Other·May 1, 2024

Code of Federal Regulations, Title 42, Section 483.25 Free Accident Hazards/Supervision/Devices Section 483.25(d) Accidents. The facility must ensure that - Section 483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and Section 483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 72311 - Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 2/27/24 at 10:10 a.m., The California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding a resident fall that resulted in injury. The Department determined the facility failed to implement measures to prevent an avoidable fall for one of four sampled residents (Resident 1) when she was transferred from her bed to a chair without the use of a mechanical lift. These failures led to Resident 1 sustaining a left distal femur (lower end of thigh bone) fracture. A review of Resident 1's admission record indicated she was admitted in August of 2014 with diagnoses including hemiplegia and hemiparesis (weakness and paralysis of the body) affecting the right dominant side and dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement). A review of Resident 1's clinical record included the following documents: A review of Resident 1's Fall Risk Care Plan, initiated 2/3/21, indicated Resident 1 was at risk for falls related to balance problems, generalized weakness, and hemiplegia/hemiparesis. A review of Resident 1's Fall Risk Assessment, dated 7/12/23, indicated Resident 1 was at high risk for falls. A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 1/8/24, indicated Resident 1 had severe cognitive impairment (severe difficulty remembering things, making decisions, concentrating, or learning). The MDS indicated Resident 1 had impairment on one side of her body in both the upper and lower extremities which interfered with daily functions or placed the resident at risk of injury. The MDS further indicated Resident 1 was dependent for bed to chair transfers with the helper doing all the effort and the resident doing none of the effort and sitting to standing had not been attempted. A review of Resident 1's Change in Condition (COC) nursing evaluation, dated 2/21/24 and completed by Licensed Nurse 1 (LN 1), indicated at 7:30 a.m. two certified nursing assistants (CNAs) had attempted to transfer Resident 1 from her bed to a shower chair by having her stand and pivot. The COC note indicated Resident 1's legs gave out and the CNAs lowered her to the floor where she sat in a squatting position. The COC further indicated Resident 1 complained of pain to the left knee, the physician (MD) was notified and an order for a left knee x-ray was obtained. A review of Resident 1's Medication Administration Record (MAR), dated February 2024, indicated a MD order for acetaminophen (a mild pain reliever), 500 milligram (mg. a unit of measurement) tablet, 1 tablet every 4 hours as needed for pain. The MAR indicated Resident 1 had been given 1 tablet on 2/21/24 at 7:39 a.m. for a reported pain level of 6 out of 10 (0-10 pain scale, with 0 indicating no pain and 10 indicating worst pain possible). A review of Resident 1's MAR, dated February 2024, indicated a MD order for hydrocodone-acetaminophen 5-325 mg. (a moderate to severe pain reliever) tablet, one time for pain management. The MAR indicated Resident 1 had been given 1 tablet on 2/21/24 at 1:46 p.m. for a reported pain level of 9 out of 10. A review of an x-ray, dated 2/21/24, indicated Resident 1 had a displaced distal femur fracture. In an interview, on 3/13/24 at 11:10 a.m., LN 1 stated she was notified by staff that Resident 1 had fallen and when she entered her room Resident 1 was in a supine position on the floor next to her bed. LN 1 stated the CNAs told her Resident 1 had refused to use the lift and they had attempted to transfer her from her bed to the chair by standing and pivoting with her instead, but her legs gave out and they assisted her to the floor. LN 1 stated Resident 1 complained of pain to her left knee and she gave her a PRN (as needed) 500 mg. tablet of acetaminophen. LN 1 stated she notified the MD after the fall and was given an order for an x-ray. LN 1 stated later in the day Resident 1 had increasing pain, LN 1 stated she notified the MD and obtained a one-time order for hydrocodone-acetaminophen 5-325 mg. for the pain and was given an order to transfer the resident to a General Acute Care Hospital (GACH) emergency room for further evaluation. LN 1 stated because Resident 1 was supposed to be transferred with a mechanical lift, the CNAs should have notified her of the refusal. LN 1 agreed the fall was avoidable and resulted in the left femur fracture. In an interview, on 3/13/24 at 11:31 a.m., CNA 1 stated Resident 1 was supposed to be transferred with a mechanical lift but on 2/21/24 she had refused to use it. CNA 1 stated she and another CNA stood on each side of Resident 1 and had her stand and pivot from the bed to the chair instead. CNA 1 stated she normally did not transfer residents that used a mechanical lift by having them stand and pivot because they could not stand or bend their legs very well. CNA 1 stated when they stood Resident 1 up her legs gave out and they ended up lowering her to the floor in a squatting position and then to her knees. CNA 1 stated Resident 1 screamed out in pain. In an interview, on 3/13/24 at 12 p.m., the Director of Nursing (DON) stated the mechanical lift was the safest method to transfer Resident 1 from the bed to a chair and agreed the CNAs should have used it when transferring Resident 1. The DON also stated transferring a resident with hemiplegia and hemiparesis by having her stand and pivot was not safe. The DON stated it was an assisted fall to the floor which could have contributed to the fracture and confirmed Resident 1 had no fractures prior to the fall. The DON agreed the event was an avoidable accident. Review of a facility policy titled, "Falls and Fall Risk, Managing," undated, stipulated, "An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall." Review of a facility policy titled, "Fall Management," dated 5/26/21, stipulated, "Patients will be assessed for falls risk as part of the nursing assessment process. Those determined at risk will receive appropriate interventions to reduce risk and minimize injury." Therefore, the Department determined the facility failed to implement measures to prevent an avoidable fall for one of four sampled residents (Resident 1) when she was transferred from her bed to a chair without the use of a mechanical lift. These failures led to Resident 1 sustaining a left distal femur (lower end of thigh bone) fracture. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.