Health inspection·March 22, 2024

The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported incident (FRI) CA00878704. Representing the Department, HFEN 28183. State Citation B was written. 42 CFR § 483.25(d) Accidents The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CR §72523. 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. On 1/12/24 at 1:30 P.M., an unannounced visit was conducted related to resident's complaint of left foot pain. It was determined the facility failed to ensure Certified Nursing Assistant (CNA) 1 was trained to operate a specialty electric wheelchair per the facility's policy, prior to assisting the resident, which resulted in the resident hitting the wall and sustaining a heel fracture. As a result, Resident 1 was sent to the hospital due to complaints of pain and was diagnosed with a comminuted calcaneus (heel) fracture of left foot. In addition, other residents were at risk for injury if assisted by untrained staff. Findings: A review of the resident's Face Sheet indicated, Resident 1 was admitted to the facility on 6/8/22, with diagnoses that included congenital malformation of spine and quadriplegia (a form of paralysis that affects all four limbs and torso). During an interview on 1/12/24 at 1:40 P.M., the Director of Nursing (DON) stated that Resident 1 was a quadriplegic and had been at the facility since 2022. The resident has a customized electric wheelchair that he brought from home which he maneuvered using a mouth joystick controller. The mouth joystick was on a wire halo (a safety device) that can be moved up or down to place in front of the resident to use. The DON stated, "When he first came, we gave training [to the CNAs] about his electric wheelchair." According to the DON, on 1/6/24, CNA 1 was getting the resident ready for bed. When CNA 1 left the room, she had turned the wheelchair off. The resident later called to be put back to bed. CNA 1 went to move the halo down in front of the resident and bumped the mouth joystick, which caused the wheelchair to move forward and into the wall, hitting the resident's left foot. Resident 1 was complaining of pain when the charge nurse went in to do an assessment. At that time, Resident 1 was already on the phone talking to 911. The resident was sent to the hospital where x-rays showed a comminuted calcaneus (heel) fracture of the left foot. According to the DON, surgery was not required, and a splint was placed on the resident's left lower leg. The resident returned to the facility on 1/7/24. The DON stated that the resident had been doing well since returning and the resident's left foot should heal on its own. The resident will follow up with the orthopedic physician for splint removal. A joint interview and record review was conducted with the DON on 1/12/24 at 2 P.M. An in-service sign-in sheet, dated 7/26/22, indicated the Therapy Department conducted staff training on Resident 1's electric wheelchair. The DON stated this was the last training conducted on the resident's wheelchair. There was no record that CNA 1 received training on operating Resident 1's electric wheelchair. The DON acknowledged that the facility policy indicated that staff should be trained on a specialty device such as an electric wheelchair. The DON stated, "They should check if the wheelchair is on or off" before proceeding. According to a nursing progress notes, dated 1/7/24, "The CNA related that she was putting the resident to bed when she bumped the joystick of the resident's wheelchair, and it moved forward into the wall." On 1/12/24 at 2:10 P.M., Resident 1 was interviewed. The resident stated he was doing ok and currently had no pain. He had a soft splint on his left lower leg. Resident 1 stated that his electric wheelchair had a joystick controller "on a wire that fits on my neck to run it with my mouth." The resident further stated, "We have a lot of trouble getting it to sit where it needs to sit." According to Resident 1, CNA 1 had turned off the wheelchair, but when she returned to help the resident back to bed, she thought the wheelchair was off, but it was turned on. The CNA went to move the halo down and touched the joystick which moved his wheelchair forward, hitting his left foot The resident did not know how it got turned back on. CNA 1 was interviewed on 1/12/24 at 2:45 P.M. According to CNA 1, she was setting Resident 1 up for bed and turned the wheelchair off before she went on break. When she came back, the resident called to go back to bed. He was in his electric wheelchair next to the bed facing the wall. CNA 1 stated she was going to let the resident maneuver his chair, so she went to move the halo down to put the mouth joystick in front of him. CNA 1 stated, "I barely touched it, and it went "zoom." It was on but I don't know who turned it on." According to CNA 1, she had recently changed nursing stations and had been working with Resident 1 for about two weeks. CNA 1 stated, "I had no training on his wheelchair. The other CNAs showed me; I knew to keep an eye on it to make sure to turn it off. I made sure to turn it off." CNA 1 further stated there are panels on the inside of each armrest of the wheelchair, the right side turns the wheelchair on, and the left side is to position/recline. CNA 1 stated, "Maybe he accidentally hit it." According to the facility's policy and procedure, titled Assistive Devices and Equipment, dated January 2020, "Staff and volunteers are trained and demonstrate competency on the use of devices and equipment prior to assisting or supervising residents." In violation of the above cited standards, the facility failed to ensure Certified Nursing Assistant (CNA) 1 was trained to operate a specialty electric wheelchair per the facility's policy, prior to assisting the resident, which resulted to hitting the resident's left foot. As a result, Resident 1 was sent to the hospital due to complaints of pain and was diagnosed with a comminuted calcaneus (heel) fracture of left foot. This violation had a direct or immediate relationship to the health and safety or security of the resident.