and pulled the machine towards the right to place Resident 1 into a shower chair, when the resident started to fall towards her right side. CNA A's statement included, "I was by myself transferring the patient (resident). I am aware that this is not the proper protocol." The Director of Nurses (DON) documented, "the facility concluded that the resident fell from the Hoyer lift (mechanical lift) due to CNA error." Review of Resident 1's Admission Record face sheet (summary overview of the resident's important information) indicated she was admitted to the facility with diagnoses including hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (weakness or inability to move on one side of the body) affecting her right-side (arm and leg), right-hand contracture (deformity) and unspecified dementia (decreased memory and thinking capabilities). Review of Resident 1's Minimum Data Set (MDS-an assessment tool) dated 4/12/2023, indicated she required extensive assistance from two staff members for transfers. Her balance during transfers indicated she was not steady and required stabilization with staff for assistance. Review of Resident 1's care plan to address her activities of daily living (ADL) care indicated on 8/12/2020, she was total dependent with transfers via a mechanical lift, which requires two people. Review of Resident 1's Progress Note, dated 6/23/2023 at 3:35 p.m., indicated Resident 1 sustained lacerations to her left forearm (approximately 8 centimeters (cm)) and to the bottom of her lip (approximately 3 cm), bruising to her right arm/elbow and crepitus to her forehead above her eyebrow. Review of Resident 1's Post-Fall Review form, dated 6/23/2023 at 3:50 p.m., indicated the Interdisciplinary Department Team (IDT) determined the root cause of the fall to be when the resident fell from the mechanical lift, the resident had no trunk control and no ability to brace herself due to hemiparesis and hemiplegia (paralysis) to her right side coupled with contractures (deformity). Review of CNA A's Performance Skill Check lists show she had met her return demonstration on the proper transferring and safety of a mechanical lift dated 12/14/2022 and again on 3/20/2023. Review of the Maintenance Safety Inspection Checklists for the two mechanical lifts, dated 6/7/2023, indicated the lifts were inspected and in proper working order. Another checklist dated 6/23/2023, was performed following Resident 1's incident. Both lifts were inspected and were in proper working order. An interview was conducted with the Director of Nursing (DON) on 6/28/2023 at 10:25 a.m. She stated Resident 1 was not able to make her needs known and her right arm and leg were contracted. The DON stated, on 6/23/2023 at approximately 3:30 p.m., she was notified of Resident 1 being on the floor. She stated when she entered Resident 1's room, only CNA A was in the room. The DON stated the mechanical lift was upright and the sling's straps were still attached except the front right strap (near the foot). She stated Resident 1 was on the floor, her torso was on top of the leg of the mechanical lift and the resident's left hand was grasping the lift. The DON stated Resident 1 was moderately bleeding above her right eyebrow, nose, and mouth. She stated further assessment of Resident 1 indicated the resident had a skin tear to her left forearm, bruises to her right elbow and her lip was bleeding. The DON stated she assessed the sling and there were no visible signs of rips or tears on the sling/straps. She confirmed two staff members should be transferring a resident when a mechanical lift was to be used. On 6/28/2023 at 12:05 p.m., an interview was conducted with the Maintenance Director. He stated he checked "the mechanical lifts monthly and the lifts are in proper functioning order." The Maintenance Director stated he performed a routine maintenance check on the mechanical lifts on 6/7/2023, and the lift was functioning properly. He was asked to recheck the lifts on 6/23/2023, after Resident 1 had fallen during a transfer and the lift and slings were in good working order. During an interview on 6/28/2023 at 1:45 p.m., CNA E stated Resident 1 was nonverbal and unable to make her needs known. She stated Resident 1 was unable to stand and required the use of a mechanical lift during transfers. CNA E stated two staff are required to assist when using a mechanical lift. On 6/28/2023 at 4:40 p.m., a telephone interview was conducted with CNA A. She stated Resident 1 was nonverbal and could move one arm, but her legs were contracted. She stated she was aware two staff members are needed to use the mechanical lift and she had previously asked another CNA to help her transfer Resident 1 with the mechanical lift, but the CNA never came back into the room, so she transferred the resident by herself. CNA A stated when she started to move the mechanical lift, the left strap came off and Resident 1 fell out of the sling. On 6/28/2023 at 6:34 p.m., a telephone interview was conducted with LVN C. She stated Resident 1 was nonverbal, moans and cries. LVN C continued to state Resident 1's right arm was flaccid (limp), and her left leg was contracted. She stated, on 6/23/2023 at approximately 3:30 p.m., CNA B came to the nurses' station and notified her that a resident was on the floor. LVN C stated when she entered Resident 1's room, she saw Resident 1 on the floor on top of the mechanical lift and a lot of blood was on the floor. She stated Resident 1's head sustained a laceration to the right side of her head. LVN C stated the sling was still attached to the mechanical lift; however, one of the straps was not hooked. She stated two staff members are needed when a resident was to be transferred using a mechanical lift. A telephone interview was conducted on 6/28/2023 at 6:45 p.m. with CNA B. She stated Resident 1 was nonverbal and unable to move her extremities. CNA B stated two staff members are needed for a resident to be transferred using a mechanical lift. Clinical record review for Resident 2 was conducted on 6/28/2023. Resident 2 was admitted to the facility with diagnoses including lack of coordination. Her MDS dated 6/13/2023 indicated a Brief Interview for Mental Status (BIMS) of 15 (13 -15: cognitively intact, 08 -12: moderately impaired, 00 -07: severe impairment). Resident 2 required extensive assistance of two staff members for transferring. Review of Resident 2's care plan problem to address her performance deficit related to muscular impairment, dated 5/31/2017, indicated she required two staff members to transfer via a mechanical lift. On 6/28/2023 at 2:30 p.m., an interview was conducted with Resident 2. She confirmed she requires a mechanical lift to transfer from the bed to her wheelchair. Resident 2 stated sometimes there is only one staff member doing the transfer because they cannot find any other staff member to help them. She stated this usually happens two to three times a month. In violation of the above cited standards, the facility failed to ensure staff followed the Policy and Procedure (P&P) titled "Lifting machine, using a mechanical" when transferring residents from the bed to a chair which had a direct and immediate relationship to the health, safety, or security of the resident, and is a Class A citation.