Other·January 24, 2023

The following reflects the findings of the California Department of Public Health during the investigation of Entity Reported Incident ERI #: CA00808806 Representing the Department. HFEN #47400 State Citation B was written CLASS B CITATION - PATIENT CARE F689 §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. The facility failed to follow the aforementioned regulation to keep patients safe when certified nursing assistants (CNA 2 and CNA 3), left Patient 1 in bed, unattended resulting in an avoidable fall out of bed and leg fracture (broken bones). Patient 1 was admitted to the facility on 08/15/2015. She had diagnoses including Cerebral Palsy (disorder that affect a person's ability to move and maintain balance), chronic pain syndrome (group of symptoms) and other muscle spasm. During a record review of Patient 1's Minimum Data Set (MDS- An assessment tool used to guide care) dated 09/11/22, Patient 1 had unclear speech, "sometimes" able to understand others and make self-understood. Patient 1 was totally dependent on staff for activities of daily living such as bathing, bed mobility, transfers and personal hygiene and had limited range of motion in both upper and lower extremities. During interview on 11/14/22, at 10:16 a.m. with Licensed Vocational Nurse 1(LVN 1), LVN 1 stated, Patient 1 was at risk for falls and she recently fell in the evening of 10/23/22, causing fracture of right lower extremity. LVN 1 also stated, Patient 1 was not able to move in bed independently and was totally dependent on staff for Activities of Daily Living (ADLs). During a phone interview on 11/18/22 at 2:36 pm, with CNA 2, CNA 2 stated, on 10/23/22 evening, after transferring Patient 1, she moved the wheelchair by the door and closed the curtain, obstructing her view of Patient 1.CNA 2 further stated, CNA 3 was facing the closet and the door, searching for incontinent supplies with one hand in the closet while talking to CNA 2. CNA 2 also stated, CNA 3 turned around and saw Patient 1 rolling from bed, CNA 3 asked CNA 2, who was closer to Patient 1 to "grab her". CNA 2 stated, she did not let Patient 1 go on the floor, she grabbed Patient 1 by her belly, Patient 1 hit the bed frame with her leg. Patient 1 started screaming in pain. CNA 2 stated, she put Patient 1 in bed by herself without help from another staff and did not notify the charge nurse on duty of the incident. CNA 2 stated, it was an avoidable situation. During a phone interview on 11/14/22, at 12:28 p.m., with CNA 3, CNA 3 stated, she was the assigned direct care staff for Patient 1 on the evening of 10/23/22. CNA 3 stated, she asked CNA 2 to assist her to put Patient 1 back to bed out of the wheelchair. CNA 3 stated, she was at the foot of the bed getting briefs from the closet while CNA 2 , transferred Patient 1 and put her in bed .CNA 3 stated, as she was turning around from the closet, she noticed Patient 1's both legs were swinging on the right side of the bed while CNA 2 was already by the door leaving the room. CNA 3 stated, "grab her, she is going to fall". CNA 3 stated, there were no fall protection padded mats on the floor. During a phone interview on 11/14/22, at 12:48 pm, with LVN 3, LVN 3 stated, she was the assigned charge nurse for Patient 1 on 10/23/22. LVN 3 stated, she thought Patient 1 fall out of bed was "questionable" as she was not sure if the staff safely transferred and positioned Patient 1 in bed. LVN 3 stated, "Patient 1 does not roll, she was always on one side, I had never seen her move, she cannot move, she can barely flex and extend extremities, she can only wiggle her toes and fingers". During a record review of "Fall Risk Care Plan", revised 10/17/22, the revised care plan indicated, Patient 1 "...is high risk for falls related to unaware of safety needs, poor communication/comprehension, deconditioning, poor trunk control, incontinence (lack of voluntary control over urination or defecation); chair bound...facility goal was patient will not sustain serious injury...intervention was two-person assistance with transfers...bed mobility..." During a record review of Patient 1's Progress Notes dated 10/23/22, progress notes indicated, LVN 3 documented "reported by CNA that Patient 1 rolled out of her bed, CNA who was closer to Patient 1, caught her to prevent the fall. She held Patient 1's back and was not sure if Patient 1 hit the ground or bed frame...physician was notified with order for immediate x-rays (images of internal bones). During a record review of Radiology Results Report, dated 10/24/22, the report indicated lower leg fracture (broken bones). During a review of Alameda County Hospital (ACH) "Emergency Department after visit summary, report indicated, Patient 1's right lower leg was splinted.