Other·June 23, 2022

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident number 772717and complaint number 772623. 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. 22 CCR § 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. On 2/10/22, at 9:55 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. Certified Nursing Assistant (CNA) 1 attempted to transfer Resident 1 from her bed to her wheelchair without the assistance of another qualified staff member. Resident 1 was an 84-year-old female with diagnoses of cerebral infarction due to embolism of left middle cerebral artery (an area of necrotic tissue in the brain caused by a disruption in the blood supply), hemiplegia (paralysis of one side of the body), muscle weakness, and unsteadiness on feet. Resident was non-verbal and was dependent upon staff for all activities of daily living. Based on interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) was transferred from bed to wheelchair by two staff as required in the resident's medical record and consistent with the facility's policy and procedure (P & P). The facility failed to implement a care plan for the transfer for Resident 1, incorporating the resident's inability to assist in transfers and requiring two staff to assist. This failure resulted in Resident 1 experiencing an assisted fall resulting in the resident fracturing her distal femur and causing pain. Findings: During a review of Resident 1's "Progress Notes (PN), dated 2/2/22, at 9:43 AM, the PN indicated "Alerted by staff member, while attempting to transfer resident from bed to wheelchair, she was uanble [sic] to transfer her and slid her down to her bottom on the floor. Upon entering residents' room, resident noted to be by her bed sitting on her bottom with assistance from staff member. Resident unable to to [sic] answer due to being non-verbal, but slightly groans of discomfort, and some facial grimacing, discomfort treated with PRN (as needed) pain medication." During a review of Resident 1's PN, dated 2/3/22 at 9:54 AM, the PN indicated, "IDT [Interdisciplinary Team] note ...Fall non-injury 2/2/22...educated staff on safe resident transfers and resident being total dependence/two person assist for transfers...Intervention...Educate staff on proper transfer technique..." During a review of Resident 1's PN, dated 2/8/22, at 2:14 PM, the PN indicated, "Communication with Physician...Situation: Resident noted to have +2 (leaves a 3-4-millimeter depression or slight indentation when pressed) swelling to right knee with redness and warmth to touch. Resident also appears to be in pain as observed by facial grimacing...Recommendations...X-ray 2V[views] to right knee r/t [related to] pain swelling..." During a review of Resident 1's "Radiology Results Report (RRR, dated 2/8/22, at 6:57 PM, the RRR indicated "Findings: There is a fracture involving right distal femur with displacement (acute knee fracture)" During a review of Resident 1's "Minimum Data Set" (MDS-comprehensive assessment of each resident's functional capabilities), dated 11/21/21, the MDS indicated, "Transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position...Self-Performance...4 (indicating resident was total dependent on staff) ...Support...3 (indicating resident required the assistance of two+ persons physical assist.)" During a review of Resident 1's "Weekly Summary Nurse Progress Note" (WSNPN), dated 1/30/22, at 12:31 AM, the WSNPN indicated, "Physical Functioning/Structural Problems...Transfer: support provided...Two+ persons physical assist..." During a review of Resident 1's MDS Kardex Report For [Facility Name]" (MDSKSKRF-informs staff on how to care for resident), printed 4/6/22, at 9:40 AM, the MDSKRF indicated as of 2/1/22 (prior to the incident), Resident 1 required "ADL (Activities of Daily Living) Transfer Total Dependence...Two+ persons physical assist" During an interview on 2/10/22, at 1:35 PM, with the Administrator stated that, Resident 1 had a fall, during a transfer, on 2/2/22. On 2/8/22 Resident 1 exhibited pain and swelling to the knee, an x-ray was done, and results indicated a fracture. Administrator stated, the facility assumed the fracture occurred when Resident 1 fell on 2/2/22. During an interview on 2/10/22, at 2:16 PM, Licensed Vocational Nurse (LVN) 1, stated, that she was assigned to Resident 1 on the day of the fall. LVN 1 stated, when she entered Resident 1's room, Resident 1 was on the floor sitting on her bottom and CNA 1 was holding her up. LVN 1 stated, CNA 1 reported when CNA 1 was transferring Resident 1 to her wheelchair Resident 1 was unable to assist with the transfer into the wheelchair and CNA 1 was unable to transfer Resident 1 unassisted, so CNA 1 guided Resident 1 to the floor. LVN 1 stated, CNA was transferring Resident 1 alone at the time of the fall. During an interview on 2/10/22, at 2:25 PM, with CNA 2, stated that, Resident 1 was unable to follow commands and bear weight. CNA 2 stated, Resident 1 required two people for transfers because she was unable to bear weight. During an interview on 2/10/22, at 3:42 PM, with CNA 3 stated that, Resident 1 was always a two person transfer because she was unable to bear weight. During an interview on 2/10/22, at 4 PM, with LVN 2, stated that Resident 1 was totally dependent upon staff for care. LVN 2 stated if staff were to attempt to have Resident 1 bear weight at all she would not be able to. During an interview on 4/5/22, at 4:15 PM with CNA 1 stated that, on 2/2/22 she sat Resident 1 on the edge of the bed so CNA 1 could stand and pivot Resident 1 into her wheelchair. CNA 1 stated, she was unable to lift Resident 1 into the wheelchair and Resident 1 began to get heavier, so CNA 1 guided her to the floor and Resident 1 sat on her bottom. CNA 1 stated, she normally transferred Resident 1 by placing her arms under Resident 1's arms, knee in between Resident 1's legs while grabbing the back of Resident 1's pants and transferring Resident 1 into the wheelchair. CNA 1 stated that, Resident 1 was totally dependent with care and was unable to stand or bear weight. During an interview on 4/5/22, at 4:42 PM with the Director of Nursing (DON) stated that, on 2/2/22 Resident 1 was transferred by one person and during the transfer Resident 1 was guided to the floor. The DON stated that, Resident 1 should have been transferred by two staff. During a review of the facility's P & P titled, "Transfer Activities dated 2018, the P & P indicated, "Transfer from Bed to Wheelchair 1. Obtain assistance of another individual if necessary for safe transfer." In violation of the above cited standards, the facility failed to ensure a safe transfer for Resident 1 from bed to wheelchair by two staff as required in the resident's medical records and consistent with the facility's P & P. The facility also failed to implement a care plan for transfers for Resident 1, incorporating the resident's inability to assist in transfers and requiring two staff to assist. These failures resulted in Resident 1 experiencing an assisted fall resulting in Resident 1 experiencing an assisted fall resulting in the resident fracturing her right knee 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.