Other·December 26, 2024

The following reflects the findings of the California Department of Public Health during the investigation of two facility reported incident numbers. 921940 and 921798. The inspection was limited to the specific facility reported incidents investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for facility reported incidents 921940 and 921798 at F-tag 656/G. F656 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. On 10/2/24 at 9 a.m., an unannounced visit was conducted to investigate a facility reported incident regarding Resident 1's fractured both lower legs who was supposed to be transferred using a Hoyer lift according to the care plan, resulting in a fracture to both lower legs. Resident 1 was an 81-year-old female resident with diagnoses of muscle spasm, abnormalities of gait and mobility, difficulty walking, lack of coordination, and muscle weakness. Based on observation, interview, and record review, the facility failed to implement comprehensive person-centered care plan for activities of daily living (ADL) when Hoyer lift (mechanical, device used to safely lift and transfer patients who have limited mobility) was not used to transfer one of three sampled residents (Resident 1) from a wheelchair to bed. This failure resulted in Resident 1 falling on two occasions and sustaining two broken bones in each lower leg, requiring an open reduction and internal fixation (ORIF, surgical procedure to repair broken bones that may include use of screws, rods, or plates) of the left upper tibia and lateral tibial plateau plate (shin bone) of both legs, and had the potential for complications of ORIF surgery such as infection, bleeding, nerve damage, damage to blood vessels, ligaments, muscles, or bones, blood clots, fat embolism, improper bone healing or alignment, hardware complications like breakage or movement, reduced mobility, compartment syndrome (a serious condition that occurs when pressure builds up in a muscle compartment, restricting blood flow and causing pain), and potential irritation from the hardware on surrounding tissues; with the severity of risks potentially increasing due to the bilateral (both lower legs) nature of the surgery. Findings: During a review of Resident 1s "Admission Record (AR)," dated 10/08/22, the "AR" indicated, Resident 1 was a readmission on 2/23/23 with diagnoses of difficulty in walking, and muscle wasting in right and left lower legs, difficulty in walking, generalized muscle weakness, other- lack of coordination, abnormality of gait (walking) and mobility, hypertensive (the heart has to work hard to pump blood against high blood pressure) heart disease with heart failure. During a review of Resident 1's "Minimum Data Set (MDS-assessment tool)," dated 8/14/24, the MDS", the "MDS" indicated Section GG - Functional Abilities and Goals GG indicated A. Roll left and Right, Resident 1's score was 01 (range of scores is from 0 to 10, with higher numbers meaning higher functioning, and a score of 01 means dependent, indicating Helper does ALL the effort). The "MDS" indicated E. chair/bed-to chair transfer: Resident 1's score was 01. During a review of Resident 1's "Fall Risk Observation/Assessment (FROA)," dated 8/14/24, the "FROA" indicated Resident 1 score was 20 (means high risk for falls). During a review of Resident 1's "Care Plan (CP)," dated 8/19/24, the "CP" indicated Resident 1 requires a Hoyer lift for transfer. During an interview on 10/2/24 at 9:00 a.m. with Director of Nursing (DON), DON stated Resident 1 required a Hoyer lift for transfers. DON stated therapy (OT) uses the sliding board (a flat board used to move individuals from one place to another) and standing pivot (assisting with guided transfer movement). During an interview on 10/22/24 at 11:50 a.m. with Occupational Therapist (OT), OT stated on 9/12/24 Resident 1 was a stand and pivot with therapy and a maximum (Hoyer lift) for staff. During an interview on 10/22/24 at 11:52 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated, "During report, I was told that therapy had given CNAs the okay to transfer the resident from walker to bed. I was helping Resident 1 to transfer from the chair to the bed on 9/12/24 when Resident [1] was already standing, and she [Resident 1] stated she was tired, and she started to go down." CNA 2 stated, "I assisted her [Resident 1] to the floor." During a review of Resident 1's "Interdisciplinary Team Progress Notes (ITPN)," dated 9/13/24 at 2:56 p.m., the "ITPN" indicated interventions for Resident 1: "ADL: dependent assist with ADLs and transfers. Anticipate resident needs, provide verbal cue, and safety education." During an interview on 10/22/24 at 1:27 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, "She [Resident 1] was assisted by three staff, they used a gait belt [a device that helps with mobility issues to move safely, a thick, woven strap that's placed around a resident's waist and fastened with a buckle] that is why I found a bruise on the left upper arm bicep [a large muscle in the upper arm] area on 9/13/24." During a concurrent observation and interview on 11/4/24 at 10:10 a.m. with Resident 1, in Resident 1's room, Resident 1 was lying in bed with casts (holds a broken bone/fracture in place and prevents the area from moving as it heals) on both lower legs. Resident 1 stated she had two recent falls this month. Resident 1 stated her first fall was on 9/12/24. Resident 1 stated, "CNA [2] asked me to stand and use the board." Resident 1 stated she tried to turn her body and fell. Resident 1 stated she had a second fall on 9/20/24. Resident 1 stated every morning the staff has her stand and use the walker from the wheelchair, and the Hoyer lift is never used. Resident 1 stated, "CNA [1] asked me to stand." Resident 1 stated she felt weak, and CNA 1 stated, "You can do it" and next thing I remember is I am on the floor. Resident 1 stated when she was on the floor her knees were bent and she was sitting on her legs. Resident 1 stated a therapist picked her up by her waist and tossed her on the bed. During a review of Resident 1's "MDS," dated 8/14/24, the "MDS" indicated Resident 1 had a Brief for Mental Status (BIMS) score of 14 (the scores range from 0 to 15 with higher scores meaning better cognition, and scores of 13-15 mean cognitively intact). During a review of the Resident 1's "Progress Notes (PN)," dated 9/21/24 at 8:30 a.m., the "PN" indicated, "[Resident 1] had bruising to bilateral lower extremities painful/hot to touch. Pain was 8/10 [using pain scale 0-10, with 0 representing no pain and 10 representing the worst pain possible] and physician was notified, and [Resident 1] was transferred to a local hospital." During a review of the hospital's "Image Report (IR)," dated 9/23/24, the "IR" indicated Resident 1 had comminuted displacement fracture (where the bones are broken in several places) to both right and left tibia (inner larger bones between the knee and the ankle on the inside) and fibula (the outer smaller bones between the knee and the ankle). During a review of the hospital's "Emergency Department Note (EDN)," dated 9/21/24, the "EDN" indicated, "Recommends admission in the hospital and will perform surgery on Monday." During a review of the hospital's "Operative Report (OR)," dated 9/23/24, the "OR" indicated, "Pre-op diagnosis: Displaced fracture (broken bone not in alignment) right upper tibia (shinbone) and displaced fracture left upper tibia." The OR report indicated (Resident 1) had a surgical procedure for open reduction and internal fixation of the left upper tibia and lateral tibial plateau plate of each leg. During a review of the facility's policy and procedure (P&P), titled, "Falls - Clinical Protocol," dated 2001, the P&P indicated, "Treatment/Management: 1. Will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling." During a review of the facility's P&P, "Care Plans, Comprehensive Person-Centered," dated 2001, the P&P indicated, "A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident." In violation of F656 §483.21(b), the facility failed to implement comprehensive person-centered care plan for activities of a daily living (ADL) when the Hoyer lift was not used to transfer Resident 1 from wheelchair to bed. This failure resulted in Resident 1 falling on two occasions and sustaining two broken bones in each lower leg and requiring surgery. This violation presented either imminent danger that serious harm would result or a substantial probability that death or serious physical harm would result and constitutes an "A" citation.