Health inspection·April 7, 2022

The following reflects the findings of the California Department of Public Health during the investigation of Facility Reported Incident 760863 and Complaint 762130. 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. California Code of Regulations, title 22 § 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. California Code of Regulations, title 22 § 72517. Staff Development (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not limited to: (5) Accident prevention and safety measures. On 11/17/21, at 11:30 AM, California Department of Public Health conducted an unannounced visit at the facility to investigate a facility reported incident and a complaint regarding Resident 1's fall and injury. Resident 1 was a 91-year-old female admitted to the facility on 6/13/20 with diagnoses of malnutrition, contracture of muscles, history of covid-19 (highly infectious respiratory coronavirus), history of heart attack (when blood flow to the heart is blocked), abnormal posture, and muscle wasting (muscle loss-when a muscle becomes thin and weak). Based on interview and record review the facility failed to provide a safe environment for one of nine sampled residents (Resident 1) when the facility failed to: 1. Ensure an air mattress was appropriately deflated prior to provision of care for Resident 1. 2. Ensure one staff (Certified Nursing Assistant [CNA] 1) was competent to perform a task prior to providing that task for Resident 1. During an interview on 11/17/21, at 12:15 PM, CNA 1 stated, she was providing care to Resident 1 when Resident 1 fell on 11/10/21. CNA 1 stated Resident 1 was on an air mattress when she was changing the resident's soiled brief. CNA 1 stated during care Resident 1 slid off the bed and fell to the floor. CNA 1 stated Resident 1 had bleeding to the back right side of her head. During a review of Resident 1's facility document titled "Investigation of [Resident 1] fall with right clavicle [collarbone] fracture" (IRCF), dated 11/11/21, the "IRCF" indicated, "[Resident 1] is a 91-year old female long-term care resident that admitted to [facility] on 11/10/2019. . . On 11/10/2021 @ [at] approximately 7:00 AM, a staff member was performing incontinence care on [Resident 1] . . . When the staff member turned [Resident 1], she began to slide off the bed. The staff member then ran to the right side of the bed in an attempt to assist her [Resident 1] down to the floor, but she was too late resulting in [Resident 1] sliding to the ground unassisted. [Resident 1] is on an airflow mattress due to her history of skin breakdown. . . [Resident 1] sustained a 4.5 x 2.5 cm [centimeter - a unit of measurement] skin tear to her right upper arm and a 3.2 x 1.4 [sic] laceration to her scalp. [Resident 1] returned from the ER [emergency department] at approximately 1300 [1 PM] with orders for wound care to her scalp and skin tear . . . The admission nurse went to evaluate [Resident 1] and found that she has swelling to her right shoulder and was complaining of pain MD [medical doctor] was notified and ordered [immediate] x-ray. The x-ray showed: an acute clavicle fracture . . . The MD was notified and ordered to send [Resident 1] to [acute hospital] for evaluation and treatment of fracture." During a review of Resident 1's acute hospital document titled "ED [emergency department] Physician Notes" (EDPN), dated 11/10/2021, the "EDPN" indicated, "91-year-old female sustained a sudden onset constant moderate fall out of bed striking her head onto the ground while staff at her skilled nursing facility were trying to change out her adult diaper. . . [Resident 1] also has a skin tear to the right elbow." Resident 1 required staples to her right scalp to close the laceration. Resident 1 also had a scan of her head done which resulted in a diagnosis of right sided scalp swelling. During an interview on 11/17/21, at 1:15 PM, CNA 1 stated, she did not deflate the air mattress Resident 1 was on during her provision of care. CNA 1 stated the air mattress remained inflated. CNA 1 stated she had not received any type of training for providing care to residents on air mattresses. During a concurrent interview and record review, on 11/17/21, at 1:30 PM, with Director of Staff Development (DSD), CNA 1's "Nursing Assistant Orientation" (NAO) competencies (documented evidence a staff is competent to perform a task by demonstration of appropriate knowledge and skills in a clinical setting) dated 8/24/21 were reviewed. The "NAO" listed every section of CNA 1's competencies including the section that involves providing resident care and, did not have a return demonstration conducted as indicated on the form (series of boxes that need to be checked off) in order to appropriately assess if CNA 1 was competent. DSD stated staff competencies are done upon hire and yearly. DSD stated return demonstrations are done so that employees are able to show what they were taught back to the educator and the educator could then be certain that the employee was proficient or needed more training. DSD stated return demonstrations should have been checked off for CNA 1 to show she had completed training and was competent. DSD stated she was not sure if staff were trained on how to care for a resident on an air mattress. During an interview on 11/17/21, at 1:55 PM, Director of Nursing (DON) stated, he was not sure how, or if staff received training on how to care for a resident on an air mattress. DON stated DSD should know if staff receive air mattress training. DON stated residents on air mattresses should have their mattresses deflated when being provided care in bed because the mattress is slippery and elevated. DON stated competencies for staff should have return demonstrations to show that they are competent in performing their task. DON stated, "competency shows they [staff] are safe." During a review of the facility's policy and procedure (P&P) titled, "Knowledge and Skills Competency Evaluation," undated, the P&P indicated, "In an effort to provide optimal clinical care, direct care nursing staff are required to meet minimum standards before caring for residents. Knowledge and skill competencies are evaluated upon hire, annually thereafter and as needed, as indicated by job performance, newly introduced procedures, specific techniques required for an individual resident or new products and equipment. Purpose . . . Provide a method to measure employee's performance based on objective data. . . To ensure that all individuals who work within the facility demonstrate the requisite knowledge and skill to fulfill their assigned responsibilities in a safe and professional manner." During a review of the facility's P&P titled, "BEDS, SPECIAL - LOW AIR LOSS THERAPY," dated 11/2012, the P&P indicated, "It is the policy of this facility to utilize low air loss therapy under the direction of a physician's order. Facility staff working directly with the low air loss therapy unit will have training in its use by company representative or a trained facility staff member . . . Procedure . . . To place and remove bedpans, turn resident away from you, deflate seat section, depress bedpan into seat position and turn resident back into pan. When finished, remove bedpan, render hygiene and return inflation of sear section to preset level." In violation of the above cited standards, the facility failed to implement their policy and procedure to ensure staff competency while providing care to Resident 1 on an air mattress. This resulted in Resident 1 falling off the bed and obtaining a skin tear to her right upper arm, laceration to her head, and fracture of her collarbone. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and led to a Class A citation.