Other·April 26, 2023

The following reflects the findings of the California Department of Public Health during the investigation of an FRI #808725. The inspection was limited to the specific FRI investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the Department: HFEN # 37697. A deficiency was written for FRI #808725 at F-tag 689/G. 42 Code of Federal Regulations, part 483.25 (d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. Based on interview and record review, the facility failed to provide the necessary assistance for one sampled resident (Resident 1) when Certified Nursing Assistant (CNA) 1 attempted to transfer the resident with no assistance from another staff resulting in the resident falling to the ground. CNA 1 referred to the Communication Document (CD - an informal document located at the nursing station which documents the required level of assistance for each resident) for Resident 1 which did not accurately reflect the level of assistance required when transferring the resident from the chair to the bed. These failures resulted in the Resident 1 falling to the floor and sustaining a fracture of the right femur (thigh bone) which required the resident to be transferred to the hospital for a higher level of care. Findings: On 11/2/22, at 10:25 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) 1 attempted to transfer Resident 1 from the shower chair to her bed without the assistance of another staff member. Resident 1 was a 75-year-old female with cerebral infarction (A lack of adequate blood supply to the brain cells that deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) admitted to the facility on 3/3/21. Resident 1 was admitted on 3/3/21 and readmitted on 11/24/21 with the following diagnoses: cerebral infarction (stroke), muscle weakness, other abnormalities of gait (manner of walking) and mobility, difficulty in walking, need for assistance with personal care, and repeated falls. During an interview on 11/2/22, at 11:41 AM, with CNA 1, CNA 1 stated that on 10/21/22, she assisted the resident with a shower. CNA 1 stated after assisting the resident with the shower she rolled the resident back to her room via the shower chair (specially designed rollable, waterproof chair used to shower a resident) to place the resident back to bed. CNA 1 stated she was by herself when she attempted to transfer Resident 1 back to the bed from the shower chair. CNA 1 stated she was holding Resident 1's left arm when Resident 1 stood up. When Resident 1 stood up to transfer from the shower chair to the bed, the resident started to slide down to the floor. CNA 1 stated she shouted for help as Resident 1 fell to the floor. The resident landed on the floor with her legs in a spread open position. CNA 1 stated after the fall to the floor Resident 1's right leg looked, "swollen". CNA 1 stated the CD form located at the nurse's station indicated Resident 1 required one person to assist the resident with transferring from a chair to the bed, and from the bed to the chair. CNA 1 stated she was not aware Resident 1 required two persons to assist the resident with transferring until after the resident fell on 10/21/22. During an interview, on 11/2/23, at 12:10 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, CNA 1 called her on the night of the incident and informed her she was attempting to get the resident up when the resident started slipping to the floor. CNA 1 guided the resident to the floor in a sitting position. CNA 1 then placed the resident back to bed. When LVN 1 arrived at the resident's room, the resident was already in bed. LVN 1 then assessed the resident and stated the resident did complain of pain and a pain pill was given. LVN 1 did state the process for when a resident falls, is for the licensed nurse to assess the resident in the position they fell, monitor every shift for 72 hours, notify the doctor and the responsible party. During a concurrent interview and record review on 11/2/22, at 12:56 PM, with Minimum Data Set Nurse (MDSN) 2, Resident 1's MDS section titled "Functional Status (FS)," dated 9/3/22 was reviewed. The FS indicated Resident 1 required extensive two-person assistance for transfers (the residents' ability to transfer in and out of bed). Resident 1's "Care Plan (CP)" dated 4/14/21 was also reviewed. The CP indicated Resident 1 required extensive two-person assistance for bed mobility and transfers from bed to chair, and from chair to bed. MDSN 2 stated this information is relayed to nursing staff via the CD located at each nursing station. MDSN 2 reviewed the CD for Resident 1, located at the nursing station, and stated the document inaccurately documented Resident 1's required level of assistance. MDSN 2 stated the CD indicated Resident 1 only required one-person assistance to transfer Resident 1 from the chair to the bed and the bed to the chair. MDSN 2 stated the nursing staff used the CD information to determine Resident 1's level of assistance required by staff. The CD did not accurately reflect what Resident 1's needs were as indicated by the FS assessment and the CP. Both the FS and the CP indicated the resident required two persons to assist with transferring. During an interview on 4/17/23, at 2:05 PM, with the Director of Staff Development (DSD), she stated the staff are taught to reference the CD, as well as the information in the facility's electronic clinical record. When DSD was asked if there is a CD policy and procedure, she stated the facility did not have a policy and procedure for the use of the CD. The staff are trained about the CD upon hire and orientation to the floor. DSD stated it is the MDS nurse who creates the CD. During a review of Resident 1's facility "Radiology Results Report (RRR)," dated 10/23/22, at 1:31 PM, the RRR indicated, Resident 1 had an acute (new) fracture (break in the bone) of her femur (large thigh bone). During a review of Resident 1's Acute Hospital "Emergency Room Note (ERN)" dated 10/23/22, at 3:09 PM, the ERN indicated Resident 1 presented to the Emergency Department with leg pain. Resident 1 had a pain level of six on 0 to 10 pain scale when motionless (a numerical pain scale is used to assess a patient's pain level with a score of zero - no pain, one to three is considered mild pain, four to six is moderate pain, and seven to nine is severe pain, and a score of 10 is very severe pain). During a review of Resident 1's Acute Hospital "History and Physical Report (HPR)" dated 10/23/22, at 9:51 PM, the HPR indicated, "[Resident 1] is a 85-year-old [sic] female . . . who presented to the ED [Emergency Department] after sustaining a fall at her [facility] on Thursday of this week, approximately 3 days ago. On reevaluation, the patient [Resident 1] was somnolent [drowsy] after receiving fentanyl [a narcotic pain medication] for severe pain. Per the patient's [Resident 1] son, they were unaware of the fall at [facility] until earlier today [10/23/22] . . . Femur CT [Computed Tomography - a form of Xray] demonstrated distal fracture at the [right] femur. . . Plan . . . Orthopedic [specialized medical field regarding bones] surgery [consult] . . . low-dose morphine [narcotic pain medication] for pain control . . . ." During a review of the facility's policy and procedure (P&P) titled, "MDS ASSESSMENT," undated, the P&P indicated, "It is the policy of this facility to conduct and document a comprehensive assessment on all residents. . .for patient care planning in order to coordinate all data collected, assess all resident's level of function and develop a plan of care." In violation of the above cited standards, the facility failed to safely transfer Resident 1, resulting in Resident 1 sliding to the floor, subsequently fracturing her right 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.