Other·March 26, 2021

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident number 712071. 42 CFR 483.25 (d) Accidents. The facility must ensure that - 48.325 (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. 42 CFR 483.21 Comprehensive person-centered care planning. (a) Baseline care plans (1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality of care. The baseline care plan must- California Code of Regulations, Title 22 § 7253. Patient Care Policies and Procedure, (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 11/19/20, at 9:10 AM, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Resident 1's fall and injury. Certified Nursing Assistant (CNA, helps patients with activities of daily living and other healthcare needs under the direct supervision of a Licensed Nurse) 2 and CNA 3 attempted to transfer Resident 1 from her bed to a shower chair without the use of a mechanical lift. Resident 1 was a 69-year-old female with dementia (group of symptoms affecting memory, thinking and social abilities severe enough to interfere with daily life) admitted to the facility on 4/22/13. Resident 1 was readmitted on 11/9/20 with the following diagnoses: contractures (shortening and hardening of muscles, tendons, or other tissues) to her right knee, left knee, right ankle and left ankle, other abnormalities of gait [manner of walking] and mobility, muscle weakness, morbid [severe] obesity and repeated falls. Based on observation, interview and record review, the facility failed to ensure staff followed Resident 1's plan of care to use a mechanical lift ([Hoyer lift] assistive device used in healthcare facilities to lift and transfer residents with a minimum of physical support) during a transfer from Resident 1's bed to the shower chair. This failure resulted in Resident 1's fall to the floor with a fractured left femur (broken bone of the thigh, extending from the hip to the knee) on 11/5/20. During a review of Resident 1's Minimum Data Set (MDS-a standardized, comprehensive assessment tool), dated 9/26/20, the MDS indicated, Resident 1 had a BIMS [Brief Interview for Mental Status-which evaluates cognition, the ability to remember and think clearly] score of 3 (0-7 indicates severe impaired cognition, 8-12 indicates moderately impaired, and 13-15 indicates intact cognition). The MDS indicated, Resident 1 required total dependence [full staff performance] with "two+ person physical assist for transfer [how resident moves between surfaces including to and from: bed, chair, wheelchair, standing position...]." Resident 1 had "Functional Limitation in Range of Motion", on both sides of her lower extremities (hip, knee, ankle, foot). During a review of Resident 1's Fall Risk Assessment, dated 9/25/20, the Fall Risk Assessment indicated, "... score 7... Moderate Risk [for falls]." During a review of Resident 1's Progress Notes, dated 11/5/20, at 10:55 AM, the Progress Notes indicated, "...2 [two] staff tried to transfer resident for shower and staff lost balance, resident was then guided to the floor on her bottom." During a review of Resident 1's Radiology Results Report, dated 11/8/20, at 10:39 AM, the Radiology Results Report indicated, "Pain in left knee ... Conclusion; Acute fracture distal femur." During a review of Resident 1's Facility Reported Event, dated 11/9/20, at 10 AM, the Facility Reported Event indicated, "On 11/5/20 2 CNA's [CNA 2 and CNA 3] were attempting to transfer resident and resident grabbed the side rail in the process of transferring, CNA's lost footing and were unable to complete the transfer and guided the resident to the floor.... On 11/7/20 resident complained of pain [to] the left leg ... MD notified and ordered x-ray for left leg. Received x-ray report on 11/8/20 and noted fracture of left femur ..." During a review of Resident 1's Progress Notes, dated 11/10/20 at 3:11 PM, the Progress Notes indicated, "Fall with fracture to left femur ... Charge Nurse responded to staff calling out for help in [Resident 1's] room. Resident was found sitting on her buttock next to her bed ... 2 [two] CNA's [CNA 2 and CNA 3] were self-transferring resident to shower chair and was unable to complete transfer when resident grabbed side rail causing staff lose footing and slowly guided resident to the floor ..." During an interview on 11/19/20, at 9:33 AM, with Restorative Nursing Assistant (RNA - help residents gain and improve quality of life by increasing their level of strength and mobility), RNA stated, Resident 1 was unable to walk and required a Hoyer lift (common brand of mechanical lift) to assist with transfers. During an interview on 11/19/20, at 9:40 AM, with CNA 1, CNA 1 stated, Resident 1 was unable to bear weight and required the use of a Hoyer lift during transfers. During an interview on 11/19/20, at 9:50 AM, with CNA 2, CNA 2 stated, she was assigned to Resident 1 on the day of the incident (11/5/20) and she and CNA 3 were transferring Resident 1 from the bed to the shower chair. CNA 2 stated, she and CNA 3 put their arm under Resident 1's arms and attempted to transfer Resident 1. CNA 2 stated, "Resident 1 grabbed the rail of the bed, would not let go. We lost control of her balance, could not hold her up anymore, and put on the floor because we did not want to drop her." During a concurrent interview and record review on 11/19/20, at 10:50 AM, with Facility Rehabilitation Coordinator (Rehab Coordinator), Resident 1's "PT [Physical Therapy] Evaluation & Plan of Treatment" (PT Evaluation and Plan), dated 10/29/20, was reviewed. The PT Evaluation and Plan indicated, "Functional Assessment ...Transfers = Total Dependence ... Precautions Includes: Fall Risk, BLE [bilateral lower extremities] Contractures ..." The Rehab Coordinator confirmed the findings and stated, Resident 1 was total dependent for transfers and the staff were doing 100% of the work. During a concurrent observation and interview on 11/19/20, at 11:23 AM, with Resident 1, in Resident 1's room, Resident 1 was lying in the bed with a pillow brace (used to immobilize the broken bone) on her left leg. Resident 1 stated, "When two CNA's were transferring me for a shower they dropped me." Resident 1 stated, she was supposed to be transferred with a lift but the CNA's decided to transfer her without it. During the transfer [Resident 1] told the CNA's "I'm slipping, I'm slipping, they could not do nothing about it, I just fell." During an interview on 11/19/20, at 11:33 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 was non-weight bearing and cannot understand safety. Resident 1 was not safe to be transferred without a Hoyer lift. During an interview on 11/19/20, at 11:36 AM, with LVN 2, LVN 2 stated, the facility was a no lift (staff avoid manually lifting) facility and the CNAs should have transferred Resident 1 with a Hoyer lift. During an interview on 11/19/20, at 11:46 AM, with the Assistant Director of Nursing (ADON), the ADON stated, Resident 1 had to be transferred with a Hoyer lift. During an interview and record review, on 11/19/20, at 12:20 PM, with the Administrator, Resident 1's "Care Plan," revised 3/26/19, was reviewed. The Care Plan indicated, "[Resident 1] has a potential for impaired physical mobility related to limited movement...Assist during transfer with safety...Provide enough support during transfer...Hoyer lift for transfer." Administrator confirmed the findings and stated, Resident 1 had to be transferred with a Hoyer lift. During an interview on 11/20/20, at 4:39 PM, with CNA 3, CNA 3 stated, she was assisting CNA 2 in transferring Resident 1 on the day of the incident (11/05/20). CNA 3 stated, during the transfer they attempted to stand Resident 1 utilizing a two-person transfer. One CNA stood on each side of the resident and placed an arm under each of Resident 1's arms. While attempting to stand Resident 1, Resident 1 began moving so CNA 2 and CNA 3 lowered Resident 1 to the ground. CNA 3 stated, she was not aware how Resident 1 was transferred but assumed Resident 1 was a two-person assist in transfer. CNA 3 stated, the facility was a no lift facility, and only residents who can bear weight should be a two-person assist in transfer. During a review of the facility's policy and procedure (P&P) titled, "Policy and Procedure for Fall Prevention Program," dated, 5/23/17, the P&P indicated, "Hoyer Lift Purpose: To move a resident by a mechanical means. To move and lift a resident safety [sic]. To prevent injury to staff members." In violation of the above cited standards, the facility failed to safely transfer Resident 1, requiring staff to lower her to the floor, subsequently fracturing her left femur and causing pain. 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.