Other·June 23, 2021

The following reflects the findings of the California Department of Public Health during the investigation of Complaint Number 727054 and Facility Reported Incident 726924. Representing the Department: 34401, HFEN State Citation A was written. §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. §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. California Code of Regulations, Title 22, § 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. On 3/4/21, at 8:45 AM, an unannounced visit was conducted at the facility to investigate both a complaint and a facility reported incident regarding Resident 1's fall and injury when a shower bed (a medical device used to transport and shower people who are unable to stand or sit in a chair) collapsed during Resident 1's shower. During a review of Resident 1's facility "Admission Record" (AR), the AR indicted, Resident 1 was admitted on 1/16/16 with multiple diagnoses including Hemiplegia (paralysis of one side of the body) following unspecified cerebrovascular disease (affects the blood vessel and blood supply to the brain), affecting left non-dominant side, and dementia (loss of cognitive functioning including thinking, remembering, and reasoning). During a review of the Minimum Data Set (MDS, a standardized clinical assessment tool) dated 1/24/21, the MDS indicated, Resident 1 had a BIMS (Brief Interview of Mental Status) score of 5 (0-7 equals severe impairment), 8-12 equals moderate impairment, 13-15 equals cognitively intact). The MDS indicated, Resident 1 required extensive assistance (individual would not be able to perform or complete the activity of daily living (ADL) without another person to aid in performing the complete task, by providing weight-bearing assistance) in bed mobility, transferring, and bathing. Based on observation, interview, and record review, the facility failed to ensure one of four shower beds (a medical device used to transport and shower people who are unable to stand or sit in a chair) was in a safe and operable manner for one of nine sampled residents (Resident 1). This failure resulted in one shower bed having a missing part which caused the shower bed to collapse while in use. Resident 1 subsequently fell from the shower bed, hitting her head on the shower wall, and Resident 1 was sent to the hospital for evaluation. On 2/27/21, Resident 1, a 93 year-old female, arrived at the hospital ED for an evaluation of accidental fall. Resident 1 was evaluated for an accidental fall and altered level of consciousness (changes in brain function), compression fracture of thoracic and lumbar spine (base of the neck to low back), atrial fibrillation (irregular heart beat), congestive heart failure (heart cannot pump adequately), and history of cardiovascular accidents (stroke with residual deficits) Resident 1 was admitted to the hospital. During a review of Resident 1's Discharge Documentation (DD), dated 3/11/21, the DD indicated Resident 1 was admitted on 2/27/21, and was minimally responsive to stimulus. On 3/1/21, the DD indicated Resident 1 had no significant change in mental status. The DD indicated, on 3/5/21 Magnetic Resonance Imaging (MRI, imaging technique used to form pictures of the structure and function of the body) showed multiple large areas of acute infarcts (recent strokes) involving left middle cerebral artery (MCA, largest cerebral artery, provides blood supply to the brain) territory with areas of restricted diffusion seen in left basal ganglia. On 3/10/21, Resident 1 was discharged to facility with hospice care (end of life comfort care). During an interview on 3/4/21, at 9:03 AM, with Certified Nursing Assistant (CNA 1) and Director of Nursing (DON), CNA 1 stated, Resident 1 was safer in a shower bed during showers because Resident 1 "slouches" and can't sit up when placed in a shower chair. CNA 1 stated, on 2/25/21, she had obtained a shower bed from Station 3 front shower room and used a Hoyer lift (a hydraulic assistive device to help patient with mobility) with CNA 2's assistance. CNA 1 stated, they transferred Resident 1 from her bed to the shower bed. CNA 1 stated, she transported Resident 1 out to the hallway and into Station 3 front shower room. CNA 1 stated, she washed Resident 1 while she (Resident 1) was lying on the shower bed. CNA 1 stated, "I had to turn her [Resident 1] to wash her backside. . . It all happened so fast, when I turned her [Resident 1] to her side, the bed started collapsing. . . The shower bed tilted to its side, with the wheels coming towards me and I saw her [Resident 1] falling to the ground. I heard her [Resident 1] hit her head on the wall first." CNA 1 stated, after the bed collapsed, the broken shower bed was inspected by facility Maintenance Director (MD) and was told the shower bed had a missing a PVC pipe (white plastic pipe commonly used for plumbing and drainage) located in front of the shower bed connecting the front two wheels. CNA 1 stated, she did not inspect the shower bed for any missing part prior to use and she did not know how long the shower bed had been missing a part. During a concurrent interview and record review, on 3/4/21, at 9:20 AM, with DON, DON stated, all staff were aware to write in the maintenance log for any broken or missing equipment including the shower bed. DON reviewed the maintenance log and confirmed there was no documentation of any shower bed with broken and/or missing parts in the Maintenance Log. During an interview on 3/4/21, at 9:26 AM, with Maintenance Director (MD), MD stated the facility had four shower beds. MD stated, the maintenance department inspected the shower beds monthly for integrity, "checking the wheels, pins are all there, make sure all the connections are nice and tight." During an interview on 3/4/21, at 9:52 AM, with the Director of Staff Development (DSD), DSD stated, if staff noted an equipment, including a shower bed to be broken or have missing part, staff were required to place signage on the broken or missing equipment, notify maintenance, and enter the information in the maintenance log. DSD stated she did not know any of the shower beds had missing parts. During an interview on 3/4/21, at 10:34 AM, with CNA 1, CNA 1 stated "Someone must have known there was a piece that had fallen off [of the shower bed], if they [staff] let maintenance know, maintenance could have fixed it [shower bed]. It [shower bed] should have never been in the shower room with no sign. The incident could have been prevented." During an interview on 3/5/21, at 8:50 AM, with MD, MD stated, the missing PVC pipe connected the front wheels of the shower bed and measured approximately 1 1/2 to 2 feet long. Maintenance stated, "The PVC pipes are glued [together], the piece that came off, came un-glued. It would have been noticeable when it [PVC pipe] fell, it's a big piece." During an interview on 3/5/21, at 9:17 AM, with Licensed Vocational Nurse (LVN) , LVN stated, she responded to CNA 1's calls for help and found Resident 1 in Station 3 front shower room "lying on her left side facing the shower wall, [Resident 1] was covered in red marks everywhere, not talking, not responsive." During an interview on 5/7/21, at 10:25 AM, with CNA 3, CNA 3 stated, she was in-serviced when hired by the DSD and MD to "always" check for any loose parts on the shower bed before use. CNA 3 stated, "They're [shower beds] old, after a while they become loose. We just have to make sure it still works and all the parts are there before we use it." During a concurrent observation and interview on 5/7/21, at 10:50 AM, with CNA 4, a shower bed, placed against the wall in hallway 3, was observed. CNA 4 stated, the PVC pipe missing from the front wheel would have been easily identified as missing. Using the shower bed placed against the wall, CNA 4 demonstrated on how to lock the wheel brakes by walking around the shower bed and using her foot, pressed down a lever located on each wheel. CNA 4 stated, "When checking the lock on the wheels, you can tell if the bar [PVC pipe] is missing especially the bar connecting the wheels, plus you can compare from the other side that there is a part missing." CNA 4 stated, the missing PVC pipe connecting the front wheels could cause the shower bed to be off balance if missing. During a review of the "Facility Reported Event" dated 2/25/21, the report indicated, "The results of the facility's interviews and thorough investigations reveal the integrity of the PVC pipes of the shower bed were compromised when they cracked. It's possible the missing PVC could have changed the balance of the shower bed causing the tilt of the shower bed." During a review of the facility's policy and procedure (P&P) titled, "Maintenance Service" dated 2009, the P&P indicated, "The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe operable manner at all times." In violation of the above-cited standards, the facility failed to ensure the shower bed was in a safe and operable condition prior to showering Resident 1. This failure resulted in the shower bed collapsing while in use, Resident 1 falling from the shower bed, hitting her head on the shower wall, and the potential for significant injury. 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.