Other·June 27, 2023

The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported incident (FRI) CA00836331. Representing the Department, HFEN 39111. State Citation B was written. 42 CFR §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. On 4/20/23 at 12 P.M., an unannounced onsite visit was conducted related to a fall of Patient 1 while being transferred using the mechanical lift. It was determined the facility failed to ensure three of three patients (Patients 1, 2, and 3) were transferred (how a patient moved from one surface to another) in a safe manner using the mechanical lift. In addition, the facility failed to develop and implement a process that ensured slings (devices a patient sits in that attach to the mechanical lift) were verified to support patient's weight and maintained in a safe working order, when: 1. Patient 1 and Patient 2 were transferred from the bed with only one certified nursing assistant (CNA) present to operate the mechanical lift. 2. CNAs transferred Patient 3 from the bed manually without using a mechanical lift. As a result, Patient 1 fell from the mechanical lift when the sling broke while being transferred by one CNA and sustained a fracture of her left pinky finger and bruised her left ribs. Patient 1 experienced pain from her injuries and was fearful of being placed in the mechanical lift again. In addition, other residents who used the mechanical lift to transfer were put at risk for accidents. Findings: A review of Patient 1's Admission Record dated, 4/21/23 indicated, the patient was admitted to the facility on 10/16/12 and readmitted on 3/21/21 with diagnoses to include hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following a stroke and morbid obesity (a disorder involving excessive body fat that increases the risk of health problems). A review of Patient 1's Minimum Data Set Assessment (MDS, an assessment tool), dated 1/13/23 indicated, the patient scored 14 on the brief interview of mental status (a score of 13-15 meant the patient was cognitively intact). The same MDS assessment indicated Patient 1 required extensive assistance (staff to provide weight-bearing support) and two or more staff to assist during transfers. A review of Patient 2's Admission Record dated, 4/21/23 indicated, the patient was admitted to the facility on 2/25/23 with diagnoses to include spinal stenosis (narrowing of the spinal canal) and morbid obesity. A review of Patient 2's MDS assessment, dated 3/24/23, indicated the patient had a score of 13 on the brief interview of mental status. The same MDS assessment further indicated Patient 2 required extensive assistance and two or more staff to assist during transfers. A review of Patient 3's Admission Record dated, 4/21/23, indicated the patient was admitted to the facility on 12/15/23 with diagnoses to include muscle weakness and an acquired absence of the left leg below the knee. Patient 3's Admission Record further indicated the patient was self-responsible (able to understand and make decisions). A review of Patient 3's MDS assessment dated, 3/29/23 indicated, the patient required extensive assistance and two or more staff to assist during transfers. On 4/20/23 at 12 P.M., an observation and interview were conducted with Patient 1 inside the patient's room. Patient 1 was in bed with her left hand wrapped with a bandage. Patient 1's left hand had dark, blue bruising visible around the bandaged area. Patient 1 stated she could only get out of bed with a mechanical lift. Patient 1 stated she was on her way to get a shower (on 4/13/23) and certified nursing assistant (CNA) 1 had been assisting her. Patient 1 stated she had purchased her own sling from the facility approximately five years ago so she would have one of her own that fit her size. Patient 1 stated she usually watched the staff to make sure the sling was connected to the lift correctly. Patient 1 stated CNA 1 seemed to be in a hurry, and she did not get a chance to verify the placement of the sling. Patient 1 stated CNA 1 had transferred her alone using the mechanical lift and her transfers from bed were usually done with one CNA as, "It's too hard to get two CNAs." Patient 1 stated while in the mechanical lift, and hoisted above the floor, she felt her left leg fall from the sling while the rest of her body was still inside the sling. Patient 1 stated CNA 1 tried to lower the lift, but she slid out of the sling and hit the floor before the lift lowered completely. Patient 1 stated "I was in such terrible pain and my sides are bruised." Patient 1 was asked if she currently had any pain related to the fall and stated, "Of course I have pain. It's in my hand, my finger's broken." Patient 1 stated she had a brief look at her sling after the incident and saw the plastic buckle that secured her left leg was cracked. Patient 1 stated it was her shower day today, but she was going to ask for a bed bath because she was afraid to get in the mechanical lift again. Patient 1 stated, "I don't feel safe. Like I can't get out of bed now." Two slings were observed hanging up beside Patient 1's bed, one for a standing mechanical lift, and another for a full body mechanical lift. The sling with the green border had a maximum weight limit on the label of 440 pounds (lbs.). The sling with the orange border had a maximum weight limit of 600 lbs. A review of Patient 1's progress notes titled Incident Note, dated 4/13/23, indicated, "CNA alerted writer that pt [patient] is on the floor. Came to check on the pt. Seen pt lying on her left side, screaming for help saying, "...it hurts, it hurts pls [please] don't move me." CNA, during transfer for a shower while pt still on [brand name] lift, the sling gave up ...." The Incident Note further indicated the CNA had used the patient's personal sling which had been used for approximately seven years. A review of Patient 1's hospital documentation titled Emergency Documentation dated 4/13/23, indicated, " ...assumed care of patient, here after a fall from a [brand name] lift at SNF [skilled nursing facility]. Pt has a fracture to left pinky and will be getting a finger splint to that finger. Pt had bruising to the left ribs and pain upon palpitation to that area ..." On 4/20/23 at 12:30 P.M., an interview was conducted with CNA 2. CNA 2 stated she was familiar with Patient 1 and had provided care to the patient many times and was "very alert. " CNA 2 stated two staff were required when operating a mechanical lift for the safety of the patient and the staff. CNA 2 stated one staff would operate the lift, while the other staff held the patient and guided the placement of the patient. CNA 2 stated after the incident in the lift, the patient seemed "More nervous." CNA 2 stated, "She doesn't want to get up out of bed anymore because she's scared to go in the lift." CNA 2 stated she saw some bruising on Patient 1 ' s ribs and the resident was complaining of pain more than usual. On 4/20/23 at 2:20 P.M., an interview was conducted with CNA 1. CNA 1 stated she had assisted Patient 1 on 4/13/23 using the mechanical lift. CNA 1 stated another CNA had been present the entire time to help during the mechanical lift transfer. CNA 1 stated the patient preferred to use her own sling and the sling had looked "okay" but that she did not know, and had not verified, how much weight it could hold. On 4/20/23 at 2:55 P.M., another interview was conducted with CNA 1 with the director of staff development (DSD) present. CNA 1 stated she had been alone when she transferred Patient 1 using the mechanical lift. CNA 1 stated she had received training prior to the incident and knew two staff were required to operate the lift while transferring a patient. CNA 1 stated she had assumed everyone was too busy to help, and that she had not asked for staff assistance when transferring Patient 1 on 4/13/23. On 4/20/23 at 3:07 P.M., a joint interview and record review was conducted with the DSD and director of nursing (DON). The in-service training sign-in sheet titled Transfer and Lifting, dated 3/27/23, indicated CNA 1 had attended the in-service. The DON stated the sling involved in the incident had belonged to Patient 1 and had been thrown away. The DON stated Patient 1's sling's label had been too faded to verify the weight limit. The DON and DSD both stated the facility did not have a system in place for checking the integrity of the slings or verifying the weight limits with the patient's current weight. The DON and DSD further stated their expectation was for two staff to participate in all patient transfers using a lift. A review of Patient 1's monthly weights were as followed: 1/4/23 449 lbs. (pounds) 2/4/23 466 lbs. 3/24/23 446 lbs. 4/4/23 442 lbs. 5/1/23 448 lbs. On 4/20/23 at 3:20 P.M., a joint observation and interview was conducted with the DSD. The DSD stated verifying that the patient's weight was below the maximum weight limit on the sling's label was important for patient safety. The DSD stated weight over the limit could cause the equipment to break or fail. The DSD observed Patient 1's sling with the green border hanging up in the patient's room and brought the sling out into the hallway for review. Patient 1's name was written on the sling and the label indicated the maximum weight limit was 440 lbs. The DSD stated, "This isn't the right sling," and that it was not safe for Patient 1's current weight. The DSD stated there needed to be a facility process to check the patient 's weight after being weighed, since weight could fluctuate, and to then evaluate the weight limit of the sling that was used. On 4/20/23 at 4:55 P.M., an interview was conducted with the physical therapist (PT) 1. PT 1 stated two staff were required when transferring a patient using a lift for both patient and staff safety. PT 1 stated the purpose of having two staff was for: one of the staff focus on the safe operation of the mechanical lift, while the other staff held onto the patient's legs, guiding the positioning of the patient, and monitoring the patient during the transfer. PT 1 stated if the second staff had been present when transferring Patient 1 on 4/13/23, they could have noticed the sling failure, held onto the patient's legs, and helped ease the patient's descent to the floor. On 4/20/23 at 5:10 P.M., an interview was conducted with the quality assurance nurse (QAN). The QAN stated two staff were required during patient transfers using any lift. The QAN stated she had investigated Patient's incident on 4/13/23 and determined that there should have been two staff transferring the patient with the lift and that personal slings should not be used. The QAN stated when the facility chose to utilize Patient 1's personal sling, the facility was responsible for ensuring the safety and maintaining the quality of it. The QAN further stated there had been no system or process in place for routinely checking the quality and functionality of the slings or verifying the patient' s weight with the sling being used after the patient was weighed. On 4/20/23 at 5:33 P.M., an interview was conducted with Patient 2 inside the patient's room. Patient 2 stated she was transferred by only one staff using the mechanical lift. Patient 2 asked, "Are two staff supposed to do it?" On 4/20/23 at 5:40 P.M., an interview was conducted with Patient 3 inside the patient's room. Patient 3 stated staff did not transfer her with a mechanical lift. Patient 3 stated, "CNAs just lift me under my armpits and move me. If there's a lift, I want to be using one." On 4/20/23 at 5:43 P.M., an interview was conducted with licensed nurse (LN) 1. LN 1 stated staff should transfer Patient 3 with the mechanical lift. On 4/20/23 at 6:10 P.M., an interview was conducted with the director of nursing (DON). The DON stated two staff were always required while a patient was transferred in a lift because one staff manned the machine while the other staff managed the patient. The DON stated this was done to ensure patient and staff safety while the lift was in use. The DON stated she had responded to Patient 1's room on 4/13/23 and had assessed the patient after the incident. The DON stated she had observed Patient 1 seated on the floor on top of the metal "legs" of the mechanical lift. The DON stated Patient 1's left hand was underneath the patient's buttocks. The DON stated Patient 1 had been upset and in pain, and expressed being afraid to use the lift again. A review of the lesson plan titled Transfer and Lifting- Safely moving Residents, dated 3/27/23, indicated, " ...Use teamwork (2 person assist) by asking your teammates for help and talking with them about what you do as you plan and while doing it ...." A review of the manufacturer's guidance for slings used by the facility titled Passive Clip Slings [brand name], revised 4/2022, indicated, "...Safe Working Load (SWL) Always follow the lowest SWL of the total system E.g. [brand name] lift spreader bar has a SWL of 160 kg [kilograms] (352 lbs.) and the [brand name] sling has a SWL of 272 kg (600lbs.). This means that the lift spreader bar has the lowest SWL. The patient is not allowed to weigh more than the lowest SWL...The caregiver shall inspect the sling before and after every use. The sling should be checked for all deviations listed below. If any of these deviations are visible, replace the sling immediately...unreadable or damaged label...Service life -Recommended period of use sling models [brand names] 1.5 years...all other slings 2 years..." A review of the facility's policy titled Safe Lifting and Movement of Residents, revised July 2017, indicated, "...2. Manual lifting of residents shall be eliminated when feasible...5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary..." A review of the facility's policy titled Assistive Devices and Equipment, revised January 2020, indicated, "...Our facility maintains and supervises the use of assistive devices and equipment for residents ...6. The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment ... b. Personal fit- the equipment or device is used only according to its intended purpose and is measured to fit the resident's size and weight. c. Device condition- devices and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired..." In violation of the above cited standards, the facility failed to must ensure that - "The resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents," including but not limited to, providing safe and adequate assistance to Patient 1 as was required. This violation threatened the patients' safety, health, and psychological well-being.