Health inspection·July 26, 2024

The following reflects the findings of the California Department of Public Health an Abbreviated Standard Survey complaint and facility reported incident #901517 and 903855. The inspection was limited to the specific complaint and facility reported incident investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the Department: 50939, HFEN A deficiency was written for the complaint and facility reported incident #901517 and 903855 at F-Tag 689/G. F689 (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §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 6/4/24, an unannounced visit was conducted at the facility to investigate a complaint and facility reported incident regarding a resident (Resident 1) fall and sustaining an injury. Resident 1 is a 67-year-old female, who was admitted at the facility on 5/1/24 with diagnoses that include difficulty in walking, unsteadiness on feet, and muscle weakness. On 5/15/24, Resident 1 had a fall during physical therapy with Director of Rehabilitation and sustaining a right shoulder full-thickness tear (completely detached from the bone). Based on observation, interview, and record review, the facility failed to provide physical assistance and/or use of transfer device during ambulation (walking) to ensure safety for one of three sampled residents (Resident 1), when the Director of Rehabilitation (DOR), who was assisting Resident 1 while walking, did not provide a hand support to Resident 1 due to DOR was holding a cellphone on her left hand and holding a wheelchair on her right hand. This failure resulted in Resident 1 falling, sustaining a right shoulder tendon (connective tissue that connects the muscle to the bone) tear, and suffering from severe pain, and going to the general acute care hospital. Findings: During a review of Resident 1's "SBAR (Situation, Background, Assessment, and Recommendation) Communication and Progress Note (SBAR)," dated 5/15/24 at 1:40 p.m., the "SBAR" indicated, "Patient [Resident 1]was being ambulated with the use of FWW [Front-Wheeled Walker] under rehab [rehabilitation] supervision while reaching back to her wheelchair to sit [sic], patient [Resident 1] loss of balance [sic] was eased down to floor by rehab staff [Director of Rehabilitation/DOR]." During a concurrent observation and interview on 6/4/24 at 10:55 a.m. in Resident 1's room, with Resident 1, Resident 1 was lying in bed. Resident 1's facial expression was grimacing. Resident 1 stated she is having a right shoulder pain due to the fall incident. Resident 1 stated DOR was on Facetime (video call) on her cellphone while DOR was assisting Resident 1while walking on 5/15/24. Resident 1 stated DOR was holding a cellphone with her left hand and using her right hand to hold the wheelchair. Resident 1 stated she told DOR she was feeling "really dizzy." Resident 1 stated she tried to sit back onto the wheelchair, but the wheelchair was too far back and not within reach when attempting to sit back. Resident 1 stated she fell forward, face down onto the floor. Resident 1 stated DOR did not apply a gait belt (transfer belt is a device applied on a resident's waist who has mobility issues, by a caregiver prior to moving or walking the resident for safety), before assisting Resident 1 to walk on 5/15/24. During an interview on 6/4/24 at 12:15 p.m. with DOR, DOR stated she was holding a cellphone with her left hand and pulling Resident 1's wheelchair with her right hand. DOR stated she grabbed and held Resident 1's upper body to ease Resident 1 to the ground. DOR stated she did not apply a gait belt on Resident 1 prior to the fall incident on 5/15/24. During a concurrent interview and record review on 6/26/24 at 10:10 a.m. with Physical Therapist (PT), Resident 1's "Physical Therapy Progress Report (PTPR)," dated 5/15/24 was reviewed. The PTPR indicated, "Patient [Resident 1] ambulated [walked] 25 feet x [times] 2 with recovery between gait distances with FWW with CGA [Contact Guard Assist-level of assistance in physical therapy where a caregiver places one hand on resident's body to help with balance or body stabilization] and cues [signal] for FWW management, posture, step strength, foot clearance, safety, and BOS (Base of Support), 2 turns CGA." PT stated Resident 1's Physical Therapy order were steady assist and CGA. PT stated CGA means have one hand on the resident to keep resident steady. During a review of Resident 1's "Minimum Data Set (MDS-Assessment Tool)," dated 5/6/24, the "MDS" indicated, Resident 1 requires the assistance of one staff with walking. During a review of Resident 1's "Admission Record (AR)," dated 5/1/24, the "AR" indicated, Resident 1 had diagnoses of difficulty in walking, unsteadiness on feet, and muscle weakness. During a review of the Resident 1's "Care Plan (CP)," dated 5/13/24, the CP indicated, "The resident [Resident 1] is high risk for falls related to fall risk score 13 [total score of 10 or above means high risk], weakness; psychotropic [medications that affect mental state] drug use. Goal: The resident [Resident 1] will be free of falls or falls will be minimized through the review date. Intervention: One person-assist with transfer." During an interview on 6/13/24 at 1:25 p.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated she assisted Resident 1 after the fall on 5/15/24. CNA 1 stated while assisting Resident 1 off the floor and back onto bed, she stated she did not see Resident 1 with a gait belt on. During a review of Resident 1's "Charting-Falls (CF)," dated 5/16/24 (after the fall), the CF indicated, "rt [right] knee pain rt ankle swelling, pain level 8/10 [level of 8-10 means severe pain]." Resident 1's CF dated 5/17/24 indicated, "right and left upper chest with swelling, right knee and right ankle with swelling, pain level 9/10." Resident 1's CF dated 5/17/24 indicated, "Resident [Resident 1] is scheduled for X-rays [imaging creates pictures of the inside of the body] this am [morning] due to c/o [complained of] severe pain: right and left shoulder, back of neck, right and left upper chest with swelling, right knee and right ankle with swelling, left knee, right and left foot. Resident with c/o severe pain." During a review of Resident 1's "Hospital Discharge Summary (HDS), the "HDS" indicated, "admit date 5/18/24." During a review of Resident 1's "Hospital Discharge Summary (HDS)," dated 5/22/24, the "HDS" indicated, "Right shoulder MRI [Magnetic Resonance Imaging-medical imaging technique used to form pictures of the inside the body] evidence of a full-thickness tear [completely detached from the bone] of the supraspinatus tendon [back of the shoulder] measuring 2.8 cm [centimeter] x 2.0 cm in axial dimension [line tear]." During a review of the facility's policy and procedure (P&P) titled, "Ambulation Program," dated April 9, 2014, the P&P indicated, "Equipment. Gait Belt. D. Observe correct guarding or spotting. 2. Use your other hand to support his/her shoulder or hip if needed." During a review of the facility's policy and procedure (P&P) titled, "Use of Gait Belt," dated February 23, 2010, the P&P indicated, "A gait belt will be used when ambulating or transferring a resident. E. Hold on to the gait belt firmly with one or both hands." In violation of the above cited, the facility failed to provide physical assistance and/or use of transfer device during ambulation to ensure safety for one of three sampled residents (Resident 1), when the Director of Rehabilitation (DOR), did not provide a hand support to Resident 1 when DOR was holding a cellphone on her left hand and holding a wheelchair on her right hand. This failure resulted in Resident 1 falling, sustaining a right shoulder tendon (connective tissue that connects the muscle to the bone) tear, and suffering from severe pain, and going to the general acute care hospital. This violation had a direct or immediate relationship to the health, safety, or security of residents and constitutes a class "B" citation.