Other·April 23, 2024

F 689 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. On 3/13/24 at 11:45 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 injury. The Department determined the facility failed to follow policy and implement measures to prevent an avoidable injury for Resident 1 when the resident was transferred from wheelchair to bed without a sit to stand lift (a device designed to assist patients who have some mobility but need help to rise from a sitting position). This failure led to Resident 1 sustaining a fracture (break) of the bone in the lower leg and increased pain. A review of Resident 1's clinical record included the following documents: Resident'1s face sheet, indicated Resident 1 was admitted 2/17/24 with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body), Cerebral Infarction (a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause part of the brain to die) and the need for assistance with personal care. A Physical Therapy (PT) evaluation and treatment plan, dated 2/19/24, indicated "Patient will safely perform functional transfers with Substantial/Maximal Assistance for correct hand/foot placement in order to perform functional mobility with reduced risk of falls." A Fall Risk Care Plan (CP), initiated 2/20/24, indicated Resident 1 was at risk for falls related to use of medications and osteomyelitis of vertebra (an infection of the spine) ...resident will be free of...injury...follow facility protocol. The Minimum Data Set (MDS, an assessment tool) dated 2/24/24 indicated Resident 1 was cognitively intact. A Therapy Note, dated 3/7/24 at 12:14 p.m., written by the Director of Rehabilitation indicated, "PT [Resident 1] is able to tolerate a stand lift [sit to stand lift]. Suggest 2 person." A Change in Condition (COC) nursing evaluation, dated 3/8/24 and completed by Licensed Nurse (LN) 3, indicated at 8 a.m. "Nursing observations, evaluation, and recommendations are:@0800 the resident complains about pain level 8 on L sheen [shin] and L ankle, with movement, cannot handle having the skin in the area being touched, no swelling or skin color or temperature changed at both sites, she can move her toes on L foot but with pain, resident received Oxycodone (narcotic pain medication)15 mg 1 tab PO @0400, and Morphine (strong narcotic pain medication) 20 mg 1 tba[tablet]PO @0900,still c/o pain level 8, she states " pain medications does not work, I want to go the hospital". A review of a "General Note" written by a LN on 3/8/24 at 10:07 a.m., indicated, "Resident was sent to [name of hospital] for uncontrolled pain leveled 8 in L sheen [shin] and L ankle." A nursing note dated 3/8/24 at 2:54 p.m. stated, "Called [name of hospital] to follow up sending resident for unrelieved pain to left leg. [name of hospital] nurse reported that resident was being discharged this afternoon. She has a fracture in left tibia and left fibula [broken bones in lower leg] and has a splint...follow up to be done with surgeon." During an interview on 3/13/24 at 12:50 p.m. with Resident 1, Resident 1 stated, "It was last Thursday, after dinner, was sitting in wheelchair, needed to get back to bed, the Certified Nursing Assistants (CNAs) were helping me to bed, I couldn't help much but they told me, 'You have to help us', pulling on my arms , one on each side stood me up from wheelchair (wheelchair was facing bed), left leg slid forward - I had no socks on - my slippers are over there (Resident 1 pointed to shelf were red slip on shoes were visible)... heard a crack... they got me in bed, moved my legs over and I heard another crack but I was in excruciating pain". Resident 1 identified one Certified Nursing Assistant (CNA) by name and stated, "She was holding my arm and shoulder and the other CNA had my left arm. They kept telling me, 'You have to help us', but I couldn't". Resident 1 stated the CNAs did not use a lift [sit to stand lift] when they helped her to bed. During an interview on 3/13/24 at 2:40 p.m. with CNA 3, CNA 3 confirmed a sit to stand lift was not used per PT safe transfer recommendations for a resident transfer from wheelchair to bed. CNA 3 stated, along with CNA 4...a two-person transfer was used to move Resident 1 from her wheelchair to bed. CNA 3 confirmed Resident 1 complained of pain to her left leg after the transfer was completed. During an interview on 3/13/24 at 3 p.m. with CNA 4, CNA 4 confirmed a lift [sit to stand lift] was required when transferring Resident 1...there was one outside the room...but Resident 1 declined. CNA 4 stated Resident 1 complained of left leg pain after two-person transfer from wheelchair to bed. During an interview on 3/13/24 at 3:30 p.m., with the Director of Nursing (DON), the DON stated, "The following morning, after Resident 1 was transferred without the lift, Resident 1 was still complaining of pain to her left leg...her doctor was notified, and Resident [1] was transferred to the hospital for further evaluation of left leg pain." The DON further confirmed, Resident 1 needed a lift [sit to stand lift] (per PT safe transfer recommendations and the facility P&P) for transfer and staff should not have transferred the resident without the use of the sit to stand lift. Residents requiring lift transfers are not safe with just a 2-person transfer...residents can be harmed if proper equipment is not used for transfers. During an interview on 3/13/24 at 3:55 p.m. with the Administrator, the Administrator stated her expectation is for staff to transfer residents safely which requires following the treatment plan and transfer recommendations. The Administrator further stated that residents can be harmed if proper equipment is not used. During a review of the P&P titled "Safety and Supervision of Residents", dated 2001 MED-PASS, Inc, (Revised July 2017), the P&P indicated, "Facility strives to make the environment as free from accident hazards as possible...Resident safety and supervision and assistance to prevent accidents are facility wide priorities... The care team shall target interventions to reduce individual risks ... including adequate supervision and assistive devices." During a review of the facility P&P titled "Fall Prevention Program", dated October 2022 Revision, the P&P indicated, [The facility will] ...provide additional interventions as directed by the resident's assessment, including but not limited to...Assistive devices [lifts]." During a review of the facility P&P titled "Safe Resident Handling/Transfers", dated 2023, the P&P indicated,..."The use of mechanical lifts are a safer alternative and should be used...Staff members are expected to maintain compliance with safe handling/transfer practices...Resident lifting and transferring will be performed according to the resident's individual plan of care." Therefore, the Department determined the facility failed to follow policy and implement measures to prevent an avoidable injury for Resident 1 when the resident was transferred from wheelchair to bed without the sit to stand lift. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.